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               Illinois Department of Revenue

               BOA-4                Financial Information Statement for Individuals

Section 1: Tell us about yourself and your employment
Part A: Your information
1 Marital status             single   married    separated
    If married, complete your spouse’s information in Part B.
2 Your name ___________________________________________ 11               Filing status  single                 married filing jointly
    3Street address ________________________________________                            head of household      married filing separately
    ____________________________________________________ 12              Average monthly take-home pay $___________________________
    City                            State      ZIP                    13 Amounts withheld from your paycheck (e.g., savings, bonds,
4 Home phone (____)____________________________________                  deferred amounts, car payments, etc.) $______________________
5 Social Security number ___ ___ ___- ___ ___- ___ ___ ___ ___           ______________________________________________________
6 Unemployed     yes     no  If “yes,” how long._______________       14 Dates paid _____________________________________________
7 Current or former employer’s name ________________________          15 Length of employment____________________________________
8 Address _____________________________________________               16 Date of birth   ___  ___/___  ___/___  ___  ___  ___
    ____________________________________________________ 17              Name and address of next of kin (other than spouse)
    City                            State      ZIP                       Name  ________________________________________________
9 Work phone (_____)____________________________________                 Street address _________________________________________
10  Occupation___________________________________________                ______________________________________________________
                                                                         City                             State               ZIP

Part B: Your spouse’s information

18  Spouse’s name _______________________________________ 25             Work phone(_____)______________________________________
19  Address (if different)____________________________________ 26        Occupation ____________________________________________
    ____________________________________________________ 27              Average monthly take-home pay $___________________________
    City                            State      ZIP                    28 Amounts withheld from your paycheck (e.g., savings, bonds,
20  Home phone (if different)(_____)__________________________           deferred amounts, car payments, etc.) $______________________
21  Social Security number ___ ___ ___-___ ___-___ ___ ___ ___           ______________________________________________________
22  Unemployed        yes      no  If “yes,” how long._______________ 29 Dates paid _____________________________________________
23  Current or former employer’s name ________________________        30 Length of employment____________________________________
24  Address _____________________________________________             31 Date of birth   ___  ___/___  ___/___  ___  ___  ___
    ____________________________________________________
    City                            State      ZIP

Section 2: Complete the following financial information
Note: Attach additional sheets in the same format for any of the following parts if necessary.
Part A:     Your bank accounts (include savings and loans, credit unions, IRA and retirement plans,
and certificates of deposit)

               ABCDE
                                                                                        Type of           Account
         Name of institution                   Address                                  account           number              Balance

32  ______________________          _______________________________________             ___________ ___________              ____________

33  ______________________          _______________________________________             ___________ ___________              ____________

34  ______________________          _______________________________________             ___________ ___________              ____________

35  ______________________          _______________________________________             ___________ ___________              ____________

36  ______________________          _______________________________________             ___________ ___________              ____________

37  ______________________          _______________________________________             ___________ ___________              ____________

38  Add Lines 32 through 37, Column E, and write the total here and on Part G, Line 56, Column B.                 38         ____________
BOA-4 (R-4/01)                                                                                                                Page 1 of 4

Part B: Your charge cards or credit lines from your banks, credit unions, and savings and loans

            ABC
     Type of account                                                                                                       Current
            or card                                Name and address of financial institution                               balance
39 _________________          _______________________________________________________________________                     ___________

40 _________________          _______________________________________________________________________                     ___________

41 _________________          _______________________________________________________________________                     ___________

42 _________________          _______________________________________________________________________                     ___________

43 _________________          _______________________________________________________________________                     ___________

44 Add Lines 39 through 43, Column C, and write the total here and on Part G, Line 57, Column C.                       44 ___________

Part C: Real property you own
                    AB                                                                       C D
            Brief description             How property
            of property                         is titled                  Physical address                                County
45 _____________________________          __________________   _______________________________________                    ___________

46 _____________________________          __________________   _______________________________________                    ___________

47 _____________________________          __________________   _______________________________________                    ___________

Part D: Your life and health insurance policies
                              A                                          BCDE
                                                               Policy                                       Face          Available
                        Insurance company                      number      Type                             amount        loan value
48 __________________________________________________          ___________ ___________                   ___________      ___________

49 __________________________________________________          ___________ ___________                   ___________      ___________

50 Add Lines 48 and 49, Column E, and write the total here and on Part G, Line 60, Column B.                           50 ___________

Part E:     Your securities (e.g., stocks, bonds, annuities, mutual funds, money market funds,
government securities, notes, personal, etc.)
            AB                                                             CDE
            Type                                                                                            Quantity or
            of security                   Location                       Owner of record                 denomination     Present value
51 _________________    ______________________________         _________________________                 ___________      ___________

52 _________________    ______________________________         _________________________                 ___________      ___________

53 Add Lines 51 and 52, Column E, and write the total here and on Part G, Line 61, Column B.                           53 ___________

Part F:     Miscellaneous information

54 a Are foreclosure, bankruptcy, receivership, or assignment for benefit of creditors proceedings pending?  Yes         No

   b What is the bankruptcy number? ______________________

   c What date was the bankruptcy filed? ___ ___/___ ___/___ ___ ___ ___   If closed, what was the date? ___ ___/___ ___/___ ___ ___ ___
                                          Month    Day    Year                                              Month Day      Year

Page 2 of 4                                                                                                               BOA-4 (R-4/01)

