Form Cd Lo-14b - Statement Of Financial Condition For Individuals - Georgia Department Of Revenue

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CD LO-14B (Rev 11/99)
STATEMENT OF FINANCIAL CONDITION
State of Georgia
(If additional space is needed,
FOR INDIVIDUALS
Department of Revenue
attach separate sheet)
The information requested in this statement should 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 Name(s) and Residence Address
2.
Daytime Phone Number
3.
Marital Status (Check One)
[ ] Single
[
] Married
[ ] Separated
[
] Divorced
4.
Social Security Number
5.
Date of Birth
Taxpayer
Taxpayer
Spouse
Spouse
County (
)
Do you own [
] or rent [
] ?
6. Previous Address If At Current Address Less Than 2 Years
7.
Income Tax Return Information
A. Year of Last Filed Federal Income Tax Return
___________
B. Federal Adjusted Gross Income From Last Return $ ___________
C. Year of Last Filed Georgia Income Tax Return
___________
SECTION II – EMPLOYMENT INFORMATION
8.
Taxpayer’ s Employer or Business – Name and Address
9.
10. Occupation
Employer Phone Number
11. Length of Employment
12.
Work Relationship
[ ] Employee [ ] Proprietor
Years _______ Mo. ________
[ ] Partner
[ ] Officer
13. Spouse’ s Employer or Business – Name and Address
14.
Employer Phone Number
15. Occupation
16.
Length of Employment
17.
Work Relationship
[ ] Employee
[ ] Proprietor
[ ] Partner
[ ] Officer
Years ________ Mo. ________
18. Taxpayer’ s Part-time or Previous Employment in Last Three Years
19. Spouse’ s Part-Time or Previous Employment in Last Three Years
Employer’ s Name
Employment Dates
Employer’ s Name
Employment Dates
To
To
To
To
To
To
20. Have your wages or salary been garnished within the previous three years?
Taxpayer [
] Yes [
] No
Spouse
[
] Yes [
] No
SECTION III – DEPENDENT INFORMATION
21. Dependent Name (Other Than Spouse)
Date of Birth
Relationship
Monthly Income
$

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