Form M-433-Ois - Statement Of Financial Condition And Other Information
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12Rev. 6/09
Form M-433-OIS
Massachusetts
Statement of Financial Condition
Department of
and Other Information
Revenue
Complete all entries with the most current information available. For entries that do not apply, enter “N/A” (not applicable). Failure to complete
all applicable entries may result in rejection or delays in the processing of your offer.
Individual and self-employed taxpayers must complete Part 1. Corporate officers, individual partners or responsible persons must also
complete Part 1. Corporations or other business taxpayers must complete Part 2.
Part 1. Individual Information
Name
Social Security number
Date of birth (mm/dd/yyyy)
Spouse’s name
Spouse’s Social Security number
Spouse’s date of birth (mm/dd/yyyy)
Residence address
City/Town
State
Zip
County of residence
Home phone number
Alternate phone number (e.g., cell, work)
1. Marital status (one only):
Single
Married
Other (specify)
2. Type of residence (check one only):
Homeowner
Renter
Other (specify, e.g., share rent, live with relatives, etc.)
3. Length of time at current residence
4. List the dependents you can claim on your tax return. Use additional pages if necessary.
a. Full name
Relationship
Age
Live with you?
Yes
No
b. Full name
Relationship
Age
Live with you?
Yes
No
c. Full name
Relationship
Age
Live with you?
Yes
No
d. Full name
Relationship
Age
Live with you?
Yes
No
5. Complete the following if you are employed. Use an additional page for each employer. Provide proof of gross earnings and deductions from each
employer you had in the past month (e.g., pay stubs, earnings statements, etc.).
Employer’s name
Your occupation
Employer’s address
City/Town
State
Zip
Your work phone number
Length of employment
May we contact you at work?
Yes
No
6. Complete the following if your spouse is employed. Use an additional page for each employer. Provide proof of gross earnings and deductions from
each employer your spouse had in the past month (e.g., pay stubs, earnings statements, etc.).
Employer’s name
Spouse’s occupation
Employer’s address
City/Town
State
Zip
Spouse’s work phone number
Length of employment
May we contact your spouse at work?
Yes
No
7. Complete the following if either you or your spouse is self-employed or owns a business.
Business name
Federal Identification number
Number of employees
Business street address (not PO box)
City/Town
State
Zip
8. Sources of income other than employment or owned business (check all that apply; proof of this income from the prior month may be required):
Pension
Social Security
Other (specify, e.g., child support, alimony, rental, trust, royalty, etc.)
For Privacy Act Notice, see page 12.
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