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m CFSEFO00122                                Idaho State tax CommISSIon
  08-23 10-

                                ComPRehenSIVe FInanCIaL Statement

 SECTION 1.  PERSONAL INFORMATION
 Your first name                                 MI             Last name                   Your Social Security number                Your date of birth

 Other names and aliases used

 Spouse’s first name                         MI              Last name                      Spouse’s Social Security number    Spouse’s date of birth

 Spouse’s other names and aliases used

 Number of dependents living with you                                               Dependent ages

 Your current physical address                                         City                               State          Zip Code   Home telephone number

 Your mailing address (if different from above)                                          City                                                      State                 Zip Code

 Previous address (if at current address less than 2 years)                      City                                                      State                 Zip Code

 Your cell phone number                                                                  Spouse’s cell phone number

 E-mail address

 Name and address of nearest relative not living with you

 Relationship                                                                      Telephone number of relative

 SECTION 2.  EMPLOYMENT INFORMATION
 Your employer or business name                                                                                                     Business telephone number

 Address                                                                                   City                                                                            State               Zip Code

 □Wage earner         □Sole proprietor      □Partner 
 How long employed:    ________Year(s)  _________Month(s)   Occupation:___________________________________________________________  
 Paid:     □Weekly    □Every two weeks    □Monthly    □Semi-monthly      Number of allowances claimed on Form W-4:_____________________
 Spouse’s employer or business name                                                                                                 Business telephone number

 Address                                                                                   City                                                                            State                Zip Code

 □Wage earner         □Sole proprietor      □Partner 
 How long employed:    ________Year(s)  _________Month(s)   Occupation:___________________________________________________________  
 Paid:     □Weekly    □Every two weeks    □Monthly    □Semi-monthly       Number of allowances claimed on Form W-4:_____________________
 How will you get the funds for your offer?  (Example:  savings, loan, credit card, borrow from family, etc.)

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EFO00122 Financial Statement Page 2
08-23 10-

SECTION 3. GENERAL FINANCIAL INFORMATION (Personal and Business)
Bank accounts. Include IRA and retirement plans, certificates of deposit, etc. For all accounts, attach copies of your last three statements. Attach
additional pages as needed.
Name of institution Address Type Date opened Account number Balance

TOTAL. Enter this amount on line 2, Section 4 (Asset and Liability Analysis) ........ $

Vehicles. Attach additional pages as needed.
Year, make, model, license number Lender/Lien holder Current market value Current payoff Available equity

TOTAL. Enter this amount on line 3, Section 4 (Asset and Liability Analysis) ........ $

Personal Property. Include watercraft, RV’s, ATV’s, aircraft, business equipment, and/or machinery. Attach additional pages as needed.
Year, make, model, license number Lender/Lien holder Current market value Current payoff Available equity

TOTAL. Enter this amount on line 4, Section 4 (Asset and Liability Analysis) ........ $

Life Insurance. Attach additional pages as needed.
Name of insurance company Agent’s name and telephone number Policy number Whole life or term Loan/Cash value

TOTAL. Enter this amount on line 5, Section 4 (Asset and Liability Analysis) ........ $

Securities. Include stocks, bonds, mutual funds, money market funds, securities, etc. Attach additional pages as needed.
Type Where located Owner of record Quantity or denomination Current value

TOTAL. Enter this amount on line 6, Section 4 (Asset and Liability Analysis) ........ $

Safe deposit Boxes. Include locations, box numbers, and contents. Attach additional pages as needed.
Name of institution Address Box identification Current value of assets

TOTAL. Enter this amount on line 7, Section 4 (Asset and Liability Analysis) ........ $

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EFO00122 Financial Statement Page 3
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SECTION 3. GENERAL FINANCIAL INFORMATION (Personal and Business)–continued
Real Property. Attach additional pages as needed.
A. Physical address and description (single family dwelling, multi-family dwelling, lot, etc.) Mortgage lender’s name and address

Purchase date:____________ Purchase price:_______________ Mortgage payoff amount:_________________ Current value:_______________
B. Physical address and description (single family dwelling, multi-family dwelling, lot, etc.) Mortgage lender’s name and address

Purchase date:____________ Purchase price:_______________ Mortgage payoff amount:_________________ Current value:_______________
C. Physical address and description (single family dwelling, multi-family dwelling, lot, etc.) Mortgage lender’s name and address

Purchase date:____________ Purchase price:_______________ Mortgage payoff amount:_________________ Current value:_______________

TOTAL. (Current values A, B, and C minus mortgage payoff) Enter this amount on line 19, Section 4 (Asset and Liability Analysis) .... $

Credit Cards. Attach additional pages as needed.
Type of account Name and address of creditor Monthly payment Credit limit Credit available Amount owed

