Form Fs-H - Financial Statement For Claim For Hardship Page 4
Download a blank fillable Form Fs-H - Financial Statement For Claim For Hardship in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Fs-H - Financial Statement For Claim For Hardship with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4If you are currently living with another individual, family or friend, and are paying no monthly expenses,
that individual must read and understand the statement below and then sign and date this form.
Under penalties of perjury, I declare that the named individual(s) on this Financial Statement are currently
residing with me and pay no monthly living expenses.
Printed Name
Signature
Date
Additional Information
Payment Plan Information
List below your requested payment plan arrangements that you can presently make.
Down Payment:
$
Monthly Payment: $
Please explain how you determined these figures:
Under penalties of perjury, I declare that this statement of assets and liabilities and all other information included in this docu-
ment or attached thereto are true and correct to the best of my knowledge and belief. I authorize the Indiana Department of
Revenue to verify any and all facts included in this document.
Your Signature
Date
Spouse’s Signature
Date
Page 6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial