Financial Information Statement - Kansas Department Of Revenue
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5Kansas Department of Revenue -
FINANCIAL INFORMATION STATEMENT
Compliance and Enforcement
915 SW Harrison
Topeka, KS 66625-2001
(If you need additional space, please attach a separate sheet.)
1. Taxpayer(s) name(s) and address (including county)
2. Home phone number
3. Social Security Number
(
)
Taxpayer
4. Marital status
Spouse
5. Date of Birth
6. Driver License number
Taxpayer
Taxpayer
Spouse
Spouse
Section I.
EMPLOYMENT INFORMATION
7. Taxpayer's employer or business
Number of exemptions How long employed
Business phone
(Check appropriate Box)
(name and address)
claimed on form W-4
(
)
Wage earner
Sole Proprietor
Pay period
Weekly
Bi -weekly
Partner
Monthly
other
Occupation
8. Spouse's employer or business
Number of exemptions How long employed
Business phone
(Check appropriate Box)
(name and address)
claimed on form W-4
(
)
Wage earner
Sole Proprietor
Pay period
Weekly
Bi -weekly
Partner
Monthly
other
Occupation
Section II
PERSONAL INFORMATION
9. Previous address(es)
10. Age and relationship of dependents living in your household (exclude yourself and spouse)
Name:
Age
Relationship
11. Other wage earners or persons living in household
12. Past tax return
Last filed income tax return (State filed in, tax year)
Number of exemptions claimed
Adjusted gross income
Taxpayer
Spouse
Page 1
revised 11/2011
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