Form M-433(I) - Statement Of Financial Condition For Individuals (Page 2 of 2) in pdf

Form M-433(I) - Statement Of Financial Condition For Individuals Page 2

M-433 (I) Rev. 01/10

Page 2

SECTION III—LIABILITIES

Type of Account

Name and Address of

Monthly

Credit

Balance

Credit

24. Other Liabilities

or Card

Financial Institution

Payment

Limit

Owed

Available

(Include car payments,

judgments, notes and

other charge accounts)

25. Federal Taxes Owed

26. Other Taxes Owed

SECTION IV—MONTHLY INCOME AND EXPENSE ANALYSIS

(a) Income

(b) Necessary Living Expenses

Source

Gross/Month

Net/Month

27. Wages/Salaries (taxpayer)

36. Rent/Mortgage (circle) Payment

28. Wages/Salaries (spouse)*

37. Groceries/Food

38. Total Monthly Payment from

29. Interest—Dividends

Section III—Liabilities

30. Net Business Income

39. Utilities—Water, Electric,

(From Form M-433 B)

Telephone, etc.

31. Rental Income

40. Insurance (monthly)

32. Pension (taxpayer)

a. Homeowners

Source:

b. Life and Health Premiums

33. Pension (spouse)*

c. Automobile

Source:

41. Monthly Medical Expenses

42. Estimated Tax Payments (only if you

34. Other (you and spouse)*

are currently making payments)

(federal-state)

43. Other Expenses (child support, etc.)

(specify)

44. TOTAL MONTHLY

35. TOTAL MONTHLY INCOME

LIVING EXPENSES

* Item s 28, 32 and 34 must be completed if you are married even if your spouse is not liable for the tax.

This information is necessary in order for us to calculate household income and expenses.

45. Net Difference (income less necessary

living expenses)

46.

Additional Information (Court proceedings, bankruptcies, repossessions, transfers of assets within 18 months, anticipated increases in income, condition of

health, etc.) Include information on trusts, estates, profit-sharing plans, etc., on which you are a participant or beneficiary. Attach additional sheet.

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.

47. Your Signature

48. Spouse’s Signature (if joint return was filed)

49. Date

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