Clear Form

Form CM - 2                                      Department of Taxation - State of Hawaii
 (Rev. 2018)
                           STATEMENT OF FINANCIAL CONDITION AND OTHER INFORMATION
 
Section I.                     General Information  -  For Individuals
1.  Taxpayer(s) name(s) and address                   2.  Home phone no.                       3.  Marital status

                                                      4a.  Taxpayer's social security no.      b.  Spouse's social security no.

5a.  Taxpayer's birth date b.  Spouse's birth date    6.  Other names or aliases

7.  Name, age, social security number, and relationship of dependents living in your household.

Section II.                                  Employment Information
8.  Taxpayer's employer or business        a.  How long employed?        b.  Business phone no.                              c.  Occupation
     (name and address)

                                           d.  Check appropriate item
                                                (   )   Wage earner          (   )   Sole proprietor          (   )   Partner

9.  Spouse's employer or business          a.  How long employed?        c.  Business phone no.                              c.  Occupation
     (name and address)

                                           d.  Check appropriate item
                                                (   )   Wage earner          (   )   Sole proprietor          (   )   Partner

Section III.                                 General Financial Information
10.  Bank accounts (include Savings & Loans, Credit Unions, IRA and Retirment Plans, Certificate of Deposits, etc.)  
     Attach additional sheets as necessary.
Name of Institution                           Address                      Type of Account           Account No.                            Balance

                                                                                               Total (Enter in Item 17)

CM2_I 2018A 01 VID01                                  ID NO 01                                                               Form CM-2   Page 1Form CM-2   Page 1

Section III.                       General Financial Information   -   continued
11.  Charge cards, lines of credit  (attach additional sheets as necessary).
   Type of Account Name and address of Financial Institution                Monthly           Credit             Amount         Credit
           or Card                                                          Payment            Limit              Owed       Available

                                                                                           Total (Enter in Item 25)
12.  Safe deposit boxes rented or accessed (List all locations, box numbers, and contents.)

13.  Real and lease property (Brief description and type of ownership)           Physical Address  (include tax map key)

14.  Life Insurance (Name of Company)           Policy Number                     Type       Face Amount       Loan Value

                                                                            Total (Enter in Item 19)
15.  Securities (stocks, bonds, mutual funds, money market funds, etc.)  Attach additional sheets if needed.
                     Quantity or      Current                                    Where                                   Owner
           Kind    Denomination        Value                                    Located                               of Record

                                                                                                                        Form CM-2   Page 2

Section IV.                                          Asset and Liability Analysis 
                                                     Current Liabilities Equity   Amount of
                                                     Market  Balance     in       Monthly
Description                                          Value   Due         Asset    Payment
ASSETS
16.  Cash
17.  Bank accounts (from Item 10)
18.  Securities (from Item 15)
19.  Cash or loan value of Insurance (from Item 14)
20.  Accounts Receivable
21.  Merchandise Inventory
22.  Vehicles (Model, year, license)
       a.
       b.
       c.
23.  Real property (from Item 13)
       a.
       b.
       c.
24.  Other assets
       a.
       b.
       c.
       d.
       e.
       f.
                                    Total Assets
LIABILITIES
25.  Bank revolving credit (from Item 11)
26.  Loan on Insurance
27.  Accounts payable
28.  Notes payable
29.  Mortgages
30.  Judgments
31.  Other liabilities
       a.
       b.
       c.
       d.
       e.
       f.
                                    Total Liabilities

                                                                                  Form CM-2   Page 3

Section V.                                                   Monthly Income and Expense Analysis 
                                                 Income
           Source                                      Gross Net             Necessary Living Expenses
32.  Wages/Salaries (Taxpayer)                                   43.  Rent
33.  Wages/Salaries (Spouse)                                     44.  Groceries (no. of people ______)
34.  Interest  -  Dividends                                      45.  Utilities (Gas _______ Water _______
35.  Net business income                                                Electric _______ Phone _______)
36.  Rental Income                                               46.  Transportation
37.  Pension (Taxpayer)                                          47.  Insurance (Home _______ Car ______
38.  Pension (spouse)                                                   Life _______ Health _______)
39.  Child Support                                               48.  Medical
40.  Alimony                                                     49.  Estimated tax payments
41.  Other                                                       50.  Court ordered payments
                                                                 51.  Other expenses (please specify)

42.  Total Income                                                52.  Total Expenses
                                                                 53.  Net difference (income less necessary
                                                                        living expenses)
        Certification          Under penalties of perjury, I declare that to the best of my knowledge and belief this statement
                               of assets, liabilities, and other information is true, correct, and complete.
54.  Your signature                                          55.  Spouse's signature (if joint return was filed) 56.  Date

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