Form Cd Lo-14b - Statement Of Financial Condition For Individuals
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CD LO-14B (Rev 02/03)
STATEMENT OF FINANCIAL CONDITION
State of Georgia
(If additional spac e is needed,
FOR INDIVIDUALS
Department of Revenue
attac h separate s heet)
The information provided in this statement must include all household income and expense.
Spouse and dependent information are required although only one person may be liable for the tax.
SECTION I – PERSONAL INFORMATION
1.
Taxpayer’s Nam e(s) and Residen ce Addr ess
3.
Marital Status (Check One)
2.
Daytim e Phon e Number
[ ] Single
[ ] Married
[ ] Separ ated
[
] Divorced
4.
Social Securit y Number
5.
Date of Birth
Taxp ayer
Taxpayer
Spouse
Spouse
County (
)
Do you o wn [ ] or r ent [ ] ?
7.
In come T ax Return Inform ation
6. Previous Address If At Curr ent Addr ess Less Than 2 Years
A. Year of Last Filed Fed eral Incom e Tax Return
___________
B. Fed eral Adjusted Gross Incom e From Last Return $ ___________
C. Year of Last Filed Georgia Income Tax Return
___________
SECTION II – EMPLOYMENT INFORMATION
8.
Taxp ayer’s Emplo yer or Bu siness – Nam e and Addr ess
10. Occupation
9.
Employer Phone Number
11. Length of Emplo ym ent
12.
W ork Relationship
[ ] Emplo yee [ ] Propr ietor
Year s _______ Mo. ________
[ ] Partner
[ ] Officer
13. Spouse’s Emplo yer or Business – Nam e and Addr ess
15. Occupation
14.
Emp lo yer Phone Number
16.
Length of Emplo yment
17.
W ork Relationship
[ ] Emplo yee
[ ] Proprietor
[ ] Partner
[ ] Officer
Year s ________ Mo. ________
18. Taxpayer’s Part-time or Previous Emplo ym ent in Last Three Years
19. Spouse’s Part-Time or Previous Emplo ym ent in Last Thr ee Years
Emplo yer’s Name
Emplo ym ent Dates
Emplo yer ’s N ame
Emplo ym ent Dates
To
To
To
To
To
To
20. Have your wages or salar y been garnished within the previous three year s?
Taxpayer [
] Yes [
] No
Spouse
[
] Yes [
] No
SECTION III – DEPENDENT INFORMATION
21. Dependent Nam e (Other Th an Spouse)
Date of Birth
Relationship
Monthly In come
$
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