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                                         Financial Information Statement (Personal)

                                         How to Complete This Statement
                                         •    Enter the most current data available in all spaces.
                                         •    Write N/A in spaces that don’t apply to you. The Taxation and Revenue Department may require
                                              additional information to support N/A entries.
                                         Important
                                         Failure to complete all spaces may result in rejection of this document and/or collection action.

Section 1                  1a Your full name                           1b Your social security number                                1c Your date of birth
Personal 
                           1d Spouse’s full name                       1e Spouse’s social security number                            1f Spouse’s date of birth
Information
                           2   Marital status (mark one box)           3   Residence (mark one box)
                                 Married     Separated                  Own home     Rent
                                 Unmarried (single, divorced, widowed)      Other (specify; e.g., share rent, live with relative): 
                           4a Street address                           4b City                                                   State                                       ZIP code  

                           4c County                                   4d How long at this address?                                 5Home phone (with area code)

                           6   List the dependents you can claim on your tax return. If you need more space, attach a separate sheet.
                                                                       Does this person                                                         Does this person
                                First Name          Relationship       Age      live with you?      First Name          Relationship       Age      live with you?
 After filling in all the                                              Yes     No                                                             Yes     No
information in Section 1, 
mark this box.                                                          Yes     No                                                             Yes     No

Section 2                  7   Are you or your spouse self-employed or do you operate a business? If either applies, mark the Yes box.
                                 Yes     No    If Yes, provide the following information:
Your Business 
Information                7a  Name of business                                                     7d  Employer ID no. 
                           7b  Street address                                                       7e  Do you have employees?                   Yes     No
 After filling in all the 7c  City, State, ZIP                                                     7f   Business contact phone  
information in Section 2, 
mark this box.             Attachments Required. Complete and attach Financial Information Statement for Businesses, ACD-31111.  

Section 3                  8a  Your employer                                                      9a  Spouse’s employer
Employment                 8b  Street address                                                     9b  Street address
Information                8c  City, State, ZIP                                                   9c  City, State, ZIP
                           8d  Work phone (with area code)                                        9d  Work phone (with area code)
                           8e  How long with this employer?                                       9e  How long with this employer?
                           8f  Occupation                                                         9f  Occupation
 After filling in all the Attachments Required. Please include proof of gross earnings and deductions for the past 3 months from each employer, such 
information in Section 3,  as pay stubs and earnings statements. If year-to-date information is available, send only one year-to-date statement as long as it 
mark this box.             represents a minimum of 3 months. 
Section 4                  10  Do you receive income from sources other than your own business or your employer? Check all that apply.
                                  Pension     Social Security     Other (specify; e.g., child support, alimony, rental)
Other Income
Information                Attachments Required. Please include proof of pension/social security/other income for the past 3 months from each payor, 
                           including any statements showing deductions. If year-to-date information is available, send only one year-to-date statement as long 
                           as it represents a minimum of 3 months.     
Section 5                  11    Checking Accounts. List all checking accounts. If you need more space, attach a separate sheet.
Banking,                           Type of      Full name of bank, savings and loan,                Bank                  Bank                                               Current
                                   Account     credit union, or financial institution               Routing Number        Account Number                                     Account Balance
Investment, Cash, 
Credit, and Life           11a  Checking   Name                                                                                                                            $
Insurance Info                              Street address 
                                           City, State, ZIP
 After filling in all the 
information in Sections 4  11b  Checking   Name                                                                                                                            $
and 5, which continues on                   Street address  
the next page, and after                   City, State, ZIP
providing all attachments, 
mark this box.             11c   Total Checking Account Balances      ................................................................................................ 11c $ 
ACD-31110                                                                                                                 Section 5 continues on the next page
int. 01/07/2014

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Financial Information Statement (Personal) Page 2 of 5

Name_______________________________________________ Social security number_____________________________

