Form Eg-13-I - Financial And Other Information Statement For Individuals - 2002
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Illinois Department of Revenue
EG-13-I
Financial and Other Information Statement for Individuals
Note:
We may require support for amounts shown on this form.
Step 1: Tell us about yourself and your employment
Debtor’s information
Spouse’s information
1
Marital status
____ single
____ married
If married, complete your spouse’s information to the right.
2
16
Your name ___________________________________________
Spouse’s name _______________________________________
Street address ________________________________________
Address (if different)____________________________________
____________________________________________________
____________________________________________________
City
State
ZIP
City
State
ZIP
3
17
Email address ________________________________________
Email address (if different) _______________________________
4
18
Home phone (_____)________________
Home phone (if different) (_____)________________
5
19
Date of birth ___ ___/___ ___/___ ___ ___ ___
Date of birth ___ ___/___ ___/___ ___ ___ ___
6
20
Social Security number
Social Security number
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ ___ - ___ ___ - ___ ___ ___ ___
7
21
Employer’s name ______________________________________
Employer’s name ______________________________________
Address _____________________________________________
Address _____________________________________________
____________________________________________________
____________________________________________________
City
State
ZIP
City
State
ZIP
8
22
Work phone (_____)________________
Work phone (_____)________________
9
23
Occupation __________________________________________
Occupation __________________________________________
10
24
Average monthly take home pay $________________________
Average monthly take home pay $________________________
11
25
Amounts withheld from your paycheck ( e.g., savings, bonds,
Amounts withheld from your paycheck ( e.g., savings, bonds,
deferred amounts, car payments) $________________________
deferred amounts, car payments) $________________________
12
26
Number of dependents in household _______________________
Number of dependents in household _______________________
13
27
Pay dates and frequency ________________________________
Pay dates and frequency ________________________________
14
28
Length of employment __________________________________
Length of employment __________________________________
15
Name and address of next of kin (other than spouse)
Name _______________________________________________
Address _____________________________________________
____________________________________________________
City
State
ZIP
Step 2: Tell us about other income and property.
Attach an additional sheet, if necessary.
29
33
Other income (source) __________________________________
Your driver’s license number _____________________________
____________________________________________________
Spouse’s driver’s license number _________________________
30
Real property (brief description, location, and value) __________
State issued (you)_________ State issued (spouse)__________
34
____________________________________________________
Name of any business which you are an owner.
____________________________________________________
Business name _______________________________________
31
List the name and address of the banks where you have accounts.
Address _____________________________________________
Name _______________________________________________
____________________________________________________
City
State
ZIP
Address _____________________________________________
35
____________________________________________________
Federal employer identification number (FEIN)
City
State
ZIP
___ ___ - ___ ___ ___ ___ ___ ___ ___
32
36
Vehicle license number
Illinois business tax (IBT) number
_____________________________________
Description___________________________________________
___ ___ ___ ___ - ___ ___ ___ ___
Step 3: Tell us about life insurance policies now in effect
If you have life insurance policies now in effect, complete the following information. Attach an additional sheet, if necessary.
Beneficiary name and
Cash surrender
Balance due
Policy number
Insurance company
relationship
value
on loan
37
________________
_________________________________
_____________________
______________
______________
38
________________
_________________________________
_____________________
______________
______________
Step 4: Tell us if bankruptcy is pending
39
42
Are foreclosure, bankruptcy, receivership, or assignment for
Have you disposed of any assets or property by sale, transfer,
benefit of creditors proceedings pending? ____yes ____no
exchange, gift, or in any other manner except for full value from
40
Bankruptcy number ____________________________________
the beginning of the period in which the liability was incurred to
41
Date filed ___ ___/___ ____/___ ___ ___ ___
the present date? ____yes ____no
If yes, attach a separate
statement showing amounts, dates, circumstances, etc.
EG-13-I front (R-1/02)
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Parent category: Financial