Form 433a - Collection Information Statement For Individuals - West Virginia State Tax Department Page 4

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Section V.
Monthly Income and Expense Analysis
Total Income
Necessary Living Expenses
(State use only)
Source
Gross
Claimed
Allowed
$
31. Wages / Salaries (Taxpayer)
$
42. Housing and utilities
32. Wages / Salaries (Spouse)
43. Transportation
33. Interest – Dividends
44. Health Care
34. Net Business Income (Form 433-B)
45. Taxes (Income and FICA)
35. Rental Income
46. Court ordered payments
36. Pension (Taxpayer)
47. Child / dependent care
37. Pension (Spouse)
48. Life insurance
38. Child Support
49. Other expenses (specify)
39. Alimony
40. Other
Total Income
0.00
.
$
0.00
$
$
Total Expenses
41.
50
$
$
Net differences
51.
0.00
(State use only)
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.
.
52. Your signature
53. Spouse's signature (if joint return filed)
54
Date
State Tax Department Use Only Below This Line
Financial Verification / Analysis
Date Information or
Date Property
Estimate
Item
Encumbrance
Inspected
Forced Sale
Verified
Equity
Real Estate
Vehicles
Other Personal Property
Income Tax Return
Sources of Income / Credit Bureau
Other Assets / Liabilities
Additional information or comments:

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