Kentucky Statement of Financial Condition for Individuals & Instructions

Statement of Financial Condition for Individuals & Instructions
12A638&I
INSTRUCTIONS FOR COMPLETING

12A638(I) (8-04)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE

STATEMENT OF FINANCIAL CONDITION FOR INDIVIDUALS

The Statement of Financial Condition for Individuals, Form
12A638, provides the Department of Revenue’s Division of
Collections with information that will be utilized in evaluating
an individual’s financial position. Every item of the financial
statement must be completed and should reflect accurate
statements and amounts. If an item is not applicable insert “N/
A.” An incomplete Statement of Financial Condition for
Individuals may not be considered.
The Statement of Financial Condition for Individuals is
presented in four segments. Instructions have been provided
only for items requiring further clarification. Most of the
requested items are self-explanatory. However, if you have a
question, call (502) 564-4921.
General Information (Items 1–5)
Please verify the Social Security numbers reported in items 1
and 5b to make sure they are correct.
Section I—Employment Information (Items 6–15)

Section IV—Monthly Income and Expense Analysis
(Items 27–45)
This section must report all sources of income, both gross and net,
earned and/or received on a monthly basis and all sources of
necessary living expenses paid and/or incurred on a monthly basis.
Additional lines have been provided for reporting income and/or
expense items not already itemized in Section IV. Each entry should
be verified for accuracy. The Department of Revenue may request
supportive documents to substantiate this information.
Items 27 and 28 should report gross and net income figures obtained
from your entire wage statements. If you are paid on a weekly
basis, multiply your weekly gross and net salary by 4.3 to arrive at
your monthly gross and net income.
Item 35 should report total income, both gross and net, from all
income sources listed under items 27–34.
Items 36–43 should report accurate amounts for expenses and
should be verified by examining your records for the last six
months.

This section should report all full-time and/or part-time
employers that currently make a payment(s) to you in the form
of wages, salaries and/or commissions for services performed.
You may use attachments as necessary.

Item 38, Total Monthly Payment from Section III—Liabilities,
includes payments on secured or legally perfected debts (car
payments, judgments, etc.). Do not include payments on
encumbered assets, which are not necessary living expenses (e.g.,
boats, recreational vehicles, etc.).

Section II—Assets (Items 16–23)

Item 40 should report monthly insurance premiums. If insurance
is paid on any frequency other than monthly, compute the monthly
amount by dividing quarterly premiums by 3, semi-annual
premiums by 6, etc.

All information furnished in this section should be verified for
accuracy. The Department of Revenue may conduct an inquiry
to substantiate this information.

Item 19 should include any line of credit available to you from
any sources including company credit unions, finance
companies, banks, etc.

Item 41 should report all monthly medical expenses incurred except
monthly medical insurance premiums and any major medical debt
listed in item 24. This includes, but is not limited to, the cost of
necessary medical products/services not covered by insurance, copayments for office visits, prescription medication, etc. Medical
insurance premiums should be reported in item 40c.

Item 20 should report insurance information as verified through
your insurance agent.

Item 44 should report total expenses from all liability sources listed
under items 36–43.

Item 21 should report the current market value of your vehicle(s)
as determined in an automobile “blue book” or by other property
valuation sources.

Item 46 should report any extraordinary situations such as recent
transfers of assets, court proceedings and anticipated changes in
employment. If you have recently filed for bankruptcy, you must
disclose the court and bankruptcy case number.

Item 18 should report actual cash on hand, not cash in banks or
other financial institutions.

Item 22 should report all business real estate holdings as well
as your personal residence.
Item 23 should report other assets such as furniture, recreational
vehicles, recreational or hobby tools, machinery and equipment,
and miscellaneous household assets.
Section III—Liabilities (Items 24–26)
Item 24 should report all other liabilities and debts owed for
major medical bills, dental bills, educational expenses and
should include any formal promissory note, loan arrangement
or financial obligation currently assigned to you.
Items 25 and 26 should report all delinquent federal and other
taxes.

Certification (Items 47–49)
Signature by you and/or your spouse certifies that statements and
entries contained in the Statement of Financial Condition and/or
accompanying schedules are correct to the best knowledge and
belief of the undersigned.
Items 47–49 must provide your signature along with the date your
signature was posted. If a joint income tax return was filed, your
spouse’s signature must also be provided.

