Form Eg-13-I - Financial And Other Information Statement For Individuals - 2002 Page 2
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1
2Step 5: Complete the following statement of assets and liabilities
Monthly
Date of
Date of
Amount of
Present
Liabilities
equity
payment
first
final
Description
value
Balance due
or asset
amount
Pledgee or obligee
payment
payment
43
_________
_________
_________
_________
__________________
________
________
Cash
44
_________
_________
_________
_________
__________________
________
________
Bank accounts
45
Stocks and bonds
_________
_________
_________
_________
__________________
________
________
46
_________
_________
_________
_________
__________________
________
________
Accounts/notes receivable
47
_________
_________
_________
_________
__________________
________
________
Household furniture
48
Home mortgage
_________
_________
_________
_________
__________________
________
________
49
_________
_________
_________
_________
__________________
________
________
Rental properties
50
Real property
_________
_________
_________
_________
__________________
________
________
51
Vehicles (model/year)
a ___________________
_________
_________
_________
_________
__________________
________
________
b ___________________
_________
_________
_________
_________
__________________
________
________
52
Other assets (describe)
a ___________________
_________
_________
_________
_________
__________________
________
________
53
Federal taxes outstanding
_________
_________
_________
_________
__________________
________
________
54
_________
_________
_________
_________
__________________
________
________
State taxes outstanding
55
Accounts/notes payable
_________
_________
_________
_________
__________________
________
________
56
Charge cards
_________
_________
_________
_________
__________________
________
________
a ___________________
_________
_________
_________
_________
__________________
________
________
b ___________________
_________
_________
_________
_________
__________________
________
________
57
Other (include judgements)
a ___________________
_________
_________
_________
_________
__________________
________
________
b ___________________
_________
_________
_________
_________
__________________
________
________
c ___________________
_________
_________
_________
_________
__________________
________
________
58
Total
_________
_________
_________
_________
__________________
________
________
Step 6: Complete the following monthly income and expense analysis
Household monthly income
Monthly expenses
Source
Net
Expense
Amount
59
67
Your take home pay
___________________
Rent (if no home mortgage in Step 5) ___________________
60
68
Your spouse’s take home pay
___________________
Groceries
___________________
61
69
Contributions from others
___________________
Monthly payments (from Line 58)
___________________
62
70
Child support/alimony
___________________
Utilities
___________________
63
71
Auto expenses ( i.e. , insurance, gas)
Pensions
___________________
___________________
64
72
Rental income
___________________
Child support paid
___________________
65
73
Other (specify)
___________________
Other (specify)
___________________
________________
___________________
___________________
___________________
________________
___________________
___________________
___________________
________________
___________________
___________________
___________________
66
74
Add Lines 59 through 65.
Add Lines 67 through 73.
This amount is your total net income.
____________________
This amount is your total expenses.
___________________
75
75
Subtract Line 74 from Line 66. This amount is your net income after expenses.
___________________
Step 7: Complete any additional asset or income information
Write any additional information you have about your assets or income that was not included in any of the steps above. Be sure to include a
statement regarding the prospect of an increase in value of your assets or in your present income.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Step 8: Sign below
Under penalties of perjury, I state that this statement of assets and liabilities and other information is, to the best of my knowledge, true,
correct, and complete.
Debtor’s signature______________________________________________________________ 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-492-2430
EG-13-I back (R-1/02)
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