Personal Financial Statement Form - State Of Maine Revenue Services Page 3
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1
2
3Taxpayer’s Name:
SSN
INCOME
Wages and Salaries
Do not enter income from your business here. See instructions on page 4. Must attach pay stub.
Employer
How often paid?
Gross pay per pay period (before deductions)
Taxpayer’s primary job
Taxpayer’s second job
Spouse’s primary job
Spouse’s second job
Business Income
See instructions on page 4.
Business owner:
Average monthly net income
Quarterly estimated income tax payments
Federal
State
Rental Income
See instructions on page 4.
Property
Monthly rental income
Miscellaneous Income
Taxpayer
Spouse
Dependent’s income
Total monthly pension income
Workers’ compensation (total received monthly)
Child support received monthly
Alimony received monthly
Installment payments received monthly (loans, installment sales, etc)
Social security income (monthly)
Public assistance payments received monthly
Other monthly income
EXPENSES
Include the average amount spent each month in each category listed. Do not include expenses shown in any of the categories on pages 1 or 2.
Category
Monthly expense
Category
Monthly expense
Rent or mortgage payment
Groceries
$
$
Utility expense
Transportation expense
$
$
Un-reimbursed medical expense
Un-reimbursed child care expense
$
$
Health insurance
Child support paid (actual payment made)
$
$
Alimony paid
Other necessary expenses
$
$
OTHER FINANCIAL INFORMATION
Circle the applicable answers below and attach a separate sheet with details for each question answered “yes”.
1. Do you have lawsuits currently pending?
Yes
No
2. Have you had property repossessed recently?
Yes
No
3. Have you declared bankruptcy in the last 10 years?
Yes
No
4. Have you had a recent sale or other transfer of assets for less than full value?
Yes
No
5. Are you anticipating increases in income in the next 12 months?
Yes
No
6. Are you a participant or beneficiary of a trust, estate, profit sharing or expected inheritance?
Yes
No
7. Do you have insurance settlements pending?
Yes
No
______________________________________________________________________________________________________________________________________________
Under penalties of perjury, I (we) declare that to the best of my (our) knowledge and belief this statement of assets, liabilities and other financial information is true, correct and
complete. I (we) hereby authorize Maine Revenue Services to obtain a complete and current credit report from any credit reporting agency to confirm certain information
contained in this financial statement.
___________________________________________________________________
_____________________________________________________________________
Taxpayer’s Signature
Date
Spouse’s Signature
Date
3
Rev 03/27/2009
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