Financial Statement Of Debtor (Submitted For Government Action On Claims Due The United States) Page 2
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4
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6SPOUSE/COMPANION
24. List current spouse’s name
25. Social Security No.
26. Birth Date (mo. day yr.)
27. If a spouse’s home address is different list below
28. List spouse’s employer’s name and address
29. Employer’s phone number
(
)
30. Job Title
31. Present employment (Length)
32. Spouse’s gross salary is $------------------------------------------------
Spouse’s take home pay is $---------------------------------------------------------
(Note: If not married, but have a live-in companion, furnish information on this companion in items 24 through 32 above)
DEPENDENTS
33. List all dependents who live with you:
NAME
AGE
RELATIONSHIP
34. List names and addresses of all dependents who do not live with you
NAME/ADDRESS
AGE
RELATIONSHIP
35. List the amount of monthly income received by dependents from any sources other
than you or your spouse
$--------------------------------------------------
36. Total amount of monthly income paid by you or your spouse to dependents
listed in item 34.
$ -------------------------------------------------
37. Does the spouse/companion receive alimony or child support from a previous
marriage? If yes, amount:
$--------------------------------------------------
38. List names and addresses of Parents/In-laws if living.
TAXES
39. Did you file a Federal Income Tax Return last year?
Yes
No
Joint
Individual
Amount of Gross Income on return was
$--------------------------------------------------
40. Are you or did you receive a tax refund from Federal, State, City or County?
Yes
No If yes, list from whom and amount for each refund:
Total Amount
$--------------------------------------------------
41. Do you owe delinquent taxes?
Yes
No If yes, list below years and amounts due:
ATTACH a copy of your last Federal income tax form filed. Include copies of all schedules and attachments to
your income tax returns.
ATTACH a copy of your latest earning statement.
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