Fillable Form Cfs - Comprehensive Financial Statement (Page 6 of 6) in pdf

Form Cfs - Comprehensive Financial Statement Page 6

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EFO00122

Financial Statement Page 6

08-23-10

56. Auto maintenance / Fuel

Average daily miles (

)

57. Life / Health insurance (not deducted from your paycheck)

58. Medical payments (not covered by insurance)

59. Estimated tax payments (not deducted from your paycheck)

60. Court ordered payments (alimony, child support, restitution, not deducted from your paycheck)

61. Garnishments (not deducted from your paycheck)

62. Delinquent tax payments (not including Idaho State Tax Commission)

63. Work-related child care expenses

64. Bank cards / Department stores

65. Membership dues: specify

66. Other expenses: specify

67. TOTAL PERSONAL EXPENSES……………………………………………………………………………………………….. .........

Business expenses

(actually paid).

68. Materials purchased

69. Supplies

70. Installment payments

71. Monthly payments

Landlord name, address, and telephone

72. Rent

73. Insurance

74. Utilities: Electric ($

) Heating gas / Oil ($

) Cable ($

)

Cell phone ($

) Phone ($

) Water / Garbage / Sewer ($

)

75. Net wages and salaries (payroll)

76. Current taxes (payroll / business)

77. Other expenses: specify

78. TOTAL BUSINESS EXPENSES……………………………………………………………………………………………….. ..........

net disposable Income

79.

(line 46 minus line 67)………………………………………………………………….. ...................

SECTION 6. AUTHORIZATION TO DISCLOSE

Under penalties of perjury, I declare that this statement of assets, liabilities, and other information is true, correct, and complete. I (we) authorize the

Idaho State Tax Commission to obtain a credit report and to verify any information on this financial statement.

Your signature

Date

Spouse’s signature

Date