+
(

Mail to: Division of Collections, P.O. Box 491, Frankfort,
Kentucky 40602-0491.
Questions: Call (502) 564-4921.

12A638 (7-04)

STATEMENT OF FINANCIAL CONDITION

Commonwealth of Kentucky
DEPARTMENT OF REVENUE

If additional space is needed,
attach separate sheet.

FOR INDIVIDUALS

(

1. Your Name and Address (including county)

2. Home Phone No.

1a. Date of Birth

5a. Spouse’s Name and Date of Birth

(
1b. Soc. Sec. No.

3. Marital Status

4. No. in Household

)
5b. Spouse’s Soc. Sec. No.

SECTION I—EMPLOYMENT INFORMATION
6. Your Employer or Business (name and address)

7. Business Phone Number

(
9. Pay Basis:
o Weekly
o Monthly
11. Spouse’s Employer or Business (name and address)

o

Other

10. (Check appropriate box)
o Employee o Partner
12. Business Phone No.

(

8. Occupation

)
o

Sole Proprietor
13. Occupation

o

Corporate Officer

o

Corporate Officer

)

15. (Check appropriate box)
14. Pay Basis:

o

o

Weekly

Monthly

o

Other

o

Employee

o

Partner

o

Sole Proprietor

SECTION II—ASSETS
Assets

Name and Address of Institution

Type of Account

Account No.

Account
Balance

Current Market Value

Balance Due

16. Bank Accounts
(include savings and
loans, credit unions,
IRA and KEOGH
accounts, certificates
of deposits, etc.)

17. Stocks, Bonds,
Investments

18. Cash
19. Bank Revolving Credit
20. Cash or Loan Value of
Life Insurance
Description and Type of Ownership
21. Vehicles (model, year,
license no.)

a.
b.
c.

22. Real Property

a.
b.
c.
d.
23. Other Assets

a.
b.

Address

12A638 (7-04)

Page 2

SECTION III—LIABILITIES
24. Other Liabilities
(include car payments,
judgments, notes and
other charge accounts)

Type of Account
or Card

Name and Address of
Financial Institution

Monthly
Payment

Credit
Limit

Amount
Owed

Credit
Available

25. Federal Taxes Owed
26. Other Taxes Owed

SECTION IV—MONTHLY INCOME AND EXPENSE ANALYSIS
(a) Income
(b) Necessary Living Expenses
Source

Gross/Month

Net/Month

27. Wages/Salaries (taxpayer)

36. Rent/House Payment

28. Wages/Salaries (spouse)*

37. Groceries

29. Interest—Dividends

38. Total Monthly Payment from
Section III—Liabilities

30. Net Business Income
(from Form 433 B)

39. Utilities—Water, Electric,
Telephone, etc.

31. Rental Income

40. Insurance (monthly)

32. Pension (taxpayer)
Source:

a. Auto
b. Life

33. Pension (spouse)
Source:

c. Medical, etc.
41. Monthly Medical Expenses
42. Estimated Tax Payments (only if you
are currently making payments)
(federal-state)

34. Other

43. Other Expenses (child support, etc.)
(specify)

44. TOTAL MONTHLY
LIVING EXPENSES

35. TOTAL MONTHLY INCOME

* Item 28 should be completed if you are married even if your spouse is not liable for the tax. This
information is necessary in order for the Department of Revenue to calculate household income and 45. Net Difference (income less necessary
expenses.
living expenses)
46. Additional Information (Court proceedings, bankruptcies, repossessions, recent transfers of assets for less than full value, anticipated increases in income, condition of
health, etc.) Include information on trusts, estates, profit-sharing plans, etc., on which you are a participant or beneficiary.

CERTIFICATION—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.
47. Your Signature

