Form 150-860-009 - Statement Of Financial Condition For Individuals
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2Clear Form
Statement of Financial
For Revenue Use Only
Due date
Condition for Individuals
Date received
• Please complete both sides, sign, and date this form.
Revenue agent
• Attach additional sheets as needed to list more information.
Your Information
Name and address
Social Security no.
Home no.
Cell no.
Work no.
Birthdate
Date hired
Employer
Job title
Paydays
Employer address and payroll phone no.
Exemptions claimed
Spouse/Registered Domestic Partner (RDP) Information
Name and address
Social Security no.
Home no.
Cell no.
Work no.
Birth date
Employer
Job title
Date hired
Paydays
Employer address and payroll phone no.
Exemptions claimed
Dependents Who Live With You (include age and relationship):
Bank Accounts—Include accounts in savings and loans and credit unions, certificates of deposit, individual retirement accounts (IRAs), and funds held
in safe deposit boxes.
Type of account
Name of institution
Branch
Account no.
Balance
(checking/savings)
Credit Cards, Loans, Lines of Credit—May be allowed, with proof, if used for monthly living expenses.
Minimum
Name of credit card/bank
Address and telephone no.
Credit limit
Amount owed
monthly payment
Real Estate Property—Including personal, rental, business, etc.
Current
Mortgage
Unpaid
Name and telephone number of
Address (including county)
assessed value
balance
property tax
person/bank that you pay
Motor Vehicle—List even if paid in full.
Name and telephone number of
Date loan will be
Loan balance
Year/make/license number/state
person/bank that you pay
paid in full
Other Assets You Own or are Currently Buying—Include stocks, bonds, boats, etc.
Name and telephone number of
Description
Current value
Loan balance
person/bank that you pay
Continued ➔
150-860-009 (Rev. 10-11)
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Parent category: Financial