Financial Information Statement - Kansas Department Of Revenue Page 4
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521 Other information relating to your financial condition. If you check "Yes", please give dates and explain:
Explaination:
a Court proceedings
yes _____
no _____
b Repossessions
yes _____
no _____
c Garnishments
yes _____
no _____
d Anticipated increase in income
yes _____
no _____
e Bankruptcy
yes _____
no _____
Attorney name, address and phone number
Case #
Filing Date
Chapter
Section V
Monthly Income and Expense Analysis
Total Income
Source
Net
Source
Net
22. Wages/salaries (taxpayer)
31. Other (list below)
$
$
23. Wages/salaries (spouse)
$
a.
$
24. Interest, dividends
$
b.
$
25 Net business income
$
c.
$
26. Rental income
$
d.
$
27. Pension (taxpayer)
$
e.
$
28. Pension (spouse)
$
f.
$
29. Child Support
$
g.
$
30. Alimony
$
h.
$
Total Income
$
Necessary Living Expenses (Monthly average)
32. House payment/Rent
45. Court ordered payments (garnishments)
$
$
33. Electric & Gas/ Propane
46. Personal Property Tax
$
$
34. Water/Trash/Sewer
47. Taxes (State and Federal Income Tax)
$
$
35. Cable/Satelite
48. Student loans
$
$
36. Cell phone/home phone
49. Personal loans
$
$
37. Groceries
50. Car loans
$
$
38. Child/dependent care
51. Health Insurance
$
$
39 Clothing
52. Home owners/ Renters Insurance
$
$
40. Credit Card payments
53. Life Insurance
$
$
41. Magazine/newspaper subscriptions
54. Other (list below)
$
$
42. Gas for transportation
$
$
43. Medical Bills
$
$
44 Prescriptions
$
$
$
55. Total Expenses
$
(KDOR use only)
Net difference (income less living expense)
Page 4
revised 11/2011
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