Total $
TOTAL. Enter this amount on line 21, Section 4 (Asset and Liability Analysis) ...... $

transfers, Repossessions, etc. List any vehicles, equipment, or property sold, given away, or repossessed during the past year.
Attach additional pages as needed.
Year, make, model of vehicle, or property address Who took possession and relationship Date of transfer

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EFO00122 Financial Statement Page 4
08-23 10-

SECTION 4. ASSETS AND LIABILITY ANALYSIS
Current assets.
1. Cash
2. Bank accounts / Balance (from Section 3)
3. Vehicles / Available equity (from Section 3)
4. Personal property (from Section 3)
5. Loan / Cash value of life insurance (from Section 3)
6. Securities (from Section 3)
7. Safe deposit box value of contents (from Section 3)
8. Notes
9. Accounts receivable
10. Judgments / Settlements received or pending
11. Interest in trusts
12. Interest in estates
13. Partnership interests
14. Other assets: major machinery / equipment
15. Other assets: business inventory
16. Other assets: collectibles / guns / jewelry / coins / gold / silver, etc.
17. Other assets: specify
18. Other assets: specify
19. Current real estate equity (from Section 3)
20. TOTAL ASSETS ...................................................................................................................................................................... $

Current Liabilities. Include judgments, notes, and other charge accounts. Don’t include vehicle or home loans.

21. Lines of credit (amount owed) (from Section 3)
22. Taxes owed to IRS
23. Liabilities owed to other Idaho agencies
24. Other liabilities: specify
25. Other liabilities: specify
26. Other liabilities: specify
27. TOTAL LIABILITIES ................................................................................................................................................................ $

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EFO00122                                                                                                                                                           Financial Statement Page 5
08-23 10-

 SECTION 5.  MONTHLY INCOME AND EXPENSE ANALYSIS
 Income.   Attach copies of all income sources that contribute to household expenses.
                                                                                                                                         Gross                              Net
 28.  Wages / Salaries / Tips (yours)
 29.  Pension (yours)
 30.  Overtime / Bonuses / Commissions (yours)
 31.  Wages / Salaries / Tips (spouse’s)
 32.  Pension (spouse’s)
 33.  Overtime / Bonuses / Commissions (spouse’s)
 34.  Business income (yours)
 35.  Business income (spouse’s)
 36.  Rental income
 37.  Interest / Dividends / Royalties (average monthly)
 38.  Payments from trust / Partnerships / Entities
 39.  Child support
 40.  Alimony
 41.  Unemployment
 42.  Disability
 43.  Seller carried contracts / Sales
 44.  Other income:  specify
 45.  Other income:  specify
 46.  TOTAL INCOME:……………………………………………………………………………………………………………………… ...    $

 Personal expenses (actually paid).
                                                                                                                                                                               Monthly Amount
 47.   □ Rent    □ Own
 If renting – name, address, and telephone number of landlord

 48.  Real estate taxes  (Is this included in your mortgage payment?)    □ Yes       □ No
 49.  Homeowners / Renters insurance:  (                                        )  Association fees: (                                )
 50.  Utilities:   Electric ($                         )   Heating gas / Oil ($                         )  Cable ($                          )                     
                  Cell phone ($                         )  Phone ($                          )  Water / Garbage / Sewer ($                          )
 51.  Groceries/Food
 52.  Gifts & entertainment
 53.  Clothing
 54.  Auto payments / Lease
 55.  Auto insurance

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EFO00122 Financial Statement Page 6
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56. Auto maintenance / Fuel Average daily miles ( )
57. Life / Health insurance (not deducted from your paycheck)
58. Medical payments (not covered by insurance)
59. Estimated tax payments (not deducted from your paycheck)
60. Court ordered payments (alimony, child support, restitution, not deducted from your paycheck)
61. Garnishments (not deducted from your paycheck)
62. Delinquent tax payments (not including Idaho State Tax Commission)
63. Work-related child care expenses
64. Bank cards / Department stores
65. Membership dues: specify
66. Other expenses: specify
67. TOTAL PERSONAL EXPENSES……………………………………………………………………………………………….. ......... $

Business expenses (actually paid).
68. Materials purchased
69. Supplies
70. Installment payments
71. Monthly payments
Landlord name, address, and telephone

72. Rent
73. Insurance
74. Utilities: Electric ($ ) Heating gas / Oil ($ ) Cable ($ )
Cell phone ($ ) Phone ($ ) Water / Garbage / Sewer ($ )
75. Net wages and salaries (payroll)
76. Current taxes (payroll / business)
77. Other expenses: specify
78. TOTAL BUSINESS EXPENSES……………………………………………………………………………………………….. .......... $

79. net disposable Income (line 46 minus line 67)………………………………………………………………….. ................... $

SECTION 6. AUTHORIZATION TO DISCLOSE
Under penalties of perjury, I declare that this statement of assets, liabilities, and other information is true, correct, and complete. I (we) authorize the
Idaho State Tax Commission to obtain a credit report and to verify any information on this financial statement.
Your signature Date Spouse’s signature Date

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