Statement Of Financial Condition For Individuals Page 2

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Income—Not valid without proof of income.

Included?

Yes

1. Bank statements for all accounts (attach bank statements from last two months) ...................................................................... 1

Yes

2. Your paystubs (attach paystubs from last two months) ................................................................................................................. 2

Yes

3. Spouse’s/RDP’s paystubs (attach paystubs from last two months) .............................................................................................. 3

Yes

4. Pension amount (for you and/or spouse/RDP) .............................................................................................................................. 4

Yes

5. Social Security amount (for you and/or spouse/RDP) ................................................................................................................... 5

Yes

6. Other income. List source (rents, unemployment benefits, profit sharing, alimony, child support, etc.) ....................................... 6

___________________________________________________________________________________________________________

Monthly Expenses Actually Paid—Must be reasonable for size of family and location.

Actually paid

7. Mortgage/rent. Provide name and address of landlord ___________________________________________________________ ...... 7

8. Groceries, toiletries, etc. ................................................................................................................................................................ 8

9. Utilities— a. Telephone ................................................................................................................................................................. 9a

b. Electricity ................................................................................................................................................................. 9b

c. Heating oil/natural gas ............................................................................................................................................. 9c

d. Water/garbage ......................................................................................................................................................... 9d

10. Transportation (gas, bus fares) ..................................................................................................................................................... 10

11. Medical (prescriptions and co-pays not paid by insurance) ........................................................................................................ 11

1 2. Auto loans (total of installment payments per month) ................................................................................................................. 12

1 3. Insurance— a. Auto .................................................................................................................................................................... 13a

b. Health/life ........................................................................................................................................................... 13b

c. Homeowner/renter ............................................................................................................................................. 13c

14. Federal (IRS) tax payments ............................................................................................. balance due: $___________________ 14

15. Alimony/child support/work-related child care ............................................................................................................................ 15

16. Other expenses not listed above (property tax, etc.) ................................................................................................................... 16

17. Total monthly expenses. Add lines 7 through 16 ....................................................................................................................... 17

18. Proposed monthly payment to Oregon Department of Revenue .............................................................................................. 18

19. What day of the month can you pay? .......................................................................................................................................... 19

Additional Information—Expected changes to income or health, bankruptcies, repossessions, etc.

Name and address of nearest relative

Telephone no.

Relationship

Authorization to Disclose

Under penalties of perjury, I declare that this financial statement is true, correct, and complete. I/We authorize the department to use my

credit report and other tools for verification and collection purposes.

Date

Your signature

Spouse’s/RDP’s signature

Return this form to: Oregon Department of Revenue

PO Box 14725