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Your Social



Security Number

23. What is your current average monthly income and expenses for your entire household. If family or friends are helping to

support you, include the amount of support as gifts under Monthly income. Under Monthly expenses, enter all expenses,

including expenses paid with income from gifts.

Monthly income

Amount

Monthly expenses

Amount

Federal, state, and local taxes deducted

Gifts ...............................................................

from your paycheck ......................................

Wages (Gross pay) ........................................

Rent or mortgage..........................................

Pensions ........................................................

Utilities ..........................................................

Unemployment ..............................................

Telephone .....................................................

Social security ...............................................

Food .............................................................

Government assistance, such as housing,

Car expenses, payments, insurance, etc.

food stamps, grants .......................................

Medical expenses, including medical

Alimony ..........................................................

insurance ......................................................

Child support .................................................

Life insurance ...............................................

Self-employment business income ................

Clothing ........................................................

Rental income................................................

Child care .....................................................

Interest and dividends ...................................

Public transportation .....................................

Other income, such as disability payments,

gambling winnings, etc.

Other expenses, such as real estate taxes,

child support, etc.

List the type below:

Type: ______________________________

Type: _____________________________

Type: ______________________________

Type: _____________________________

Type: ______________________________

Type: _____________________________

Total ..............................................................

Total ...............................................................

24. Describe your assets (money and property). Property includes real estate, motor vehicles, stocks, bonds, and

other property that you own. Tell us the amount of cash you have on hand and in your bank accounts. Also give a

description of each item of property, the fair market value of each item, and the balance of any outstanding loans you

used to acquire each item. Do not list any money or property you listed on line 23. If you need more room, attach

more pages.

_____________________________________________________________________________________________

25. Provide any other information you want us to consider in determining whether it would be unfair to hold you liable

for the tax. If you need more room, attach more pages. Write your name and social security number on the top of all

pages you attach.

_____________________________________________________________________________________________

Part VII - Declaration/Signature

Declaration: I declare under penalty of law that I have examined this statement (including any accompanying schedules and statements) and, to the best of my knowledge

and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false statement to DRS is a ﬁ ne of not more than $5,000, imprisonment for not

more than ﬁ ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.

Your signature

Date

Sign Here

Keep a

Paid preparer’s signature

Date

Telephone number

(

)

copy of

this return

Firm’s name, address, and ZIP code