Page 4 of 7
Section 3
Personal Asset Information
(Continued)
Total value of vehicles listed from attachment [current market value X .8 less any loan balance(s)]
(6d) $
Add lines (6a) through (6d) = (6)
$
Other valuable items
.
(artwork, collections, jewelry, items of value in safe deposit boxes, etc)
Description of asset:
Current Market Value
Less Loan Balance
= (7a) $
$
X .8 = $
– $
Description of asset:
Current Market Value
Less Loan Balance
$
X .8 = $
– $
= (7b) $
Total value of valuable items listed from attachment [current market value X .8 less any loan balance(s)]
(7c) $
Add lines (7a) through (7c) = (7)
$
Section 4
Business Asset Information (for Self-Employed)
List business assets such as bank accounts, tools, books, machinery, equipment, business vehicles and real property that is
owned/leased/rented. If additional space is needed, attach a list of items. Do not enter a number less than zero.
Cash
Checking
Savings
Money Market
Online Account
Stored Value Card
Bank Name
Account Number
(8a) $
Checking
Savings
Money Market
Online Account
Stored Value Card
Bank Name
Account Number
(8b) $
Total value of bank accounts from attachment
(8c) $
Add lines (8a) through (8c) for total bank account(s) = (8)
$
Description of asset:
Current Market Value
Less Loan Balance
$
X .8 = $
– $
= (9a) $
Description of asset:
Current Market Value
Less Loan Balance
$
X .8 = $
– $
= (9b) $
Total value of assets listed from attachment [current market value X .8 less any loan balance(s)]
(9c) $
Add lines (9a) through (9c) = (9)
$
IRS allowed deduction for professional books and tools of trade – (10) $ [4,290]
Enter the value of line (9) minus line (10). If less than zero enter zero. = (11) $
Notes Receivable
Do you have notes receivable?
Yes
No
If yes, attach current listing which includes name and amount of note(s) receivable.
Accounts Receivable
Do you have accounts receivable?
Yes
No
If yes, you may be asked to provide a list of the Account(s) Receivable.
Box 1 Available Equity in Assets
Do not include amount on the lines with a letter beside the number.
Add lines (1) through (8), and line (11) and enter the amount in Box 1 =
$
433-A (OIC)
Catalog Number 55896Q
Form
(Rev. 5-2012)