Form Cd Lo-14b - Statement Of Financial Condition For Individuals - Georgia Department Of Revenue Page 4

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CD LO-14B (Rev. 11/99)
Page 4
SECTION VIII – INCOME & EXPENSE ANALYSIS
42. Monthly Household Disposable Income
Gross Monthly Income
Monthly Living Expenses
Source
Taxpayer
Spouse
Source
Amount
Salary, Wages, Commissions, Tips
$
$
House or Rent Payment
$
Self-Employment Income
Income Taxes (Federal, State, FICA)
Pensions, Disability & Social Security
Estimated Tax (If Applicable)
Dividends & Interest
Groceries
Gift or Loan Proceeds
Medical Expenses & Prescriptions
Rental Income
Utilities:
Estate, Trust & Royalty Income
Electric $_______ +
Gas $________+
Workers’ Comp. & Unemployment
Water
$_______+ P hone $________=
Alimony & Child Support
Insurance:
Other (Specify)
Life
$_______+ Health $ _______+
Auto
$_______+ Home $________=
Court Ordered Payment
Personal Loan Payment
Religious & Charitable Donations
Clothing & Personal Grooming
Entertainment & Recreation
Legal Fees
Transportation Expense
Vehicle Loan Payment
Vehicle Lease Payment
Property & Ad Valorem Taxes
Child Care
Installment & Credit Card Payments
Tuition Payment
Other (Specify)
Subtotal
$
$
Combined Monthly Income $
Total Monthly Living Expenses
$
43. Net Monthly Household Disposable Income (“Combined Monthly Income” Minus “Total Monthly Living Expenses”) $
I/we have examined this Statement of Financial Condition for Individuals and hereby affirm that to the best of my/our knowledge
and belief, it is true, correct and complete.
Taxpayer’ s Signature
_______________________________________________________ Date __________________________
Spouse’ s Signature
_______________________________________________________ Date __________________________
POA Signature
_______________________________________________________ Date __________________________
(Attach Power of Attorney - Use Department of Revenue Form RD-1061 Only)

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