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Financial Information Statement

BASIC INFORMATION

Enter the number of people in the household (including you and your spouse):

If you or your spouse are self employed or have self-employment income, provide the following information:

Not counting owner

Important Note: If business is conducted as a sole proprietorship, complete section E1 below. However, if the business is conducted through any of the other entity types described above, skip sections E1 and E2 below and instead upload a copy of the most recent Profit and Loss Statement and Balance Sheet in section E3 below for the entity type selected in this section.

A. ACCOUNTS

Bank Accounts

Include checking, online, mobile (e.g., PayPal), savings accounts, money market accounts.

more bank accounts

Investments

Include Certificates of Deposit, Trusts, Individual Retirement Accounts (IRAs), Keogh Plans, Simplified Employee Pensions, 401 (k) Plans, Profit Sharing Plans, Mutual Funds, Stocks, Bonds, Commodities (Silver, Gold, etc.), and other investments. If applicable, include business accounts.

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Virtual Currency (Cryptocurrency)

List all virtual currency you own or in which you have a financial interest (e.g., Bitcoin, Ethereum, Litecoin, Ripple, etc.).

Use a comma to separate locations

add more virtual currency (cryptocurrency)

B. REAL ESTATE

Include home, vacation property, timeshares, vacant land and other real estate.

add more real estate

C. OTHER ASSETS

Important Notes:

  • Include cars, boats, recreational vehicles and any whole life insurance policies in this section.
  • For cars, boats or recreational vehicles, include make, model and year. If a vehicle is leased, write “lease” in the “Year Purchased” section.
  • For life insurance policies, include name of insurance company (omit term life insurance policies).
  • If self-employed and operating business as a sole proprietorship, include business assets such as tools, equipment, inventory, etc.
  • List “Other Assets” with a brief description such as “Coin Collections, Paintings, Antiques, etc.” If intangible assets, add brief description such as “patent, domain name, copyright, etc.”

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D. CREDIT CARDS

List all credit cards and lines of credit, even if there is no balance owed (and add last 4 digits of account number)

add more non-tax debt

E. BUSINESS INFORMATION

Complete E1 for Accounts Receivable owed to you or your business. Complete E2 if you or your business accepts credit card payments. Include virtual currency wallet, exchange or digital currency exchange.

E1. Accounts Receivable Owed to You or Your Business

List all Accounts Receivable owed to you or your business. Include federal, state and local grants and contracts.

Add the total of “Amount Owned”

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E2. Merchant Account(s)

Complete if you or your business accepts credit card payments (e.g., Visa, MasterCard, etc.) and/or virtual currency wallet, exchange or digital currency exchange.

add more merchant account

E3. Entity Financial Statements

Attach a copy of the most recent Profit and Loss Statement and Balance Sheet for the entity described above in the basic Information Section.

Click or drag file to this area to upload

PDF, SVG, PNG, JPG or GIF (max. 3MB)

F. EMPLOYMENT INFORMATION

If you (or your spouse) have more than one employer, please add additional employment information below or you can upload pay stubs from each employer.

Click or drag file to this area to upload

PDF, SVG, PNG, JPG or GIF (max. 3MB)

Fed

State

Local

add more employment information

Fed

State

Local

add more employment information (your spouse)

G. NON-WAGE HOUSEHOLD INCOME

List monthly amounts. For Self-Employment and Rental Income, list the monthly amount received after expenses or taxes and attach a copy of your current year profit and loss statement.

Based upon Schedule C of your Tax Return

Based upon Schedule E of your Tax Return

Attach Profit and Loss Statement for Self-Employment or Rental Activity

Click or drag file to this area to upload

PDF, SVG, PNG, JPG or GIF (max. 3MB)

Include any other sources of income including distributions from partnerships, subchapter S corporations or limited liability companies.

H. MONTHLY NECESSARY LIVING EXPENSES

List monthly expenses below

1. Food / Personal Care

2. Transportation

3. Housing & Utilities

Do not enter mortgage payments here. Mortgage payments should be listed in section B

4. Medical

5. Other

Divide the quarterly amount due on Form 1040ES by 3

Enter the amount you pay for term life insurance only. For Whole Life Insurance, if there is any “cash surrender value,” enter the amount in Section C

Provide description

add other monthly necessary living expenses (not listed)

(Rev. 11-2-2022)