Part G: Analyze your assets and liabilities
Note: Write amounts in all unshaded areas that apply

               A             BCDE                                                F                   G
                                                     Equity          Monthly                         Date of
                             Fair market Liabilities (Column B minus payment                         final
         Description         value       balance due Column C)       amount       Pledgee or obligee payment

55 Cash                      ___________ ___________ ___________     ___________ ___________________ ____________
56 Total bank accounts
   from Section 2, Part A,
   Line 38                   ___________ ___________ ___________     ___________ ___________________ ____________
57 Total charge cards balance
   from Section 2, Part B,
   Line 44                   ___________ ___________ ___________     ___________ ___________________ ____________
58 Vehicles (model, year)
a ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
b ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
c ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
59 Real property listed
   in Section 2,
   Part C, (Line 45)         ___________ ___________ ___________     ___________ ___________________ ____________
         (Line 46)           ___________ ___________ ___________     ___________ ___________________ ____________
         (Line 47)           ___________ ___________ ___________     ___________ ___________________ ____________
60 Total cash or loan value
   of insurance from
   Section 2, Part D,
   Line 50                   ___________ ___________ ___________     ___________ ___________________ ____________
61 Total securities from
   Section 2, Part E,
   Line 53                   ___________ ___________ ___________     ___________ ___________________ ____________
62 Other assets (specify)
a ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
b ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
c ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
63 Other liabilities not
   covered above
   (e.g., judgments,
   charities, tuition)
a ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
b ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
c ___________________        ___________ ___________ ___________     ___________ ___________________ ____________
64 Federal taxes owed        ___________ ___________ ___________     ___________ ___________________ ____________
65 State taxes owed
   a Illinois individual
     income tax              ___________ ___________ ___________     ___________ ___________________ ____________
   b Illinois business
     income tax              ___________ ___________ ___________     ___________ ___________________ ____________
   c Other state taxes       ___________ ___________ ___________     ___________ ___________________ ____________

66 Total                     ___________ ___________ ___________     ___________ ___________________ ____________

BOA-4 (R-4/01)                                                                                       Page 3 of 4

Part H: Analyze your monthly income and expenses

                                            Income                                            Necessary monthly living expenses
            ABCA B
   Source                                   Gross                          Net                Expense                                                             Amount

67 Your wages or salary  ___________________                    ___________________       78  Rent (not included
68 Your spouse’s                                                                              in Part G, Line 59)                             ___________________
   wages or salary       ___________________                    ___________________       79  Groceries
69 Interest or dividends ___________________                    ___________________           (number of people____)                          ___________________
70 Business income       ___________________                    ___________________       80  Installment pmts. from
71 Rental income         ___________________                    ___________________           Part G, Line 66, Col. E                         ___________________
72 Your pension          ___________________                    ___________________       81  Utilities                        a  gas         ___________________
73 Your spouse’s pension ___________________                    ___________________                                            b  water       ___________________
74 Child support         ___________________                    ___________________                                            c  electric    ___________________
75 Alimony               ___________________                    ___________________                                            d  telephone   ___________________
76 Other (specify)                                                                        82  Transportation                                  ___________________
   ________________      ___________________                    ___________________       83  Insurance                        a  life        ___________________
   ________________      ___________________                    ___________________           (monthly                         b  health      ___________________
   ________________      ___________________                    ___________________           premiums) c                         home        ___________________
   ________________      ___________________                    ___________________                                            d  car         ___________________
   ________________      ___________________                    ___________________       84  Medical (not covered
   ________________      ___________________                    ___________________           in Line 83b above)                              ___________________
   ________________      ___________________                    ___________________       85  Estimated tax payments                          ___________________
   ________________      ___________________                    ___________________       86  Court-ordered payments                          ___________________
   ________________      ___________________                    ___________________       87  Other (specify)
   ________________      ___________________                    ___________________           __________________                              ___________________
   ________________      ___________________                    ___________________           __________________                              ___________________
   ________________      ___________________                    ___________________           __________________                              ___________________
                                                                                          88  Add Lines 78 through 87.
77 Add Lines 67 through 76, Column C.                                                         This amount is your
   This amount is your total net income.                        ____________________          total expenses.                                 ___________________

89 Subtract Line 88 from Line 77.           This amount is your net income after expenses.                                                 89 ___________________

Part I: Complete any additional asset or income information

90 Write any additional information you have about your assets or income that was not included in any of the preceding parts. Be sure to
   include a statement regarding the prospect of any increase in the value of your assets or your present income.

   _____________________________________________________________________________________________________________

   _____________________________________________________________________________________________________________

   _____________________________________________________________________________________________________________

   _____________________________________________________________________________________________________________

   _____________________________________________________________________________________________________________

   _____________________________________________________________________________________________________________

Section 3: Sign below

Under penalties of perjury, I state that I have examined this statement of assets, liabilities, and other information and, to the best of my
knowledge, it is true, correct, and complete.

______________________________________________/___/_____                   ______________________________________________/___/_____
Petitioner’s signature (not representative)                     Date       Spouse’s signature                                                                     Date

                    This form is authorized as outlined by the Illinois Income Tax Act. Disclosure of this information is REQUIRED. Failure to provide information
Page 4 of 4         could result in this form not being processed. This form has been approved by the Forms Management Center.          IL-492-3683               BOA-4 (R-4/01)

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