Form MD 433-A (Rev. 7-2000) Page 4
Section V Monthly Income and Expense Analysis
Form MD 433-A
Total Income Necessary Living Expenses (Rev. July 2000)
Comptroller’s use Only Collection Information Statement for Individuals
Source Gross Claimed Allowed State of Maryland (If you need additional space, please attach a separate sheet)
31 Wages/salaries (taxpayer) $ 42 National Standard Expenses (1) $$ Comptroller of Maryland
32 Wages/salaries (spouse) 43 Housing and utilities (2) Note: Complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply.
33 Interest, dividends 44 Transportation (3) 1 Taxpayer(s) name(s) and address 2 Home phone number 3 Marital status
34 Net business income 45 Health care ( )
(from Form MD 433-B)
35 Rental income 46 Taxes (income and FICA) 4a Taxpayer’s Social Security number 4b Spouse’s Social Security number
36 Pension (taxpayer) 47 Court ordered payments County ______________________
37 Pension (spouse) 48 Child/dependent care Section I Employment Information
38 Child support 49 Life insurance
5 Taxpayer’s employer or business a How long employed b Business phone number c Occupation
39 Alimony 50 Secured or legally-perfected (name and address)
debts (specify)
40 Other income 51 Other expenses (specify)
d Number of exemptions e Pay period: ! Weekly ! Bi-weekly f (Check appropriate box)
claimed on W-4 ! Monthly ! ________ ! Wage earner
! Sole proprietor
Payday: ___________ (Mon-Sun) ! Partner
6 Spouse’s employer or business a How long employed b Business phone number c Occupation
41 Total income $ 52 Total Expenses $ $ (name and address)
53 (Comptroller’s use only) Net $
difference (income less necessary
living expenses) d Number of exemptions e Pay period: ! Weekly ! Bi-weekly f (Check appropriate box)
claimed on W-4 ! Monthly ! ________ ! Wage earner
! Sole proprietor
Certification Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of Payday: ___________ (Mon-Sun) ! Partner
assets, liabilities, and other information is true, correct, and complete.
54 Your signature 55 Spouse’s signature (if joint return filed) 56 Date Section II Personal Information
7 Name, address and telephone number of 8 Other names or aliases 9 Previous address(es)
next of kin or other reference
Notes
1 Clothing and clothing services, food, housekeeping supplies, personal care products and services, and miscellaneous.
2 Rent or mortgage payment for the taxpayer’s principal residence. Add the average monthly payment for the following expenses if they are not
included in the rent or mortgage payment: property taxes, homeowner’s or renter’s insurance, parking, necessary maintenance and repair, 10 Age and relationship of dependents living in your household (exclude yourself and spouse)
homeowner dues, condominium fees and utilities. Utilities include gas, electricity, water, fuel oil, coal, bottled gas, trash and garbage collection,
wood and other fuels, septic cleaning, and telephone.
3 Lease or purchase payments, insurance, registration fees, normal maintenance, fuel, public transportation, parking, and tolls.
Additional information or comments:
11 Date a Taxpayer b Spouse 12 Last filed income a Number of exemptions b Adjusted gross income
of birth tax return (tax year) claimed
Section III General Financial Information
Comptroller of Maryland Use Only Below This Line
13 Bank accounts (include savings and loans, credit unions, IRA and retirement plans, certificates of deposit, etc.)
Explain any difference between Item 53 and the installment payment amount: Name of Institution Address Type of Account Account No. Balance
Name of Originator Date
Total (Enter in Item 21) ..................................................................................................................................................................................