Form M-433-OIS Statement of Financial Condition and Other Information - Massachusetts

Form M-433-OIS or the "Statement Of Financial Condition And Other Information" is a form issued by the Massachusetts Department of Revenue.

Download a PDF version of the Form M-433-OIS down below or find it on the Massachusetts Department of Revenue Forms website.

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Rev. 6/09
Form M-433-OIS
Massachusetts
Statement of Financial Condition
Department of
and Other Information
Revenue
Complete all entries with the most current information available. For entries that do not apply, enter “N/A” (not applicable). Failure to complete
all applicable entries may result in rejection or delays in the processing of your offer.
Individual and self-employed taxpayers must complete Part 1. Corporate officers, individual partners or responsible persons must also
complete Part 1. Corporations or other business taxpayers must complete Part 2.
Part 1. Individual Information
Name
Social Security number
Date of birth (mm/dd/yyyy)
Spouse’s name
Spouse’s Social Security number
Spouse’s date of birth (mm/dd/yyyy)
Residence address
City/Town
State
Zip
County of residence
Home phone number
Alternate phone number (e.g., cell, work)
1. Marital status (one only):
Single
Married
Other (specify)
2. Type of residence (check one only):
Homeowner
Renter
Other (specify, e.g., share rent, live with relatives, etc.)
3. Length of time at current residence
4. List the dependents you can claim on your tax return. Use additional pages if necessary.
a. Full name
Relationship
Age
Live with you?
Yes
No
b. Full name
Relationship
Age
Live with you?
Yes
No
c. Full name
Relationship
Age
Live with you?
Yes
No
d. Full name
Relationship
Age
Live with you?
Yes
No
5. Complete the following if you are employed. Use an additional page for each employer. Provide proof of gross earnings and deductions from each
employer you had in the past month (e.g., pay stubs, earnings statements, etc.).
Employer’s name
Your occupation
Employer’s address
City/Town
State
Zip
Your work phone number
Length of employment
May we contact you at work?
Yes
No
6. Complete the following if your spouse is employed. Use an additional page for each employer. Provide proof of gross earnings and deductions from
each employer your spouse had in the past month (e.g., pay stubs, earnings statements, etc.).
Employer’s name
Spouse’s occupation
Employer’s address
City/Town
State
Zip
Spouse’s work phone number
Length of employment
May we contact your spouse at work?
Yes
No
7. Complete the following if either you or your spouse is self-employed or owns a business.
Business name
Federal Identification number
Number of employees
Business street address (not PO box)
City/Town
State
Zip
8. Sources of income other than employment or owned business (check all that apply; proof of this income from the prior month may be required):
Pension
Social Security
Other (specify, e.g., child support, alimony, rental, trust, royalty, etc.)
For Privacy Act Notice, see page 12.
Rev. 6/09
Form M-433-OIS
Massachusetts
Statement of Financial Condition
Department of
and Other Information
Revenue
Complete all entries with the most current information available. For entries that do not apply, enter “N/A” (not applicable). Failure to complete
all applicable entries may result in rejection or delays in the processing of your offer.
Individual and self-employed taxpayers must complete Part 1. Corporate officers, individual partners or responsible persons must also
complete Part 1. Corporations or other business taxpayers must complete Part 2.
Part 1. Individual Information
Name
Social Security number
Date of birth (mm/dd/yyyy)
Spouse’s name
Spouse’s Social Security number
Spouse’s date of birth (mm/dd/yyyy)
Residence address
City/Town
State
Zip
County of residence
Home phone number
Alternate phone number (e.g., cell, work)
1. Marital status (one only):
Single
Married
Other (specify)
2. Type of residence (check one only):
Homeowner
Renter
Other (specify, e.g., share rent, live with relatives, etc.)
3. Length of time at current residence
4. List the dependents you can claim on your tax return. Use additional pages if necessary.
a. Full name
Relationship
Age
Live with you?
Yes
No
b. Full name
Relationship
Age
Live with you?
Yes
No
c. Full name
Relationship
Age
Live with you?
Yes
No
d. Full name
Relationship
Age
Live with you?
Yes
No
5. Complete the following if you are employed. Use an additional page for each employer. Provide proof of gross earnings and deductions from each
employer you had in the past month (e.g., pay stubs, earnings statements, etc.).
Employer’s name
Your occupation
Employer’s address
City/Town
State
Zip
Your work phone number
Length of employment
May we contact you at work?
Yes
No
6. Complete the following if your spouse is employed. Use an additional page for each employer. Provide proof of gross earnings and deductions from
each employer your spouse had in the past month (e.g., pay stubs, earnings statements, etc.).
Employer’s name
Spouse’s occupation
Employer’s address
City/Town
State
Zip
Spouse’s work phone number
Length of employment
May we contact your spouse at work?
Yes
No
