Form Md 433-A - Collection Information Statement For Individuals - 2000 Page 4

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Form MD 433-A
Page 4
(Rev. 7-2000)
Section V
Monthly Income and Expense Analysis
Total Income
Necessary Living Expenses
Comptroller’s use Only
Source
Gross
Claimed
Allowed
31 Wages/salaries (taxpayer)
$
42 National Standard Expenses (1)
$
$
32 Wages/salaries (spouse)
43 Housing and utilities (2)
33 Interest, dividends
44 Transportation (3)
34 Net business income
45 Health care
(from Form MD 433-B)
35 Rental income
46 Taxes (income and FICA)
36 Pension (taxpayer)
47 Court ordered payments
37 Pension (spouse)
48 Child/dependent care
38 Child support
49 Life insurance
39 Alimony
50 Secured or legally-perfected
debts (specify)
40 Other income
51 Other expenses (specify)
41 Total income
$
52 Total Expenses
$
$
53 (Comptroller’s use only) Net
$
difference (income less necessary
living expenses)
Certification
Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of
assets, liabilities, and other information is true, correct, and complete.
54 Your signature
55 Spouse’s signature (if joint return filed)
56 Date
Notes
1 Clothing and clothing services, food, housekeeping supplies, personal care products and services, and miscellaneous.
2 Rent or mortgage payment for the taxpayer’s principal residence. Add the average monthly payment for the following expenses if they are not
included in the rent or mortgage payment: property taxes, homeowner’s or renter’s insurance, parking, necessary maintenance and repair,
homeowner dues, condominium fees and utilities. Utilities include gas, electricity, water, fuel oil, coal, bottled gas, trash and garbage collection,
wood and other fuels, septic cleaning, and telephone.
3 Lease or purchase payments, insurance, registration fees, normal maintenance, fuel, public transportation, parking, and tolls.
Additional information or comments:
Comptroller of Maryland Use Only Below This Line
Explain any difference between Item 53 and the installment payment amount:
Name of Originator
Date

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