Personal Financial Statement Form - State Of Maine Revenue Services
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1
2
3PERSONAL FINANCIAL STATEMENT
STATE OF MAINE
Instructions on Page 4
MAINE REVENUE SERVICES
Contact:
Case#:
Taxpayer’s name and address
Spouse’s name and address
SSN
Date of birth
SSN
Date of birth
Home phone #
Cell phone #
Home phone #
Cell phone #
Employer
Employer
Business phone #
Occupation
How long employed?
Business phone #
Occupation
How long employed?
Pay period: Weekly __ Bi-weekly __ Monthly __ Other ________________
Pay period: Weekly __ Bi-weekly __ Monthly __ Other _____________________
Highest level of education attained?
Highest level of education attained?
Age and relationship of others living in your household (exclude self and spouse)
ASSETS
Bank Accounts
(Savings, checking, CDs, share and share draft accounts, similar deposit accounts on banks and credit unions)(add separate sheet if needed)
Name of institution
City
Type of account
Account #
Balance
Credit Cards, Lines of Credit, Loans from Banks, Credit Unions and Other Financial Institutions
Name of institution
Type of account
Credit limit
Amount owed
Monthly payment
Pension Plans
Account holder (employer, funds manager, etc)
Type of pension (401K, IRA, employer, etc)
Loan value
Total value
Real Property
Property 1: Brief description
Property location (town & county)
Mortgage holder
Estimated market value
Amount owed
Payments remaining
Monthly payment
Property 2: Brief description
Property location (town & county)
Mortgage holder
Estimated market value
Amount owed
Payments remaining
Monthly payments
Property 3: Brief description
Property location (town & county)
Mortgage holder
Estimated market value
Amount owed
Payments remaining
Monthly payments
1
Rev 03/27/2009
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Parent category: Financial