48. Spouse’s Signature (if joint return was filed)

✍

✍

49. Date

YOUR RIGHTS AS A KENTUCKY TAXPAYER
The mission of the Kentucky Department of Revenue (DOR) is to
provide courteous, accurate and efficient services for the benefit of
the Commonwealth and administer Kentucky tax laws in a fair and
impartial manner.
As a Kentucky taxpayer, you have the right to expect the DOR to
honor its mission and uphold your rights every time you contact or
are contacted by the DOR.
RIGHTS OF TAXPAYER
Privacy—You have the right to privacy of information provided to
the DOR.
Assistance—You have the right to advice and assistance from the
DOR in complying with state tax laws.
Explanation—You have the right to a clear and concise
explanation of:
• basis of assessment of additional taxes, interest and penalties, or
the denial or reduction of any refund or credit claim;
• procedure for protest and appeal of a determination of the DOR;
and
• tax laws and changes in tax laws so that you can comply with the
law.
Protest and Appeal—You have the right to protest and appeal a
determination of the DOR if you disagree with an assessment of tax
or penalty, reduction or a denial of a refund, a revocation of a license
or permit, or other determination made by the DOR.
Conference—You have the right to a conference to discuss a tax
matter.
Representation—You have the right to representation by your
authorized agent (attorney, accountant or other person) in any
hearing or conference with the DOR. You have the right to be
informed of this right prior to the conference or hearing. If you
intend for your representative to attend the conference or hearing in
your place, you may be required to give your representative a power
of attorney before the DOR can discuss tax matters with your
authorized agent.
Recordings—You have the right to make an audio recording of any
meeting, conference or hearing with the DOR, or to be notified in
advance if the DOR plans to record the proceedings and to receive
a copy of any recording.
Consideration—You have the right to consideration of:
• waiver of penalties or collection fees if "reasonable cause" for
reduction or waiver is given ("reasonable cause" is defined in
KRS 131.010(9) as: "an event, happening, or circumstance
entirely beyond the knowledge or control of a taxpayer who has
exercised due care and prudence in the filing of a return or report
or the payment of monies due the department pursuant to law or
administrative regulation");
• installment payments of delinquent taxes, interest and penalties;
• waiver of interest and penalties, but not taxes, resulting from
incorrect written advice from the DOR if all facts were given and
the law did not change or the courts did not issue a ruling to the
contrary;
• extension of time for filing reports or returns; and
• payment of charges incurred resulting from an erroneous filing of
a lien or levy by the DOR.

Guarantee—You have the right to a guarantee that DOR
employees are not paid, evaluated or promoted based on taxes
assessed or collected, or a tax assessment or collection quota or goal
imposed or suggested.
Damages—You have the right to file a claim for actual and direct
monetary damages with the Kentucky Board of Claims if a DOR
employee willfully, recklessly and intentionally disregards your
rights as a Kentucky taxpayer.
Interest—You have the right to receive interest on an overpayment
of tax, except delinquent property tax, payable at the same rate you
would pay if you underpaid your tax.
REVENUE DEPARTMENT RESPONSIBILITIES
The DOR has the responsibility to:
• perform audits, conduct conferences and hearings with you at
reasonable times and places;
• authorize, require or conduct an investigation or surveillance of
you only if it relates to a tax matter;
• make a written request for payment of delinquent taxes which are
due and payable at least 30 days prior to seizure and sale of your
assets;
• conduct educational and informational programs to help you
understand and comply with the laws;
• publish clear and simple statements to explain tax procedures,
remedies, your rights and obligations, and the rights and
obligations of the DOR;
• notify you in writing when an erroneous lien or levy is released
and, if requested, notify major credit reporting companies in
counties where lien was filed;
• advise you of procedures, remedies and your rights and
obligations with an original notice of audit or when an original
notice of tax due is issued, a refund or credit is denied or reduced,
or whenever a license or permit is denied, revoked or canceled;
• notify you in writing prior to termination or modification of a
payment agreement;
• furnish copies of the agent’s audit workpapers and a written
narrative explaining the reason(s) for the assessment;
• resolve tax controversies on a fair and equitable basis at the
administrative level whenever possible; and
• notify you in writing at your last known address at least 60 days
prior to publishing your name on a list of delinquent taxpayers for
which a tax or judgment lien has been filed.
The DOR has a Taxpayer Ombudsman’s Office which consists of
the Ombudsman and a staff whose job is to serve as an advocate for
taxpayers’ rights. One of the main functions of the office is to ensure
that your rights as a Kentucky taxpayer are protected.
The Taxpayer Ombudsman’s Office may be contacted by telephone
at (502) 564-7822 (between 8:00 a.m. and 4:30 p.m. weekdays).
From a Telecommunication Device for the Deaf (TDD), call (502)
564-3058. The mailing address is: Office of Taxpayer Ombudsman,
P.O. Box 930, Frankfort, Kentucky 40602-0930.
**************
For more information concerning the Statement of Financial
Condition, contact the Division of Collections, P.O. Box 491,
Frankfort, Kentucky 40602-0491, (502) 564-4921.