INSTRUCTIONS FOR COMPLETING DEPARTMENT OF …

1 The Statement of financial Condition for Individuals, Form12A638, provides the DEPARTMENT of Revenue s Division ofCollections with information that will be utilized in evaluatingan individual s financial position. Every item of the financialstatement must be completed and should reflect accuratestatements and amounts. If an item is not applicable insert N/A. An incomplete Statement of financial Condition forIndividuals may not be Statement of financial Condition for Individuals ispresented in four segments. INSTRUCTIONS have been providedonly for items requiring further clarification. Most of therequested items are self-explanatory. However, if you have aquestion, call (502) Information (Items 1 5)Please verify the Social Security numbers reported in items 1and 5b to make sure they are I Employment Information (Items 6 15)This section should report all full-time and/or part-timeemployers that currently make a payment(s) to you in the formof wages, salaries and/or commissions for services may use attachments as II Assets (Items 16 23)All information furnished in this section should be verified foraccuracy.

2 The DEPARTMENT of Revenue may conduct an inquiryto substantiate this 18 should report actual cash on hand, not cash in banks orother financial 19 should include any line of credit available to you fromany sources including company credit unions, financecompanies, banks, 20 should report insurance information as verified throughyour insurance 21 should report the current market value of your vehicle(s)as determined in an automobile blue book or by other propertyvaluation 22 should report all business real estate holdings as wellas your personal 23 should report other assets such as furniture, recreationalvehicles, recreational or hobby tools, machinery and equipment,and miscellaneous household III Liabilities (Items 24 26)Item 24 should report all other liabilities and debts owed formajor medical bills, dental bills, educational expenses andshould include any formal promissory note, loan arrangementor financial obligation currently assigned to 25 and 26 should report all delinquent federal and FOR COMPLETINGSTATEMENT OF financial CONDITION FOR INDIVIDUALS12A638(I) (8-04)Commonwealth of KentuckyDEPARTMENT OF REVENUES ection 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 ofnecessary living expenses paid and/or incurred on a monthly lines have been provided for reporting income and/orexpense items not already itemized in Section IV.

3 Each entry shouldbe verified for accuracy. The DEPARTMENT of Revenue may requestsupportive documents to substantiate this 27 and 28 should report gross and net income figures obtainedfrom your entire wage statements. If you are paid on a weeklybasis, multiply your weekly gross and net salary by to arrive atyour monthly gross and net 35 should report total income, both gross and net, from allincome sources listed under items 27 36 43 should report accurate amounts for expenses andshould be verified by examining your records for the last 38, Total Monthly Payment from Section III Liabilities,includes payments on secured or legally perfected debts (carpayments, judgments, etc.). Do not include payments onencumbered assets, which are not necessary living expenses ( ,boats, recreational vehicles, etc.).Item 40 should report monthly insurance premiums. If insuranceis paid on any frequency other than monthly, compute the monthlyamount by dividing quarterly premiums by 3, semi-annualpremiums by 6, 41 should report all monthly medical expenses incurred exceptmonthly medical insurance premiums and any major medical debtlisted in item 24.

4 This includes, but is not limited to, the cost ofnecessary medical products/services not covered by insurance, co-payments for office visits, prescription medication, etc. Medicalinsurance premiums should be reported in item 44 should report total expenses from all liability sources listedunder items 36 46 should report any extraordinary situations such as recenttransfers of assets, court proceedings and anticipated changes inemployment. If you have recently filed for bankruptcy, you mustdisclose the court and bankruptcy case (Items 47 49)Signature by you and/or your spouse certifies that statements andentries contained in the Statement of financial Condition and/oraccompanying schedules are correct to the best knowledge andbelief of the 47 49 must provide your signature along with the date yoursignature was posted. If a joint income tax return was filed, yourspouse s signature must also be to: Division of Collections, Box 491, Frankfort,Kentucky : Call (502) @STATEMENT OF financial CONDITIONFOR INDIVIDUALS12A638 (7-04)Commonwealth of KentuckyDEPARTMENT OF REVENUEIf additional space is needed,attach separate Your Name and Address (including county)2.

5 Home Phone Marital Status4. No. in Household()1a. Date of Birth1b. Soc. Sec. Spouse s Name and Date of Birth5b. Spouse s Soc. Sec. I EMPLOYMENT INFORMATION6. Your Employer or Business (name and address)7. Business Phone Number8. Occupation()10.(Check appropriate box)9. Pay Basis: Weekly Monthly Other Employee Partner Sole Proprietor Corporate Officer11. Spouse s Employer or Business (name and address)12. Business Phone Occupation()15.(Check appropriate box)14. Pay Basis: Weekly Monthly Other Employee Partner Sole Proprietor Corporate OfficerSECTION II ASSETSA ssetsName and Address of InstitutionType of AccountAccount Bank Accounts(include savings andloans, credit unions,IRA and KEOGH accounts, certificatesof deposits, etc.)17. Stocks, Bonds,Investments18. Cash19. Bank Revolving Credit20. Cash or Loan Value ofLife InsuranceDescription and Type of OwnershipAddressCurrent Market ValueBalance Due21. Vehicles (model, year,license no.) Real Other @12A638 (7-04)Page 2 SECTION III LIABILITIES24.

