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         Illinois Department of Revenue

         EG-13-I  Financial and Other Information Statement for Individuals     
         Note: We may require support for amounts shown on this form.
Step 1:   Tell us about yourself and your employment 
Debtor’s information                                                          Employment information                 
 1 Your name   ___________________________________________                    7 Employer’s name _____________________________________ 

    Street address ________________________________________                     Address  ____________________________________________

    ____________________________________________________                        ____________________________________________________
    City                         State                ZIP                       City                  State                      ZIP 
 2 Email address  ________________________________________                    8 Work phone  (_____)________________

 3 Home phone   (_____)________________                                       9 Length of employment  _________________________________ 

  4 Date of birth   ___ ___/___ ___/___ ___ ___ ___         
   
  5 Social Security number  ___  ___  ___  -  ___  ___  -  ___  ___  ___  ___ 

 6  Number of dependents in household _______________________ 

Step 2:   Tell us about other income and property. Attach an additional sheet, if necessary.
10  Real property (brief description and location)  ________________ _________________________________________________________  

    _____________________________________________________________________________________________________________                     
 
    _____________________________________________________________________________________________________________                     
 
 11 List the name and address of the banks where you have accounts.              

    Name_______________________________________________                         Name_______________________________________________

   Address _____________________________________________                        Address _____________________________________________

    ____________________________________________________                        ____________________________________________________ 
    City                        State                 ZIP                       City                  State                      ZIP 

    Name_______________________________________________                         Name_______________________________________________

   Address _____________________________________________                        Address _____________________________________________

    ____________________________________________________                        ____________________________________________________ 
    City                        State                 ZIP                       City                  State                      ZIP 
 
12   Vehicle license number _____________________________________________________________________________________________________

    Vehicle description  _____________________________________________________________________________________________

Step     3:  Tell us if bankruptcy is pending
13  Are foreclosure, bankruptcy, receivership, or assignment for  benefit of creditors proceedings pending?   ____yes  ____no     

14  Bankruptcy number ____________________________________                       

15  Date filed ___  ___/___  ____/___  ___  ___  ___   

EG-13-I front (R-5/12)                                                               Continue to next page....  

Step 4:  Complete the following statement of assets and liabilities
                                 A              B               C            D                    E                                                                          F            G
                                                          Amount of          Monthly                                                                      Date of                   Date of       
                                 Present    Liabilities   equity or asset    payment                                                                                         first        final  
Description                       value    Balance due   (Col. A minus B)    amount         Pledgee or obligee                                            payment                   payment
 16   Bank accounts             _________  _________      _________       _________       __________________                                              ________                  ________ 
  17  Household furniture       _________  _________      _________       _________       __________________                                              ________                  ________
18    Home mortgage             _________  _________      _________       _________       __________________                                              ________                  ________
19    Rental properties         _________  _________      _________       _________       __________________                                              ________                  ________
20    Real property             _________  _________      _________       _________       __________________                                              ________                  ________
21    Vehicles (model/year)
      a  __________________     _________  _________      _________       _________       __________________                                              ________                  ________    
      b  __________________     _________  _________      _________       _________       __________________                                              ________                  ________  
22    Other assets (describe)
      a  __________________     _________  _________      _________       _________       __________________                                              ________                  ________    
      b  __________________     _________  _________      _________       _________       __________________                                              ________                  ________  
23    Federal taxes outstanding _________  _________      _________       _________       __________________                                              ________                  ________
24    State taxes outstanding   _________  _________      _________       _________       __________________                                              ________                  ________
25    Accounts/notes payable    _________  _________      _________       _________       __________________                                              ________                  ________
26    Charge cards 
      a  __________________     _________  _________      _________       _________       __________________                                              ________                  ________    
      b  __________________     _________  _________      _________       _________       __________________                                              ________                  ________  
27    Other (include judgments)
      a  __________________     _________  _________      _________       _________       __________________                                              ________                  ________    
      b  __________________     _________  _________      _________       _________       __________________                                              ________                  ________  
28    Total                     _________  _________      _________       _________                 

Step 5:  Complete the following monthly income and expense analysis
                     Household monthly income                                                    Monthly expenses
               Source                                   Net                              Expense                                                                                   Amount 
 
29   Your take home pay                     ___________________           35  Rent (if no home mortgage in Step 4)  ___________________                                                           
30   Your spouse’s take home pay            ___________________           36  Groceries                                                                   ___________________                     
31   Pensions                               ___________________           37  Monthly payments (from Line 28)                                             ___________________                     
32   Rental income                          ___________________           38  Utilities                                                                   ___________________
33   Other (specify)                                                      39  Auto expenses (i.e., insurance, gas)                                        ___________________
    ________________                        ___________________           40  Child support paid                                                          ___________________
    ________________                        ___________________           41  Other (specify)                                                                                                     
    ________________                        ___________________                ___________________                                                        ___________________                     
    ________________                        ___________________               ___________________                                                         ___________________                     
    ________________                        ___________________               ___________________                                                         ___________________
34    Add Lines 29 through 33.                                            42 Add Lines 35 through 41.                                                                                             
    This amount is your total net income.  ____________________               This amount is your total expenses.                                         ___________________
43   Subtract Line 42 from Line 34. This amount is your monthly net income after expenses.                                                              43 ___________________ 

Step 6:  Sign below
Under penalties of perjury, I state that this statement of assets and liabilities and other information is, to the best of my knowledge, true, correct, 
and complete.
Debtor’s signature______________________________________________________________  Date ___  ___/___  ___/___  ___  ___  ___

Spouse’s signature_____________________________________________________________  Date ___  ___/___  ___/___  ___  ___  ___
                                           
                               This form is authorized as outlined by the Illinois Income Tax Act and the Retailers’ Occupation and related occupation taxes and fees acts.  
EG-13-I back (R-5/12)         Disclosure of this information is REQUIRED. Failure to provide information could result in this form not being processed. 

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