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INSTRUCTIONS FOR COMPLETING

FORM M-433(I)

Rev 01/10

Commonwealth of Massachusetts

STATEMENT OF FINANCIAL CONDITION FOR INDIVIDUALS

DEPARTMENT OF REVENUE

Section IV—Monthly Income and Expense Analysis

The Statement of Financial Condition for Individuals, Form

(Items 27-45)

M-433(I) provides the Department of Revenue’s Collections

Bureau with information that will be utilized in evaluating an

This section must report all sources of income, both gross and net,

individual’s financial position. Every item of the financial

earned and/or received on a monthly basis and all sources of

statement must be completed and should reflect accurate

necessary living expenses paid and/or incurred on a monthly basis.

statements and amounts. If an item is not applicable insert

Additional lines have been provided for reporting income and/or

“N/A.” An incomplete Statement of Financial Condition

expense items not already itemized in Section IV. Each entry should

for Individuals will not be considered.

be verified for accuracy. The Department of Revenue may request

The Statement of Financial Condition for Individuals is

supportive documents to substantiate this information.

presented in four segments. Instructions have been provided

Items 27 and 28 should report gross and net income figures obtained

only for items requiring further clarification. Most of the

from your entire wage statements. If you are paid on a weekly

requested items are self-explanatory. However, if you have a

basis, multiply your weekly gross and net salary by 4.3 to arrive at

question, contact the tax examiner handling your case.

your monthly gross and net income.

General Information (Items 1-5)

Item 35 should report total income, both gross and net, from all

income sources listed under items 27-34.

Please verify the Social Security numbers reported in items 1

and 5b to make sure they are correct.

Items 36-43 should report accurate amounts for expenses and

should be verified by examining your records for the last six

Section I—Employment Information (Items 6-15)

months.

Item 38, Total Monthly Payment from Section III—Liabilities,

This section should report all full-time and/or part-time

includes payments on secured or legally perfected debts (car

employers that currently make a payment(s) to you in the form

payments, judgments, etc.). Do not include payments on

of wages, salaries and/or commissions for services performed.

encumbered assets, which are not necessary living expenses (e.g.,

You may use attachments as necessary.

boats, recreational vehicles, etc.).

Section II—Assets (Items 16-23)

Item 40 should report monthly insurance premiums. If insurance

is paid on any frequency other than monthly, compute the monthly

All information furnished in this section should be verified for

amount by dividing quarterly premiums by 3, semi-annual

accuracy. The Department of Revenue may conduct an inquiry

premiums by 6, etc.

to substantiate this information.

Item 41 should report all monthly medical expenses incurred except

Item 18 should report actual cash on hand, not cash in banks or

monthly medical insurance premiums and any major medical debt

other financial institutions.

listed in item 24. This includes, but is not limited to, the cost of

necessary medical products/services not covered by insurance, co-

Item 19 should include any line of credit available to you from

payments for office visits, prescription medication, etc. Health

any source including company credit unions, finance

insurance premiums should be reported in item 40b.

companies, banks, etc.

Item 43 should itemize all other expense categories including child

Item 20 should report insurance information as verified through

support, alimony, personal expenses, automobile maintenance,

your insurance agent.

gasoline etc. Use separate sheet if necessary.

Item 21 should report the current market value of your vehicle(s) as

Item 44 should report total expenses from all liability sources listed

determined in an automobile “blue book” or by other property

under items 36-43.

valuation sources.

Item 46 should report any extraordinary situations such as recent

Item 22 should report all business real estate holdings as well

transfers of assets, court proceedings and anticipated changes in

as your personal residence.

employment. If you have recently filed for bankruptcy, you must

Item 23 should report other assets such as contents of safe deposit

disclose the court and bankruptcy case number. Attach additional

boxes, furniture, recreational vehicles, recreational or hobby tools,

sheet if necessary.

machinery and equipment, and miscellaneous household assets.

Certification (Items 47-49)

Section III—Liabilities (Items 24-26)

Signature by you and/or your spouse certifies that statements and

Item 24 should report all other liabilities and debts owed for

entries contained in the Statement of Financial Condition and/or

major medical bills, dental bills, educational expenses and

accompanying schedules are correct to the best knowledge and

should include any formal promissory note, loan arrangement or

belief of the undersigned. Items 47-49 must provide your signature

financial obligation currently assigned to you.

along with the date your signature was posted. If a joint income

Item 26 should report all other taxes including real estate and

tax return was filed, your spouse’s signature must also be

excise taxes.

provided.

Form M-433(I) - Instructions For Completing Statement Of Financial Condition For Individuals - Department Of Revenue - Massachusetts

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