State of New Jersey Division of Taxation
Financial Statement of Debtor
Section I – Employment Data
1. __________________________________________ 2. ______________ 3. _________________
Name (Debtor) Birth Date Social Security #
4. ______________________________________________________________ ___________________
Home Address Phone Number
5. __________________________________________ 6. ______________ 7. _________________
Name (Spouse) Birth Date Social Security #
(Provide address if different from yours)
DEBTOR EMPLOYMENT DATA
8. Occupation: ________________________ 9. How Long in Present Employment? ___________
10. Present Employer’s Name: _______________________________________________________
Address: ________________________________________ Phone Number________________
11. Present Monthly Income Total: $_______________
(Provide breakdown on line below)
Salary or Wages $__________ Commissions $_________ Other (State Source) $_________
12. Other Employment – Within the last three years:
Employer’s Name Address Phone Number Employment Dates
________________ _____________________________ _____________ ________________
________________ _____________________________ _____________ ________________
________________ _____________________________ _____________ ________________
SPOUSE’S EMPLOYMENT DATA
13. Occupation: ________________________ 14. How Long in Present Employment? ___________
15. Present Employer’s Name: _______________________________________________________
Address: ________________________________________ Phone Number________________
16. Present Monthly Income Total: $_______________
(Provide breakdown on line below)
Salary or Wages $__________ Commissions $_________ Other (State Source) $_________
17. Other Employment – Within the last three years:
Employer’s Name Address Phone Number Employment Dates
________________ _____________________________ _____________ _______________
________________ _____________________________ _____________ _______________
________________ _____________________________ _____________ _______________
DEPENDENTS
18. Total Number: _______
Relationship __________ Age ___ Relationship __________ Age ___ Relationship _________ Age ___
19.Total Monthly Income of Dependents (except spouse): $_______________
Section II – Financial Data
20. For what period did you last file a Federal tax return? _________________________
21. For what period did you last file a New Jersey Income tax return? _______________
22. Amount of Gross Income reported on last Federal tax return filed? $_____________
Monthly
Income and Expense Analysis
Total Income
Gross
Necessary Living Expenses
Claimed
23. Wages/Salaries (Taxpayer) $ 34. National Standard Expenses (1)
$
24. Wages/Salaries (Spouse)
35. Rent/ Mortgage
25. Interest / Dividends
36. Utilities
26. Net Business Income
37. Health Care
27. Rental Income
38. Taxes (Income) - Federal
28. Pension (Taxpayer)
39. Taxes (Income) – State
29. Pension (Spouse)
40. Property Taxes
(If not included with mortgage)
30. Child Support
41. Court Ordered Payments
31. Alimony
42. Child/Dependent Care
32. Other Income (Specify)
43. Other Expenses (Specify)
33. Total Income
$
44. Total Expenses
$
(1) Select value from National Standard Expenses Table on last page of this application
Section III – Assets and Liabilities
Assets
45. Cash $ _____________
46. Checking Account _____________
47. Savings Account _____________
48. Stocks, Bonds & Other Securities _____________
49. Cash or Loan Value of Insurance _____________
50. Motor Vehicles (Model and Year)
a. Owned Vehicles
1. ____________________________ _____________
2. ____________________________ _____________
3. ____________________________ _____________
b. Leased Vehicles
1. ____________________________ _____________
2. ____________________________ _____________
3. ____________________________ _____________
51. Debts Owed to You _____________
52. Household Furniture and Goods _____________
53. Items Used in Trade or Business _____________
54. Real Estate
1. __________________________________ _____________
2. __________________________________ _____________
3. __________________________________ _____________
4. __________________________________ _____________
55. Any Other Assets - Specify
1. __________________________________ _____________
2. __________________________________ _____________
3. __________________________________ _____________
4. __________________________________ _____________
Total Assets $ _____________
Section III – Assets and Liabilities Continued
Liabilities
56. Bills Owed (Doctors, Lawyers, etc.)
1. __________________________________ $_____________
2. __________________________________ _____________
3. __________________________________ _____________
57. Installment Debt (Car, Credit Card, etc.)
1. __________________________________ _____________
2. __________________________________ _____________
3. __________________________________ _____________
4. __________________________________ _____________
5. __________________________________ _____________
58. Federal Taxes Owed _____________
Has Federal lien been filed? _________
(If yes please supply copy)
59. State Taxes Owed _____________
60. Real Estate Mortgages (2)
1. __________________________________ _____________
2. __________________________________ _____________
3. __________________________________ _____________
61. Loans Payable (To Banks, Finance Co., etc.) (2)
1. __________________________________ _____________
2. __________________________________ _____________
3. __________________________________ _____________
62. Judgments Owed (Other Than Federal or State)
(Please supply copy)
1. __________________________________ _____________
2. __________________________________ _____________
3. __________________________________ _____________
63. Other Debts (Itemize)
1. __________________________________ _____________
2. __________________________________ _____________
3. __________________________________ _____________
Total Liabilities $ _____________
(2) Note: Please include your current statement from lender with monthly payment amount and
current balance due.
