Form R-20223 Fillable Statement of Financial Condition for Individuals
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

Employee Partner Separated Single Yes No Yes No Bankruptcy Case Number Yes No If No identify tax type and period Yes No If Yes date the offer was approved or declined Yes No If Yes explain Yes No If Yes identify Yes No If Yes identify Relationship Yes No N/A If Yes date discontinued (: 1) Unchecked (: 1) Unchecked (: 1) Unchecked (: 1) Unchecked (: 1) Unchecked (: 1) Unchecked (: 1) Unchecked (: 1) Unchecked (: 2) Unchecked (: 2) Unchecked (: 2) Unchecked (: 2) Unchecked (: 2) Unchecked (: 2) Unchecked (: 2) Unchecked (: 2) Unchecked (: 3) Unchecked (: 3) Unchecked (: 4) Unchecked (: 4) Unchecked (Add Taxpayer and Spouse Monthly Income ) $ (Attach Power of Attorney Form R 7006 ) (checkbox) Unchecked (mm/dd/yyyy) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) *If additional lines are needed check this box and attach additional pages noting line number and description + Auto $ + Home $ = + Water $ + Phone $ = 1 Taxpayer(s) Name(s) and Residence Address 2 Daytime Telephone Number 10 Occupation 11 Length of Employment 12 Work Relationship 13 Spouse s Employer or Business Name and Address 14 Employer Telephone Number 15 Occupation 16 Length of Employment 17 Work Relationship 18 Taxpayer(s) Part time or Previous Employment in Last Three Years 19 Spouse s Part time or Previous Employment in Last Three Years 20 Have your wages or salary been garnished within the last three years? Taxpayer 21 Dependent Name (Other than Spouse) Date of Birth Relationship Monthly Income 22 Cash Total (Enter also on Line 30 A ) $ 23 Bank or Credit Union Accounts (Checking Savings Certificate of Deposit etc )* 24 Bank Credit Cards (Visa MasterCard Discover American Express etc )* 25 Securities (Stocks Bonds Mutual Funds IRA Government Securities Money Market Funds etc )* 26 Real Property (Personal Residence Vacation or Second Home Investment Property Unimproved Land etc )* 27 Vehicles Excluding Leased Vehicles (Including Motor Homes Campers Motorcycles Boats Trailers etc )* 28 Other Assets* 29 Liabilities (Do Not Include Any Mortgages or Vehicle Loans) 3 Marital Status (Mark One ) 30 Assets (Section IV) 31 Liabilities (Total of Section V Line 29) $ 32 Net Worth (Total Assets from Line 30 minus Total Liabilities from Line 31) $ 33 Are you currently in filing compliance with all Louisiana taxes? 34 If the tax liability was incurred in the operation of a business has the business been discontinued? 35 Have you disposed of any assets or property by sale transfer exchange gift or in any other manner during the past 18 months? 36 Is a foreclosure proceeding pending on any real estate that you own or have an interest in? 37 Is anyone holding any assets on your behalf? 38 Are you a party to any lawsuit now pending? 39 Do you anticipate any significant change in your current income levels or financial situation within the next four years? 4 Social Security Number 40 Have you previously petitioned the Louisiana Department of Revenue for an Offer in Compromise for any tax liability within the last ten years? 41 Are you or any business that you own currently under bankruptcy court jurisdiction? 42 Monthly Household Disposable Income 43 Net Monthly Household Disposable Income (Subtract Total Monthly Living Expenses from Combined Monthly Income ) $ 5 Date of Birth 6 Previous Address if at Current Address Less than Two Years 7 Income Tax Return Information 8 Taxpayer(s) Employer or Business Name and Address 9 Employer Telephone Number A Cash (Section IV Line 22) $ A Year of Last Filed Federal Income Tax Return Alimony and Child Support Amount Owed Equity in Property Amount Owed Equity in Vehicle B Bank or Credit Union Accounts (Section IV Line 23) B Federal Adjusted Gross Income from Last Return $ Bank Revolving Credit Baton Rouge LA 70896 6658 C Bank Credit Cards (Section IV Line 24) C Year of Last Filed Louisiana Income Tax Return Cash Surrender Value of Life Insurance Child Care Clothing and Personal Grooming Collectibles Antiques or Artwork Combined Monthly Income correct and complete Court Ordered Payment Current Market Current or Appraised Value Current or Appraised Value Current Value D Securities (Section IV Line 25) Denomination Description Address Description Make Dividends and Interest Divorced E Real Property (Section IV Line 26) Education or Student Loans Electric $ + Gas $ Employer Name Employment Date Employer Name Employment Date Entertainment and Recreation Estate Trust and Royalty Income Estimated Tax (If Applicable) F Vehicles (Section IV Line 27) for Individuals Formal Installment Agreement for Individuals G Other Assets (Section IV Line 28) Gift or Loan Proceeds Groceries GROSS MONThLY INCOME MONThLY LIVING ExPENSES House or Rent Payment $ How long at this address? Years Months Do you own I/We have examined this Statement of Financial Condition for Individuals and hereby affirm that to the best of my/our knowledge and belief it is true Income Taxes (Federal State FICA) Installment & Credit Card Payments Installment or Personal Loans Insurance: Judgments or Settlements Receivable Judgments Payable Legal Fees Life $ + Health $ Louisiana Department of Revenue Married Medical Expenses and Prescriptions MM DD YY Name of Institution Account Number Type of Account Balance Name of Issuer Account Number Credit Limit Amount Owed Credit Available No Spouse Notes Payable $ Notes Receivable $ Officer or rent Other (Specify ) Other (Specify ) Other Liabilities: P O Box 66658 Past Due Federal Taxes Past Due Other Taxes $ Past Due State Taxes Patents or Copyrights Pensions Disability and Social Security Personal Loan Payment Power of Attorney Signature Date Property and Ad Valorem Taxes Proprietor Purchase Quantity or R 20223 (6/13) R 20223 (6/13) Religious and Charitable Donations Rental Income Salary Wages Commissions Tips $ Section I Personal Information Section II Employment Information Section III Dependent Information Section IV Assets as of Section V Liabilities as of Section VI Net Worth Calculation Section VII Other Information Section VIII Income and Expense Analysis Self Employment Income Source Taxpayer Spouse Source Amount Spouse Spouse and dependent information are required even though only one person is liable for the tax Spouse Signature Date Statement of Financial Condition Subtotal $ Taxpayer Taxpayer Signature Date The information provided in this statement must include all household employment assets liabilities income and expenses Timber Mineral or Drilling Rights $ Total (Enter also on Line 30 B ) $ Total (Enter also on Line 30 C ) $ Total (Enter also on Line 30 D ) $ Total (Enter also on Line 30 E ) $ Total (Enter also on Line 30 F ) $ Total (Enter also on Line 30 G ) $ Total (Enter also on Line 31 ) $ Total Amount Owed Total Amount Owed Total Assets (Add Lines 30A 30G ) $ Total Monthly Living Expenses $ Transportation Expense Tuition Payment Type Issuer Unemployment Utilities Value Vehicle Lease Payment Vehicle Lease: Make Year Vehicle Loan Payment Vested Retirement Account Workers Compensation and Year Tag Number Years Months