Section 5 12 Other Accounts. List all accounts, including brokerage, savings, and money market accounts not listed on line 11.
Banking, Type of Full name of bank, savings and loan, Institution Institution Current
Account credit union, or financial institution Routing Number Account Number Account Balance
Investment, Cash,
Credit, and Life 12a Name of institution $
Insurance Info Street address
(continued) City, State, ZIP
12b Name of institution $
Street address
City, State, ZIP
12c Subtotal from Supplement Page (page 5) ......................................................................................... 12c $
12d Total Other Account Balances .................................................................................................... 12d $
Attachments Required. Please include current bank statements (e.g., checking, savings, money market, and brokerage accounts)
for the past 3 months for all accounts.
13 Investments. List all investment assets, including stocks, bonds, mutual funds, stock options, certificates of deposits, and
retirement assets, such as IRAs, Keoghs, and 401(k) plans. If you need more space, attach Supplemental Page (page 5).
Number of *Current Used as collateral Loan Net Value
Company Name Shares/Units Value (a) on loan? Amount (b) (a-b)
* For Current Value, 13a $  Yes  No $ $
enter the amount you 13b $  Yes  No $ $
could sell the asset for
today. 13c Subtotal from Supplemental Page (page 5) .................................................................. .................... 13c $
13d Total Net Investments ............................................................................................................ 13d $
14 Cash On Hand. Enter the total amount of any cash you have that is not currently in a bank. ............. 14 $
15 Available Credit. List all lines of credit, including credit cards. If you need more space, attach Supplemental Page (page 5).
Full name of credit institution Credit Limit Amount Owed Available Credit
15a Name $ $ $
Street address
City, State, ZIP
15b Name $ $ $
Street address
City, State, ZIP
15c Subtotal from Supplement Page (page 5) ......................................................................................... 15c $
15d Total of Available Credit .............................................................................................................. 15d $
16 Life Insurance. Do you have life insurance with a cash value? ....................................................................  Yes  No
(Term life insurance doesn’t have a cash value.) If Yes, answer 16a through 16f and include attachments.
16a Name of insurance company
16b Policy number(s)
16c Owner of policy
16d Current cash value .......................................................................................... 16d $
16e Outstanding loan balance ................................................................................ 16e $
 After filling in all the
information and providng 16f Total Cash Value. Subtract line 16e from line 16d and enter the difference ...................................... 16f $
all the attachments for Attachments Required. Please include a statement from the life insurance companies that shows type and cash/loan value amounts.
Section 5, mark this box. If life insurance is currenlty borrowed against, include the loan amount and the date of the loan.
Section 6 17 Federal Taxes. Do you owe any federal taxes? ...........................................................................................  Yes  No
Federal and Other If Yes, how much? $ Amount of payment $
Taxes Owed 17a Other Taxes. Do you owe any other government agency? ............................................................................  Yes  No
If Yes, what is the name of the agency?
How much do you owe? $ Amount of payment $
Section 7 18 Other Information. Answer the following questions related to your financial situation. If you need more space, attach a
separate sheet.
Other
Information 18a Are there any garnishments against you or your spouse’s wages? ...................................................................  Yes  No
If Yes, who is the creditor? Date creditor obtained judgement
Amount of debt $
18b Are there any judgements against you? .........................................................................................................  Yes  No
 After filling in all the
information in Sections 6 If Yes, who is the creditor? Date creditor obtained judgement
and 7, mark this box. Amount of debt $

ACD-31110 Section 7 continues on the next page
int. 01/07/2014

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Financial Information Statement (Personal)                                                                                                                                                Page 3 of 5
    
Name________________________________________________     Social security number_____________________________

