Idaho Comprehensive Financial Statement (CFS)

Comprehensive Financial Statement (CFS)
FORM CFS
CFS

F
O
R
M EFO00122

Idaho State Tax Commission

08-23-10

COMPREHENSIVE FINANCIAL STATEMENT

SECTION 1. PERSONAL INFORMATION
Your first name

MI

Last name

		

MI

Last name			

Your Social Security number	

Your date of birth

Spouse’s Social Security number	

Spouse’s date of birth

Other names and aliases used
Spouse’s first name

Spouse’s other names and aliases used
Number of dependents living with you							
Your current physical address

City

State

Dependent ages
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									
Address

City

□Wage earner
How long employed:
Paid:

Business telephone number
State

□Sole proprietor □Partner
________Year(s) _________Month(s) Occupation:___________________________________________________________

□Weekly □Every two weeks □Monthly □Semi-monthly

Number of allowances claimed on Form W-4:_____________________

Spouse’s employer or business name									
Address

City

□Wage earner
How long employed:
Paid:

Zip Code

Business telephone number
State

Zip Code

□Sole proprietor □Partner
________Year(s) _________Month(s) Occupation:___________________________________________________________

□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.)

Financial Statement Page 2

EFO00122
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	

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

$

Available equity

$

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	

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	

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	

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	

Available equity

$

Loan/Cash value

$

Current value

$

Current value of assets

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

$	

EFO00122
8-23-10

Financial Statement Page 3

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

EFO00122
08-23-10

Financial Statement Page 4

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................................................................................................................................................................. 	

$

EFO00122
08-23-10

Financial Statement Page 5

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

□

Rent
Own
47.
If renting – name, address, and telephone number of landlord

48. Real estate taxes (Is this included in your mortgage payment?)
49. Homeowners / Renters insurance: (
50. Utilities: Electric ($
Cell phone ($
51. Groceries/Food
52. Gifts & entertainment
53. Clothing
54. Auto payments / Lease
55. Auto insurance

) Heating gas / Oil ($
) Phone ($

□

Yes

□

No

) Association fees: (
) Cable ($
) Water / Garbage / Sewer ($

$

)
)
)

EFO00122
08-23-10

Financial Statement Page 6

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 ($
Cell phone ($

) Heating gas / Oil ($
) Phone ($

) Cable ($
) 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