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                                                     Utah State Tax Commission
                                210 North 1950 West - Salt Lake City - Utah 84134 - Telephone (801) 297-2200                     TC-805
                                                                                                                                 Rev. 1/09
                                Collection Information For Individuals
Agent’s name

1. Taxpayers’ Names and Addresses (including county)                                    2. Home Telephone Number 3. Marital Status

                                                                                        4. Social Security number
                                                                                        a. Taxpayer:
                                                                                        b. Spouse:
Section One: Employment Information
5. Taxpayer’s Employer or Business Name and Address                                     6. Business Telephone    7. Occupation

                                                                                        8. Paydays               9. Type       Partner   Sole
                                                                                                                               Employee
10. Spouse’s Employer or Business Name and Address                                      11. Business Telephone   12. Occupation

                                                                                        13. Paydays
                                                                                                                 14. Type      Partner   Sole
                                                                                                                               Employee

Section Two: Personal Information
15. Name, Address and Telephone Number of Next of Kin or Other Reference

16. Age and Relationship of Dependents (excluding husband and wife in your household)                            17. Number of Exemptions
                                                                                                                 Claimed on W-4.

18. a. Taxpayer’s Date of Birth                                         b. Spouse’s Date of Birth

Section Three: General Financial Information
19. Latest Filed State Income                                           20. Adjusted Gross Income
Tax Return (Tax Year)
21. Bank Accounts (including savings and loans, credit unions, IRA and retirement plans,
certificates of deposit, money market accounts, savings bonds, etc.)

                                                                                                   Type of       Account
Name of Institution                                  Address                                       Account       Number          Balance

                                                                                                                               $

                                                                                                                 Total         $         0.00
DO NOT mail with your tax return. To insure proper processing, mail separately to: Taxpayer Services Division, 210 North 1950 West, SLC, UT 84134

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                                                                                                                                             TC-805, Page 2
Section Three: General Financial Information Continued
22. Bank charge cards, credit unions, savings and loans, lines of credit, signature loan and other liabilities, including taxes.
   Type of Account                                 Name and Address of                            Credit       Credit                 Amount Monthly
       or Card                                     Financial Institution                          Limit        Available              Owed   Payment

                                                                            TOTAL for 22                $0.00                   $0.00 $0.00  $0.00
23. Safe Deposit Boxes Rented or Accessed (List all locations, box numbers and contents)

24. Real Property (Brief description and type of ownership)                                       Address (Include County and State)
a.

b.

c.

25. Life Insurance (Name of Company)                       Policy Number        Type        Face Amount        Accumulated            Monthly payment
                                                                                                               cash Value
                                                                                          $$$

                                                                  TOTAL for 25            $             0.00 $                  0.00  $         0.00

Section Four: Asset and Liability Analysis
26. Vehicles       Model                     Year                 License #                 Value              Amount owed                   Monthly payment
a.                                                                                        $$$
b.
c.

                                                                      TOTAL for 26        $$$0.00                               0.00            0.00

27. Real property (from item 24)                                                            Value              Amount owed                   Monthly payment
                                 Description
a                                                                                         $$$
b
c

                                                                      TOTAL for 27        $$$0.00                               0.00            0.00

28. Other Assets (recreational vehicles, jewelry, antiques, collectible items, guns, etc.)
                                 Description                                                Value              Amount owed                   Monthly payment
a.
b.                                                                                        $$$
c.

                                                                      TOTAL for 28        $$$0.00                               0.00            0.00
   29. Asset/Payment totals (add totals from lines 22, 25, 26, 27 and 28)                 $$$0.00                               0.00            0.00
DO NOT mail with your tax return. To insure proper processing, mail separately to: Taxpayer Services Division, 210 North 1950 West, SLC, UT 84134

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                                                                                                                                 TC-805, Page 3
Section Five: Monthly Income and Expense Analysis

                              INCOME                                                                   NECESSARY LIVING EXPENSES

           Source                    Gross                        Net                  Type of expense                            Amount

30. Taxpayer’s wages/salaries        $$                                     40. Rent (do not show mortgage listed
(attach 2 most recent check stubs)                                          in item 27)
31. Spouse’s wages/salaries
(attach 2 most recent check stubs)                                          41. Groceries (no. of people ____)                  $
                                                                            42. Payment Totals
32. Interest/Dividends                                                      (from line 29) "Official Use Only"
33. Net business income                                                     43. Utilities (average of last 12 months)
(from form_____)                                                            Gas $______                     Water $_______            0.00
34. Rental income                                                           Electric $_____                 Telephone $_____
                                                                            44. Transportation (bus, fares, gasoline
35. Pension (taxpayer)                                                      maintenance, etc.)
                                                                            45. Insurance
36. Pension (spouse)
                                                                            Home $____                      Health $_____             0.00
37. Child Support                                                                                           Car $______
                                                                            46. Medical
38. Alimony
                                                                            Doctor $______                  Dentist $_____            0.00
39. Other                                                                   Hospitals $_____                Other $______
                                                                            47. Payments made to IRS for
                                                                            delinquent taxes
                                                                            48. Child support

                                                                            49. Estimated tax prepayments
                                                                                                                                      0.00
                                                                            IRS ______                      State ______

                                                                            50. Other expenses (specify)

TOTAL                                $$0.00                            0.00 TOTAL                                               $     0.00

                                                                                                            Net difference      $     0.00

Information contained in this document is subject to verification by the Utah State Tax Commission. You may be required
to provide documentation in support of your statement(s).

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

Your signature: (required)                                        Date      Spouses signature (required if jointly liable)        Date

If you need an accommodation under the American’s with Disabilities Act, contact the Tax Commission at (801) 297-3811 or
Telecommunications Device for the Deaf (801) 297-3819. Please allow three working days for a response.
** Failure to furnish ALL requested information will result in delaying the resolution of your account.
DO NOT mail with your tax return. To insure proper processing, mail separately to: Taxpayer Services Division, 210 North 1950 West, SLC, UT 84134