Section 7                  18c  Are you party in a lawsuit? ...........................................................................................................................       Yes     No
                                   If Yes, amount of suit  $                                       Possible completion date
Other                              Subject matter of suit                                    
Information
(continued)                18d  Have you ever filed bankruptcy? ...................................................................................................................  Yes     No
                                   If Yes, date filed                                              Date discharged
                           18e  In the past 10 years, have you transferred any assets out of your name for less than their actual value? ...........  Yes     No           
                                   If Yes, what asset?
                                   When was it transferred?                                        To whom or where was it transferred?
                           18f   Do you anticipate any increase in household income in the next 2 years? ........................................................  Yes     No
                                   If Yes, why will the income increase? If you need more space, attach a sheet.
                                   How much will it increase?  $                                    per month     per year
                           18g  Are you a beneficiary of a trust or an estate? .................................................................................................  Yes     No
                                   If Yes, name of the trust or estate
                                   Anticipated amount to receive?  $                               When do you expect to receive it?
 After filling in all the 
information in Section 7,  18h  Are you a participant in a profit sharing plan? ................................................................................................  Yes     No
mark this box.                     If Yes, name of plan                                            Value in plan  $
Section 8                  19    Purchased and Leased Automobiles, Trucks, and Other Licensed Assets. List all licensed assets, including boats, RVs, 
                                   motorcycles, and trailers. If you need more space, attach a separate sheet.
Assets and                                                                                 *Current        Loan/Lease       Name of                Purchase/Lease      Monthly
Liabilities                        Description                                              Value                Balance            Lender/Lessor      Date                      Payment
* For Current Value,       19a  Year                      
enter the amount you               Make/model
could sell the asset for           Mileage                                               $                   $                                                                           $
today.
                           19b  Year                      
                                   Make/model
                                   Mileage                                                   $                   $                                                                           $
                           20    Real Estate. List all real estate you own. If you need more space, attach a separate sheet.
                                   Street Address               Date              Purchase   *Current             Loan          Name of Lender                                Monthly     ** Date of
                                   City, State, ZIP                  Purchased    Price            Value               Balance     or Lien Holder                             Payment          Final Payment
** For Date of Final       20a
Payment, enter the date 
the loan or lease will be 
fully paid.
                                    County                                               $               $                $                                             $
                           20b

                                    County                                               $               $                $                                             $
                           Attachments Required. Please include your current statement from lender, showing the monthly payment amount and the current 
                           balance for each piece of real estate you own.                                  
                           21    Personal Assets. List all personal assets. If you need more space, attach a separate sheet.
                                   Furniture/Personal Effects includes the total current market value of your household, such as furniture and appliances.
                                   Other Personal Assets includes all artwork, jewelry, collections (e.g., coins and ceramic figures), antiques, or other assets.
                                                                                           *Current        Loan           Name of                          Monthly             ** Date of
                                   Description                                              Value(a)           Balance       Lender                             Payment          Final Payment
                           21a  Furniture/Personal Effects                    $                  $                                                       $
                               
                                   Other Personal Assets (list below)
                           21b  Artwork                                                  $                  $                                                       $
                           21c  Jewelry                                                   $                  $                                                       $
                           21d                                                                   $                  $                                                       $
                           21e                                                                   $                  $                                                       $
                           21f                                                                    $                  $                                                       $
                           21g                                                                   $                  $                                                       $
 After filling in all the 
information and providng   21h                                                                   $                  $                                                       $
all the attachments for 
Section 8, mark this box.  21i                                                                    $                  $                                                       $

ACD-31110                                                                                                                                          Section 9 begins on the next page
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Financial Information Statement (Personal) Page 4 of 5

Name_______________________________________________ Social security number_____________________________

