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 / Finance / Property Auctions / Counter sale Properties / Financial Statement

Financial Statement

 

JACKSON COUNTY

 

PO Box 1569 – Medford, OR 97501

STATEMENT OF PERSONAL FINANCIAL CONDITION

 

FOR COUNTY USE ONLY

 

 

Date Received

Reference No. __________________________________________

Social Security No.

Prog Code

Year

Period

Liability

 

 

 

 

 

Reviewed By

 

 

Please complete both sides of this form.

Return By

 

Your Name and Spouse’s Name

Your Birth Date

Spouse’s Birth Date

Street Address (and post office box, if applicable)

Your Social Security Number

Spouse’s Social Security Number

City

State

Zip Code

Your Driver’s License Number/State

Spouse’s Driver’s License Number/State

Telephone Numbers –
Circle Best Daytime Telephone Number

Home phone

Cell Phone

Your Work Phone

Spouse’s Work Phone

Age and Relationship of Dependents Who Live with You

Name of Your Employer or Business

Exemptions Claimed

Name of Spouse’s Employer or Business

Exemptions Claimed

Job Title

Date Hired

Pay Days

Job Title

Date Hired

Pay Days

 

BANK ACCOUNTS – Include accounts in savings and loans and credit unions, certificates of deposit, individual retirement accounts (IRAs), and funds held in safe deposit boxes. Please attach bank statements for the last two months.

 

Name of Institution

Branch

 

Type of account (Checking/Savings)

Account Number

Balance

 

 

 

 

 

 

 

 

 

 

 

 

CREDIT CARDS, LOANS, LINES OF CREDIT

 

Name of Credit Card/Bank

Address and Telephone Number

Credit Limit

Amount Owed

Minimum
Monthly Payment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REAL ESTATE

 

Address (including county)

Current Assessed Value

Mortgage Balance

Payment Amount

Name and Telephone number of Person/Bank that you Pay

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR VEHICLES – List additional vehicles on a separate sheet.

 

Year/Make/License Number/State

Date Loan Will Be Paid

Loan Balance

Payment

Amount

Name and Telephone number of Person/Bank that you Pay

 

 

 

 

 

 

 

 

 

 

OTHER ASSETS OVER $15,000 THAT YOU OWN OR ARE CURRENTLY BUYING – Include stocks, bonds, boats, etc.

 

Description

Current Value

Loan Balance

Name and Telephone number of Person/Bank that you Pay

 

 

 

 

 

 

 

 

 

 

 

                                                                                                                                          Page 1 of 2


 

INCOME AND EXPENSES

This column for Office Use Only

MONTHLY INCOME

Budgeted

Allowable

 1. Your net pay. Attach two months recent pay stubs ............................................................................................................................................................................. 1

$

 

 2. Spouse’s net pay. Attach two months recent pay stubs ..................................................................................................................................................................... 2

 

 

 3. Rent paid to you. Names and addresses of tenants .............................................................................................................................................................................. 3

 

 

 4. Income from other members of household ............................................................................................................................................................................................. 4

 

 

 5. Pensions (list source) ................................................................................................................................................................................................................................ 5

 

 

 6. Social Security ............................................................................................................................................................................................................................................ 6

 

 

 7. Profit from your business. Attach statement ............................................................................................................................................................................................ 7

 

 

 8. Commissions ............................................................................................................................................................................................................................................  8

 

 

 9. Other income. List source (stocks, unemployment benefits, profit sharing, alimony, child support) ....................................................................................................... 9

 

 

10. TOTAL INCOME. Add lines 1 through 9 ............................................................................................................................................................................................... 10

 

 

 

 

 

MONTHLY EXPENSES ACTUALLY PAID – Must be reasonable for size of family and location.

Budgeted

Allowable

11. Mortgage/rent. State name and address of landlord ........................................................................................................................................................................... 11

 

 

12. Alimony/child support/garnishments ................................................................................................................................................................................................... 12

 

 

13. Groceries, toiletries, etc. ........................................................................................................................................................................................................................ 13

 

 

14. Utilities –

a. Telephone/cell ........................................................................................................................................................................................................ 14a

 

 

 

b. Electricity ................................................................................................................................................................................................................. 14b

 

 

 

c. Heating-oil/natural gas ........................................................................................................................................................................................... 14c

 

 

 

d. Water/garbage ........................................................................................................................................................................................................ 14d

 

 

 

e. Cable TV .................................................................................................................................................................................................................. 14e

 

 

15. Transportation (gas, bus fares) ............................................................................................................................................................................................................. 15

 

 

16. Insurance –

a. Auto

}

                                                                                                                                                                                         16a

 

 

 

c. Health/life

Figure the monthly average for these............................................................................................................................ 16b

 

 

 

d. Homeowner/renter

                                                                                                                                                                                         16c

 

 

17. Medical (doctors and medicine not paid by insurance) ........................................................................................................................................................................... 17

 

 

18. Auto loans (total of installment payments per month) ............................................................................................................................................................................. 18

 

 

19. Installment payments (per month). List name of store, bank, or credit card.

Balance Due

 

 

 

a. .............................................................................................................................................................................................................. $

 

19a

 

 

 

b. .............................................................................................................................................................................................................. $

 

19b

 

 

 

c. .............................................................................................................................................................................................................. $

 

19c

 

 

 

d. .............................................................................................................................................................................................................. $

 

19d

 

 

 

e. .............................................................................................................................................................................................................. $

 

19e

 

 

 

f. ............................................................................................................................................................................................................... $

 

19f

 

 

 

g. .............................................................................................................................................................................................................. $

 

19g

 

 

20. Total monthly expenses. Add lines 11 through 19g. .......................................................................................................................................................................... 20

$

 

21. Disposable monthly income. Subtract line 20 from line 10 ................................................................................................................................................................. 21

$

 

22. Attach last two years OR State and Federal tax returns ...................................................................................................................................................................... 22

$

 

23. On what day of the month can you pay? .............................................................................................................................................................................................. 23

 

 

 

 

 

 

 

 

ADDITIONAL INFORMATION – Expected changes to income or health, filed or anticipated bankruptcies, foreclosures, liens. Explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and address of nearest relative

Telephone No.

Relationship

 

 

 

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 Multnomah County Tax Title to verify any information on this financial statement, which may include credit reports.

Your signature

Date

Spouse’s signature (if joint return was filed)

Date

X

 

X

 

 

 

 

 

 

Return this form to:

Jackson County Property Management

PO Box 1569

Medford OR 97501

Page 2 of 2



 


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