Form Fs - Idaho State Tax Commission Financial Statement
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1
2F
FS
O
IDAHO STATE TAX COMMISSION
R
M
EFO00208
FINANCIAL STATEMENT
05-18-12
Your Name
Spouse’s Name
Cell phone number
Cell phone number
Daytime phone number
Daytime phone number
Address
Address
Social Security Number
Age
Spouse’s Social Security Number
Age
Employer
How long?
Employer
How long?
Email address/webpage
Email address/webpage
Number of dependent children living with you:
Children’s ages:
Are there any other persons living with you? Please attach an explanation.
Name, address and phone number of a close living relative:
BANKING, INVESTMENT INFORMATION, and ACCOUNTS RECEIVABLE
Bank Accounts
Account Numbers
Balance
Name of bank
Checking #
Name of bank
Checking #
Name of bank
Savings #
Name of bank
Savings #
Retirement / 401K
Stocks and bonds
Does anyone owe you money? Please list names and reason below.
If self-employed and using a credit card machine at place of business, please list Routing Transaction Number (RTN).
REAL ESTATE and MORTGAGE LOANS
Year
Value of
Amount
Payment
Name of Lender
Acquired
Property
Owed
Amount
MOTOR VEHICLES
Including cars, trucks, motorcycles, camp trailers, boats, ATVs, snowmobiles, etc.
Balance
Payment
Date Paid
Year
Make
Model
Value
Owed
Amount
Lien Holder
In Full
AUTHORIZATION TO DISCLOSE: Under penalties of perjury, I declare that this statement of assets, liabilities, and
other information on pages 1 and 2 of this form 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
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