Form 40pa - Idaho Payment Agreement Request Page 4
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4EFO00208p2
Finanical Statement Page 2
05-18-12
INCOME
Monthly Amount
Do you have income from self-employment? If so, please list the name and address of the business and your
average monthly income. ____________________________________________
________________________________________________________________________ .........................................
$
$
Your Income - includes wages and/or retirement
Gross: $ ________________ .................................. Net
$
Spouse’s income - includes wages and/or retirement
Gross: $ ________________ .................................. Net
(Copies of your last two pay stubs required)
$
Social Security .................................................................................................................................................................
$
Rental income ..................................................................................................................................................................
$
Investment income ...........................................................................................................................................................
$
Child support ....................................................................................................................................................................
$
Alimony .............................................................................................................................................................................
$
Other income (please list) ________________________________________________________ ..............................
Income Total
$
EXPENSES
Monthly Amount
$
House payment or rent ....................................................................................................................................................
$
2nd mortgage or other property ........................................................................................................................................
$
Car and truck payments - total of all payments ...............................................................................................................
$
Car maintenace and gas .................................................................................................................................................
$
Groceries .........................................................................................................................................................................
Balance Owed
Utilities:
$
Power ................................................................................ __________________ ...................................................
$
$
Gas ................................................................................... __________________ ...................................................
$
$
Water and garbage ........................................................... __________________ ..................................................
$
$
Cell phone ........................................................................ __________________ ..................................................
$
$
Home phone ..................................................................... __________________ ..................................................
$
$
Cable or satellite TV ......................................................... __________________ ..................................................
$
$
Internet .............................................................................. __________________ ..................................................
$
Credit Cards (please list):
$
___________________________________________
$
__________________ ..................................................
$
___________________________________________
$
__________________ ..................................................
$
___________________________________________
$
__________________ ..................................................
$
___________________________________________
$
__________________ ..................................................
$
Hospital, medical labs, and other service providers ............ __________________ ..................................................
$
$
Child support payments ....................................................... __________________ ..................................................
$
$
Life insurance ....................................................................... __________________ ..................................................
$
$
Health insurance.................................................................... __________________ ..................................................
$
$
Idaho State Tax Commission ............................................... __________________ ..................................................
$
$
Internal Revenue Service (IRS) ........................................... __________________ ..................................................
$
Other expenses (please list):
$
__________________________________________
$
__________________ ..................................................
$
__________________________________________
$
__________________ ..................................................
$
__________________________________________
$
__________________ ..................................................
$
__________________________________________
$
__________________ ..................................................
$
Expense Total
$
Income Minus Expenses
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