Form Boa-4 - Financial Information Statement For Individuals Page 4
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4Part H: Analyze your monthly income and expenses
Income
Necessary monthly living expenses
A
B
C
A
B
Source
Gross
Net
Expense
Amount
67
78
Your wages or salary
___________________
___________________
Rent (not included
68
Your spouse’s
in Part G, Line 59)
___________________
79
wages or salary
___________________
___________________
Groceries
69
Interest or dividends
___________________
___________________
(number of people____)
___________________
70
80
Business income
___________________
___________________
Installment pmts. from
71
Rental income
___________________
___________________
Part G, Line 66, Col. E
___________________
72
81
Your pension
___________________
___________________
Utilities
a gas
___________________
73
Your spouse’s pension
___________________
___________________
b water
___________________
74
Child support
___________________
___________________
c electric
___________________
75
Alimony
___________________
___________________
d telephone
___________________
76
82
Other (specify)
Transportation
___________________
83
________________
___________________
___________________
Insurance a life
___________________
________________
___________________
___________________
(monthly
b health
___________________
________________
___________________
___________________
premiums) c home
___________________
________________
___________________
___________________
d car
___________________
84
________________
___________________
___________________
Medical (not covered
________________
___________________
___________________
in Line 83b above)
___________________
85
________________
___________________
___________________
Estimated tax payments
___________________
86
________________
___________________
___________________
Court-ordered payments
___________________
87
________________
___________________
___________________
Other (specify)
________________
___________________
___________________
__________________
___________________
________________
___________________
___________________
__________________
___________________
________________
___________________
___________________
__________________
___________________
88
Add Lines 78 through 87.
77
Add Lines 67 through 76, Column C.
This amount is your
This amount is your total net income.
____________________
total expenses.
___________________
89
89
Subtract Line 88 from Line 77. This amount is your net income after expenses.
___________________
Part I: Complete any additional asset or income information
90
Write any additional information you have about your assets or income that was not included in any of the preceding parts. Be sure to
include a statement regarding the prospect of any increase in the value of your assets or your present income.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Section 3: Sign below
Under penalties of perjury, I state that I have examined this statement of assets, liabilities, and other information and, to the best of my
knowledge, it is true, correct, and complete.
______________________________________________/___/_____
______________________________________________/___/_____
Petitioner’s signature (not representative)
Date
Spouse’s signature
Date
This form is authorized as outlined by the Illinois Income Tax Act. Disclosure of this information is REQUIRED. Failure to provide information
could result in this form not being processed. This form has been approved by the Forms Management Center.
IL-492-3683
Page 4 of 4
BOA-4 (R-4/01)
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