Form Crs-13f-2.0 - Financial Statement Of Debtor Page 3
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4D. SPOUSE/COMPANION
•
By providing this information, you are not indicating spouse liability for invoice
•
Spouse information is voluntary, however if bills listed in spouse name, their income is required.
•
If not married but have a live-in companion, you may choose to furnish information on this companion below.
Current Spouse’s Name:
Birth Date (mm/dd/yy):
If spouse’s home address is different, list:
Employer Name:
Employer Phone:
Employment length:
Job Title:
Gross salary: $
Take home pay: $
E. DEPENDENTS
Name
Age
Relationship
F. TAXES
•
Must attach a copy of your last filed Federal income tax form
☐ Yes
☐ No
Did you file a Federal Income Tax Return last year?
If Yes, ☐ Joint ☐ Individual
Amount of Gross Income on return was $
☐ Yes
☐ No
Are you or did you receive a tax refund from Federal, State, City or County?
If yes, list from whom and amount for each refund:
Entity:
$
Entity:
$
Entity:
$
Entity:
$
☐ Yes
☐ No
Do you owe delinquent taxes?
If yes, list below, years and amounts due:
Entity:
Year:
Amount Due: $
Entity:
Year:
Amount Due: $
G. ASSETS
REAL PROPERTY: FARM/LAND/VACATION HOME/RENTAL
☐ Yes
☐ No
Are you buying the home in which you live?
Are you buying or do you own real property other than your home? ☐ Yes
☐ No
Property Description
Value
Equity
Is any of the above property owned jointly another? ☐ Yes ☐ No
If yes, list property and the name of the co-owner:
Property:
Co-Owner:
Property:
Co-Owner:
CASH
Provide name of the bank or financial institution, and the amount in each account or on deposit:
Name of Bank or Institution
Balance
Name of Bank or Institution
Balance
Check Account $
Money Market Account $
Certificate of Deposit $
Savings Account $
Credit Union Account $
IRA or Keogh Account $
CRS-13F-2.0, CRS Financial Statement Form - Individual
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