Form 433-A - How To Prepare Form 433-A And Templates Page 6
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6Section V.
Monthly Income and Expense Analysis
Total Income
Source
31. Wages / Salaries (Taxpayer)
32
Wages / Salaries (Spouse)
33. Interest - Dividends
34. Net Business Income (Form 433-B)
35
Rental Income
36
Pension (Taxpayer)
37. Pension (Spouse)
38. Child Support
39
Alimony
40. Other
41. Total Income
□
Gross
$
3,333.00
1,833.00
$
5,166.00
Necessary Living Expenses
42. Housing and utilities
43. Transportation
44. Healthcare
45. Taxes (Income and FICA)
46. Court ordered payments
47. Child / dependent care
48. Life insurance
49. Other expenses (specify)
food
out of pocket medical
50. Total Expenses
51. Net differences
(State use only)
Claimed
$
1,700.00
1,310.00
65.00
832.00
0.00
0.00
61.00
350.00
75.00
$
4,393.00
$
(State use only)
Allowed
$
$
Certification
Under penalties of perjury, 1 declare that to the best of my knowledge and belief this statement of assets, liabilities, and other
information is true, correct, and complete.
52
Your signature
53. Spouse's signature (ifjoint return riled)
54.
Date
State Tax Department Use Only Below This Line
Financial Verification / Analysis
Item
Real Estate
Vehicles
Other Personal Property
Income Tax Return
Sources of Income / Credit Bureau
Other Assets / Liabilities
Date Information or
Encumbrance
Verified
Date Property
Inspected
Estimate
Forced Sale
Equity
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