Va Form 21-4185 - Report Of Income From Property Or Business Page 2
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1
210
INTEREST ON BUSINESS DEBT
11
OTHER (Explain briefly in Item 13, "Remarks" )
12
TOTAL EXPENSES
$
$
IMPORTANT: Report total gross income in Line 1, total expenses in Line 2, and total net income in Line 3. If the property or
business is owned jointly, report your share of the net income in Line 4 and your fractional share of property ownership in Line 5. List
the name(s), address(es), and fractional share(s) of ownership for all remaining owner(s) in Line 6. If your spouse and/or dependent
child(ren) are joint owners, report their net property or business income in Item 13, " Remarks."
(12B)
(12C)
EXPENSES FOR THE PERIOD
EXPENSES FOR THE PERIOD
(12A)
FROM
THRU
FROM
THRU
LINE
GROSS INCOME, TOTAL EXPENSES, AND NET INCOME
NO.
FROM PROPERTY OR BUSINESS
(If no dates are shown, report expenses
(If no dates are shown, report
for last calendar year)
expenses for current calendar year)
1
GROSS INCOME FROM RENTAL PROPERTY AND BUSINESS
$
$
2
TOTAL EXPENSES (Enter total from line 12, above)
$
$
NET INCOME FROM RENTAL PROPERTY OR RECEIPTS
3
$
$
FROM BUSINESS (Subtract line 2 from line 1)
NOTE: Complete Items 4, 5, and 6 only if property or business is owned jointly.
CLAIMANT'S SHARE OF NET INCOME FROM RENTAL
4
$
PROPERTY OR RECEIPTS FROM BUSINESS
$
SHARE OF PROPERTY OR BUSINESS OWNED BY
5
CLAIMANT (Fractional)
LIST THE NAME(S), ADDRESS(ES), AND FRACTIONAL SHARES(S) OF OWNERSHIP FOR ALL REMAINING OWNERS
6
13. REMARKS
I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge.
14A. SIGNATURE OF CLAIMANT
14B. DATE
15A. DAYTIME TELEPHONE NUMBER (Including Area Code)
15B. EVENING TELEPHONE NUMBER (Including Area Code)
WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK: Signature made by mark must be witnessed by two
persons who know the claimant personally, and the signatures and addresses of such witnesses must be shown below.
16A. SIGNATURE OF WITNESS
16B. PRINTED NAME AND ADDRESS OF WITNESS
17A. SIGNATURE OF WITNESS
17B. PRINTED NAME AND ADDRESS OF WITNESS
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement of a material
fact knowing it to be false.
VA FORM 21-4185, DEC 2011
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