Section 9 Total Monthly Income Total Monthly Expenses
Monthly Income Source Gross Net Expense Items Actual TRD Use
and Expense 22 Wages (yours) $ $ 33 Rent/Mortgage $
Analysis 23 Wages (spouse’s) $ $ 34 Groceries (# of people _____) $
24 Interest, Dividends $ $ 35 Installment Payments $
If only one spouse has 25 Net Income From Business $ 36 Utilities
a tax liability, but both
spouses have income, 26 Net Rental Income $ 36a Gas $
list the total household 27 Pension/Social Security (yours) $ $ 36b Water $
income and expenses.
28 Pension/Social Security (spouse’s) $ $ 36c Electric $
29 Child Support $ 36d Phone $
30 Alimony $ 36e Total Utilities Expense $
31 Other Income $ $ 37 Transportation $
32 TOTAL INCOME $ $ 38 Insurance
38a Life $
38b Health $
38c Car $
38d Total Insurance Expense $
39 Medical Expenses $
40 Estimated Tax Payments $
41 Court Ordered/Child Support Payment $
42 Child/Dependent Care $
43 Other Expenses $
44 TOTAL LIVING EXPENSES $
45 NET DIFFERENCE. Subtract Total Living Expenses (line 44) from Total Net Income (line 32) $
Wages, Salaries, Pensions, and Social Security. Enter your gross monthly wages and/or salaries. Enter your net income and
deduct withholding or allotments you elect to take out of your pay, such as insurance payments, credit union deductions, and car
payments. Calculate your gross monthly wages and/or salaries as described next, depending on how often you are paid.
• If paid weekly: Multiply your weekly gross wages by 4.3. For example, $425.89 x 4.3 = $1,831.33.
• If paid bi-weekly (every 2 weeks): Multiply your bi-weekly gross wages by 2.17. For example, $972.45 x 2.17 = $2,110.22.
• If paid semi-monthly (twice each month): Multiply your semi-monthly gross wages by 2. For example, $856.23 x 2 = $1,712.46.
Net Income From Business. Enter your monthly net business income. This is the amount you earn after you pay ordinary and
necessary monthly business expenses. If your net business income is a loss, enter 0. Do not enter a negative number.
Net Rental Income. Enter your monthly net rental income. This is the amount you earn after you pay ordinary and necessary monthly
rental expenses. If your net rental income is a loss, enter 0. Do not enter a negative number.
Rent/Mortgage. For your principal residence, enter the total of rent or mortgage payment. Add the average monthly expenses for
property taxes, homeowner’s or renter’s insurance, maintenance, dues, and fees.
Groceries. Total of food expenses for one month.
Transportation. Total of lease or purchase payments, registration fees, normal maintenance, fuel, public transportation, parking, and
tolls for one month.
Medical Expenses. List medical expenses not covered by insurance.
Attachments Required. Please include the following attachments:
• Proof of all current expenses that you paid for the past 3 months, including utilities, rent, insurance, and property tax.
• Proof of all non-business transportation expenses (e.g., car payments, lease payments, fuel, oil, insurance, parking, and registration).
 After filling in all the • Proof of all payments for healthcare for the past 3 months, including health insurance premiums, co-payments, and other out-of-
information and providng pocket expenses.
all the attachments for • Copies of any court orders requiring payment and proof of such payments for the past 3 months (e.g., cancelled checks, money
Section 9, mark this box. orders, and earning statements showing these types of deductions).
Failure to complete all entry spaces may result in rejection of this document and/or collection action.
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.
 After filling in all the
information, providng all Your signature Date
the attachments for all
sections, and signing,
mark this box. Spouse’s signature Date
ACD-31110 Supplement Page for other accounts on the next page
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Financial Information Statement (Personal) Page 5 of 5

Name_______________________________________________ Social security number_____________________________

Supplemental Page
for Investment, Bank, Credit, and Other Accounts
List additional accounts not listed on page 2, showing the full name of the investment company, bank, savings and loan, credit, or other
financial institution.

A Company Name Street Address City, State, ZIP

Type of Account
 Investment account No. Shares/Units Current Value (a) Used as collateral on loan? Loan Amount (b) Net Value (a-b)
$  Yes  No $ $
 Credit account Credit Limit Amount Owed Available Credit
$ $ $
Other type of account: Routing No. Account No. Current Balance
$

B Company Name Street Address City, State, ZIP

C Company Name Street Address City, State, ZIP

D Company Name Street Address City, State, ZIP

a. Subtotal of Investment Account Net Values. List here and on page 2, line 13c .................................................................... a $
b. Subtotal of Other Account Current Balances. List here and on page 2, line 12c ................................................................... b $
c. Subtotal of Credit Available. List here and on page 2, line 15c .............................................................................................. c $

ACD-31110
int. 01/07/2014

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