Hawaii Statement of Financial Condition and Other Information

Statement of Financial Condition and Other Information
CM-2 (Rev. 2018), Statement of Financial Condition and Other Information
Clear Form

Form CM - 2
(Rev. 2018)

Department of Taxation - State of Hawaii
STATEMENT OF FINANCIAL CONDITION AND OTHER INFORMATION

Section I.

General Information - For Individuals

1. Taxpayer(s) name(s) and address

5a. Taxpayer's birth date

b. Spouse's birth date

2. Home phone no.

3. Marital status

4a. Taxpayer's social security no.

b. Spouse's social security no.

6. Other names or aliases

7. Name, age, social security number, and relationship of dependents living in your household.

Section II.

Employment Information

8. Taxpayer's employer or business
(name and address)

a. How long employed?

b. Business phone no.

d. Check appropriate item
( ) Wage earner
( ) Sole proprietor
9. Spouse's employer or business
(name and address)

a. How long employed?

( ) Partner

c. Business phone no.

d. Check appropriate item
( ) Wage earner
( ) Sole proprietor

Section III.

c. Occupation

c. Occupation

( ) Partner

General Financial Information

10. Bank accounts (include Savings & Loans, Credit Unions, IRA and Retirment Plans, Certificate of Deposits, etc.)
Attach additional sheets as necessary.
Name of Institution

Address

Type of Account

Account No.

Balance

Total (Enter in Item 17)

CM2_I 2018A 01 VID01

ID NO 01

Form CM-2 Page 1

Section III.

General Financial Information - continued

11. Charge cards, lines of credit (attach additional sheets as necessary).
Type of Account
Name and address of Financial Institution
or Card

Monthly
Payment

Credit
Limit

Amount
Owed

Credit
Available

Total (Enter in Item 25)
12. Safe deposit boxes rented or accessed (List all locations, box numbers, and contents.)

13. Real and lease property (Brief description and type of ownership)

Physical Address (include tax map key)

14. Life Insurance (Name of Company)

Type

Policy Number

Face Amount

Total (Enter in Item 19)
15. Securities (stocks, bonds, mutual funds, money market funds, etc.) Attach additional sheets if needed.
Quantity or
Current
Where
Kind
Denomination
Value
Located

Loan Value

Owner
of Record

Form CM-2 Page 2

Asset and Liability Analysis

Section IV.

Current
Market
Value

Description

Liabilities
Balance
Due

Equity
in
Asset

Amount of
Monthly
Payment

ASSETS
16. Cash
17. Bank accounts (from Item 10)
18. Securities (from Item 15)
19. Cash or loan value of Insurance (from Item 14)
20. Accounts Receivable
21. Merchandise Inventory
22. Vehicles (Model, year, license)
a.
b.
c.
23. Real property (from Item 13)
a.
b.
c.
24. Other assets
a.
b.
c.
d.
e.
f.
Total Assets
LIABILITIES
25. Bank revolving credit (from Item 11)
26. Loan on Insurance
27. Accounts payable
28. Notes payable
29. Mortgages
30. Judgments
31. Other liabilities
a.
b.
c.
d.
e.
f.
Total Liabilities
Form CM-2 Page 3

Monthly Income and Expense Analysis

Section V.
Income
Source

Gross

Net

Necessary Living Expenses

32. Wages/Salaries (Taxpayer)

43. Rent

33. Wages/Salaries (Spouse)

44. Groceries (no. of people ______)

34. Interest - Dividends

45. Utilities (Gas _______ Water _______

35. Net business income

Electric _______ Phone _______)

36. Rental Income

46. Transportation

37. Pension (Taxpayer)

47. Insurance (Home _______ Car ______

38. Pension (spouse)

Life _______ Health _______)

39. Child Support

48. Medical

40. Alimony

49. Estimated tax payments

41. Other

50. Court ordered payments
51. Other expenses (please specify)

42. Total Income

52. Total Expenses
53. Net difference (income less necessary

Certification
54. Your signature

living expenses)
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.
55. Spouse's signature (if joint return was filed)
56. Date

Form CM-2 Page 4