Pa Form 8857 - Request For Relief From Joint Liability Page 11

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SECTION III – GENERAL FINANCIAL INFORMATION (continued)
(Court proceedings, bankruptcies, repossessions, recent transfers of assets for less than full value, anticipated increases
26. Additional Information
in income, condition of health, etc., include information on trusts, estates, retirement plans, etc., on which you are a participant of beneficiary)
SECTION IV – ASSET AND LIABILITY ANALYSIS
(c)
(d)
(e)
(a)
(b)
Current Market
Liabilities
Amount of
Asset or Liability
Description
Value
Balance Due
Monthly Payment
27. Cash
$
28. Bank accounts
29. Stocks, bonds, investments
$
$
30. Cash or loan value of insurance
(model, year, license)
31. Vehicles
a.
b.
c.
32. Real property
a.
b.
c.
33. Other assets
a.
b.
c.
34. Bank revolving credit
35. Other liabilities
a.
(include judgements, notes
and other charge accounts)
b.
c.
d.
36. Federal taxes owed
37. State taxes owed
38. TOTALS
$
$
$
– Page 2 –

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