Section IV – General Financial Information
64. Real Property (Brief description and type of ownership)
Physical Address Date Acquired Cost
______________________________________ _______________ ___________
______________________________________ _______________ ___________
______________________________________ _______________ ___________
______________________________________ _______________ ___________
65. Bank Accounts
(Include Savings and Loans, Credit Unions, IRAs & Retirement Plans, Certificate of Deposit, etc.)
Name of Institution Address Type Acct # Balance
________________ _________________ ___________ ___________ ___________
________________ _________________ ___________ ___________ ___________
________________ _________________ ___________ ___________ ___________
Total $ ___________
66. Securities (Stocks, bonds, mutual funds, money market funds, government securities, etc.)
Kind Quantity Owner of Record Current Value
_______________________ ___________ ________________ ________________
_______________________ ___________ ________________ ________________
_______________________ ___________ ________________ ________________
_______________________ ___________ ________________ ________________
Total $________________
67. Charge Cards and lines of credit from banks, credit unions and savings and loans
Financial Credit Amount Monthly
Type of Account or Card Institution Limit Owed Payment
______________________ ________________ ______ __________ __________
______________________ ________________ ______ __________ __________
______________________ ________________ ______ __________ __________
______________________ ________________ ______ __________ __________
______________________ ________________ ______ __________ __________
Total $__________
68. Life Insurance
Type Face Available
Name of Company Policy Number Whole/Term Amount Loan Value
________________ ________________ __________ ___________ ____________
________________ ________________ __________ ___________ ____________
________________ ________________ __________ ___________ ____________
Total $____________
Section V – General Information
69. Are you a party in any lawsuit now pending? ____ Yes ____No
If yes please explain: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
70. Are you a trustee, executor or administrator? ____ Yes ____No
If yes please explain: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
71. Is anyone holding any monies on your behalf? ____ Yes ____No
If yes please explain: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
72. Is there any likelihood you would receive an inheritance? ____ Yes ____No
If yes please explain: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
73. Do you receive or under any circumstances expect to receive benefits from an established
trust from a claim for compensation or damages from a contingent or future interest in
property of any kind? ____ Yes ____No
If yes please explain: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
With knowledge of the penalties for false statements provided by 2C:21-4(b) ($7,500 fine and /or
3-5 years imprisonment) and with the knowledge that this financial statement is submitted by me to
affect action by the Division of Taxation, I certify that I believe the above statements are true and
that it is a complete statement of all my income and assets, real and personal, whether held in my
name or by any other.
___________________ _____________________________________
Date Signature
Revised 08/2004
National Standards: Food, Clothing and Other Items
Disclaimer: IRS Collection Financial Standards are intended for use in calculating repayment of
delinquent taxes. These Standards are effective on April 1, 2013 for purposes of federal tax
administration only. Expense information for use in bankruptcy calculations can be found on the website
for the U.S. Trustee Program.
Download the national standards for food, clothing and other items in PDF format for printing. Please note
that the standard amounts change, so if you elect to print them, check back periodically to assure you
have the latest version.
National Standards have been established for five necessary expenses: food, housekeeping supplies,
apparel and services, personal care products and services, and miscellaneous.
The standards are derived from the Bureau of Labor Statistics (BLS) Consumer Expenditure Survey
(CES) and defined as follows:
Food includes food at home and food away from home. Food at home refers to the total expenditures for
food from grocery stores or other food stores. It excludes the purchase of nonfood items. Food away from
home includes all meals and snacks, including tips, at fast-food, take-out, delivery and full-service
restaurants, etc.
Housekeeping supplies includes laundry and cleaning supplies, stationery supplies, postage, delivery
services, miscellaneous household products, and lawn and garden supplies.
Apparel and services includes clothing, footwear, material, patterns and notions for making clothes,
alterations and repairs, clothing rental, clothing storage, dry cleaning and sent-out laundry, watches,
jewelry and repairs to watches and jewelry.
Personal care products and services includes products for the hair, oral hygiene products, shaving needs,
cosmetics and bath products, electric personal care appliances, and other personal care products.
The miscellaneous allowance is for expenses taxpayers may incur that are not included in any other
allowable living expense items, or for any portion of expenses that exceed the Collection Financial
Standards and are not allowed under a deviation. Taxpayers can use the miscellaneous allowance to
pay for expenses that exceed the standards, or for other expenses such as credit card payments, bank
fees and charges, reading material and school supplies.
Taxpayers are allowed the total National Standards amount monthly for their family size, without
questioning the amounts they actually spend. If the amount claimed is more than the total allowed by the
National Standards for food, housekeeping supplies, apparel and services, and personal care products
and services, the taxpayer must provide documentation to substantiate those expenses are necessary
living expenses. Deviations from the standard amount are not allowed for miscellaneous expenses.
Generally, the total number of persons allowed for National Standards should be the same as those
allowed as exemptions on the taxpayer’s most recent year income tax return.
Expense One Person Two Persons Three Persons Four Persons
Food $315 $556 $645 $777
Housekeeping supplies $30 $66 $65 $74
Apparel & services $88 $162 $209 $244
Personal care products & services $34 $60 $64 $70
Miscellaneous $116 $209 $251 $300
Expense One Person Two Persons Three Persons Four Persons
Total $583 $1,053 $1,234 $1,465
More than four persons Additional Persons Amount
For each additional person, add to four-person total allowance: $281
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