Form Boa-4 - Financial Information Statement For Individuals
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Illinois Department of Revenue
BOA-4
Financial Information Statement for Individuals
Section 1: Tell us about yourself and your employment
Part A: Your information
1
Marital status
single
married
separated
If married, complete your spouse’s information in Part B.
2
11
Your name ___________________________________________
Filing status
single
married filing jointly
3
Street address ________________________________________
head of household
married filing separately
12
____________________________________________________
Average monthly take-home pay $___________________________
City
State
ZIP
13
Amounts withheld from your paycheck ( e.g. , savings, bonds,
4
Home phone (____)____________________________________
deferred amounts, car payments, etc.) $______________________
5
Social Security number ___ ___ ___ ___ ___ ___ ___ ___ ___
______________________________________________________
6
14
Unemployed
yes
no If “yes,” how long._______________
Dates paid _____________________________________________
7
15
Current or former employer’s name ________________________
Length of employment ____________________________________
8
16
Address _____________________________________________
Date of birth ___ ___/___ ___/___ ___ ___ ___
17
____________________________________________________
Name and address of next of kin (other than spouse)
City
State
ZIP
Name ________________________________________________
9
Work phone (_____)____________________________________
Street address _________________________________________
10
Occupation___________________________________________
______________________________________________________
City
State
ZIP
Part B: Your spouse’s information
18
25
Spouse’s name _______________________________________
Work phone(_____)______________________________________
19
26
Address (if different)____________________________________
Occupation ____________________________________________
27
____________________________________________________
Average monthly take-home pay $___________________________
City
State
ZIP
28
Amounts withheld from your paycheck (e.g., savings, bonds,
20
Home phone (if different)(_____)__________________________
deferred amounts, car payments, etc.) $______________________
21
Social Security number ___ ___ ___ ___ ___ ___ ___ ___ ___
______________________________________________________
22
29
Unemployed
yes
no If “yes,” how long._______________
Dates paid _____________________________________________
23
30
Current or former employer’s name ________________________
Length of employment ____________________________________
24
31
Address _____________________________________________
Date of birth ___ ___/___ ___/___ ___ ___ ___
____________________________________________________
City
State
ZIP
Section 2: Complete the following financial information
Note: Attach additional sheets in the same format for any of the following parts if necessary.
Part A: Your bank accounts (include savings and loans, credit unions, IRA and retirement plans,
and certificates of deposit)
A
B
C
D
E
Type of
Account
Name of institution
Address
account
number
Balance
32
______________________
_______________________________________
___________
___________
____________
33
______________________
_______________________________________
___________
___________
____________
34
______________________
_______________________________________
___________
___________
____________
35
______________________
_______________________________________
___________
___________
____________
36
______________________
_______________________________________
___________
___________
____________
37
______________________
_______________________________________
___________
___________
____________
38
38
Add Lines 32 through 37, Column E, and write the total here and on Part G, Line 56, Column B.
____________
Page 1 of 4
BOA-4 (R-4/01)
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