6 Other Liabilities(include car payments,judgments, notes andother charge accounts)25. Federal Taxes Owed26. Other Taxes OwedSECTION IV MONTHLY INCOME AND EXPENSE ANALYSIS(a) IncomeSourceGross/MonthNet/Month27. Wages/Salaries (taxpayer)36. Rent/House Payment28. Wages/Salaries (spouse)*37. Groceries38. Total Monthly Payment from29. Interest DividendsSection III Liabilities30. Net Business Income39. Utilities Water, Electric,(from Form 433 B)Telephone, Rental Income40. Insurance (monthly)32. Pension (taxpayer)a. AutoSource:b. Life33. Pension (spouse)c. Medical, :41. Monthly Medical Expenses42. Estimated Tax Payments (only if you34. Otherare currently making payments)(federal-state)43. Other Expenses (child support, etc.)(specify) MONTHLY INCOMELIVING EXPENSES* Item 28 should be completed if you are married even if your spouse is not liable for the tax. Thisinformation is necessary in order for the DEPARTMENT of Revenue to calculate household income and Difference (income less expenses)46.

7 Additional Information (Court proceedings, bankruptcies, repossessions, recent transfers of assets for less than full value, anticipated increases in income, condition ofhealth, etc.) Include information on trusts, estates, profit-sharing plans, etc., on which you are a participant or Under penalties of perjury, I declare that to the best of my knowledge and belief, this statement of assets, liabilities andother information is true, correct and Your Signature48. Spouse s Signature (if joint return was filed)49. DateType of AccountName and Address ofMonthlyCreditAmountCreditor CardFinancial InstitutionPaymentLimitOwedAvailable(b) Necessary Living Expenses The mission of the Kentucky DEPARTMENT of Revenue (DOR) is toprovide courteous, accurate and efficient services for the benefit ofthe Commonwealth and administer Kentucky tax laws in a fair andimpartial a Kentucky taxpayer, you have the right to expect the DOR tohonor its mission and uphold your rights every time you contact orare contacted by the OF TAXPAYERP rivacy You have the right to privacy of information provided tothe You have the right to advice and assistance from theDOR in complying with state tax You have the right to a clear and conciseexplanation of: basis of assessment of additional taxes, interest and penalties, orthe denial or reduction of any refund or credit claim; procedure for protest and appeal of a determination of the DOR.

8 And tax laws and changes in tax laws so that you can comply with and Appeal You have the right to protest and appeal adetermination of the DOR if you disagree with an assessment of taxor penalty, reduction or a denial of a refund, a revocation of a licenseor permit, or other determination made by the You have the right to a conference to discuss a You have the right to representation by yourauthorized agent (attorney, accountant or other person) in anyhearing or conference with the DOR. You have the right to beinformed of this right prior to the conference or hearing. If youintend for your representative to attend the conference or hearing inyour place, you may be required to give your representative a powerof attorney before the DOR can discuss tax matters with yourauthorized You have the right to make an audio recording of anymeeting, conference or hearing with the DOR, or to be notified inadvance if the DOR plans to record the proceedings and to receivea copy of any You have the right to consideration of: waiver of penalties or collection fees if "reasonable cause" forreduction or waiver is given ("reasonable cause" is defined inKRS (9) as: "an event, happening, or circumstanceentirely beyond the knowledge or control of a taxpayer who hasexercised due care and prudence in the filing of a return or reportor the payment of monies due the DEPARTMENT pursuant to law oradministrative regulation"); installment payments of delinquent taxes, interest and penalties.

9 Waiver of interest and penalties, but not taxes, resulting fromincorrect written advice from the DOR if all facts were given andthe law did not change or the courts did not issue a ruling to thecontrary; extension of time for filing reports or returns; and payment of charges incurred resulting from an erroneous filing ofa lien or levy by the You have the right to a guarantee that DORemployees are not paid, evaluated or promoted based on taxesassessed or collected, or a tax assessment or collection quota or goalimposed or You have the right to file a claim for actual and directmonetary damages with the Kentucky Board of Claims if a DORemployee willfully, recklessly and intentionally disregards yourrights as a Kentucky You have the right to receive interest on an overpaymentof tax, except delinquent property tax, payable at the same rate youwould pay if you underpaid your DEPARTMENT RESPONSIBILITIESThe DOR has the responsibility to: perform audits, conduct conferences and hearings with you atreasonable times and places; authorize, require or conduct an investigation or surveillance ofyou only if it relates to a tax matter.

10 Make a written request for payment of delinquent taxes which aredue and payable at least 30 days prior to seizure and sale of yourassets; conduct educational and informational programs to help youunderstand and comply with the laws; publish clear and simple statements to explain tax procedures,remedies, your rights and obligations, and the rights andobligations of the DOR; notify you in writing when an erroneous lien or levy is releasedand, if requested, notify major credit reporting companies incounties where lien was filed; advise you of procedures, remedies and your rights andobligations with an original notice of audit or when an originalnotice 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 apayment agreement; furnish copies of the agent s audit workpapers and a writtennarrative explaining the reason(s) for the assessment; resolve tax controversies on a fair and equitable basis at theadministrative level whenever possible; and notify you in writing at your last known address at least 60 daysprior to publishing your name on a list of delinquent taxpayers forwhich a tax or judgment lien has been filed.