IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
(ET+) 02-22
OFFICIAL USE ONLY
REV-488
STATEMENT OF
FINANCIAL CONDITION
FOR INDIVIDUALS
If additional space is needed, attach separate sheet
SECTION I TAXPAYER INFORMATION MM/DD/YYYY
Start Taxpayer’s Name Date of Birth SSN
Ü
Taxpayer’s Street Address
City County State ZIP Code
Spouse’s Name (if applicable) Date of Birth SSN
Spouse’s Street Address (if different from above)
City County State ZIP Code
Phone Number Marital Status Number of Exemptions Claimed on W-4
SECTION II EMPLOYMENT INFORMATION
Employer or Business Name
Employer or Business Street Address
City County State ZIP Code
Business Phone Number Occupation Paydays Fill In Appropriate Oval
Wage Earner Partner Sole Proprietor
Spouse’s Employer or Business Name
Employer or Business Street Address
City County State ZIP Code
Business Phone Number Occupation Paydays Fill In Appropriate Oval
Wage Earner Partner Sole Proprietor
SECTION III PERSONAL INFORMATION
Name of Next of Kin or Other Reference Phone Number
Next of Kin or Other Reference Street Address
City County State ZIP Code
Dependents Living in Your Household (exclude husband and wife)
AGE RELATIONSHIP AGE RELATIONSHIP
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