7. Complete the following if either you or your spouse is self-employed or owns a business.
Business name
Federal Identification number
Number of employees
Business street address (not PO box)
City/Town
State
Zip
8. Sources of income other than employment or owned business (check all that apply; proof of this income from the prior month may be required):
Pension
Social Security
Other (specify, e.g., child support, alimony, rental, trust, royalty, etc.)
For Privacy Act Notice, see page 12.
Page 2
9. Statement of assets and liabilities. Enter your most recent financial information below.
a. Assets
Fair market value
Cash (from line 10)
Bank accounts (from line 11)
Real estate (from line 12)
Vehicles (from line 13)
Personal assets (from line 14)
Investments (from line 15)
Life insurance (from line 16)
Available credit (from line 17)
Business assets (from line 18)
Accounts receivable (from line 19)
Notes receivable (from line 20)
Other
Total assets
b. Liabilities
Amount
Mortgage (from line 12)
Vehicle loans (from line 13)
Loans on insurance (from line 16)
Credit card debt (from line 17)
Accounts payable
Notes payable
State taxes
Federal taxes
Other taxes
Judgments
Other
Total liabilities
Page 3
10. Total cash on hand. Include any money that is not held in a bank
11. List all checking, savings, money market and brokerage accounts. Copies of your current statements may be required. Use additional pages if necessary.
a. Name of financial institution
Type of account
Account number
Current balance
b. Name of financial institution
Type of account
Account number
Current balance
c. Name of financial institution
Type of account
Account number
Current balance
d. Name of financial institution
Type of account
Account number
Current balance
e. Name of financial institution
Type of account
Account number
Current balance
f. Name of financial institution
Type of account
Account number
Current balance
12. List all real estate that you own. Provide a copy of your lender’s current statement indicating the monthly payment amount and the current balance
due for each piece of real estate owned. Use additional pages if necessary.
a. Street address
City/Town
State
Zip
County
Date of purchase
Purchase price
Current value
Mortgage balance
Lender or lien holder
Monthly payment
Date of final payment
b. Street address
City/Town
State
Zip
County
Date of purchase
Purchase price
Current value
Mortgage balance
Lender or lien holder
Monthly payment
Date of final payment
c. Street address
City/Town
State
Zip
County
Date of purchase
Purchase price
Current value
Mortgage balance
Lender or lien holder
Monthly payment
Date of final payment
d. Street address
City/Town
State
Zip
County
Date of purchase
Purchase price
Current value
Mortgage balance
Lender or lien holder
Monthly payment
Date of final payment
13. List all purchased and leased vehicles and other licensed assets. Include all automobiles, trucks, boats, RV’s, motorcycles, trailers, etc. Provide a copy
of your lender’s current statement indicating the monthly payment amount and the current balance due for each vehicle. Use additional pages if necessary.
a. Year
Make/model
Plate number
Mileage
Own
Lease
Date of purchase/lease Current value
Loan balance
Lender or lessor
Monthly payment
Date of final payment
b. Year
Make/model
Plate number
Mileage
Own
Lease
Date of purchase/lease Current value
Loan balance
Lender or lessor
Monthly payment
Date of final payment
c. Year
Make/model
Plate number
Mileage
Own
Lease
Date of purchase/lease Current value
Loan balance
Lender or lessor
Monthly payment
Date of final payment
d. Year
Make/model
Plate number
Mileage
Own
Lease
Date of purchase/lease Current value
Loan balance
Lender or lessor
Monthly payment
Date of final payment
Page 4
14. List all personal assets. “Furniture or personal effects” includes the current market value of your household assets such as furniture and appliances.
“Other personal assets” includes all artwork, jewelry, collections (coin/gun, etc.), antiques or other assets. Use additional pages if necessary.
a. Furniture or personal effects
Current value
Loan balance
Lender
Monthly payment
Date of final payment
b. Other personal assets
Current value
Loan balance
Lender
Monthly payment
Date of final payment
c. Other personal assets
Current value
Loan balance
Lender
Monthly payment
Date of final payment
d. Other personal assets
Current value
Loan balance
Lender
Monthly payment
Date of final payment
e. Other personal assets
Current value
Loan balance
Lender
Monthly payment
Date of final payment
f. Other personal assets
Current value
Loan balance
Lender
Monthly payment
Date of final payment
15. List all investment assets including stocks, bonds, mutual funds, stock options, certificates of deposit and retirement assets such as IRAs, Keogh and
401(k) plans. Use additional pages if necessary.
a. Name of company
Number of shares or units
Current value
Used as loan collateral? Loan balance
Yes
No
b. Name of company
Number of shares or units
Current value
Used as loan collateral? Loan balance
Yes
No
c. Name of company
Number of shares or units
Current value
Used as loan collateral? Loan balance
Yes
No
d. Name of company
Number of shares or units
Current value
Used as loan collateral? Loan balance
Yes
No
e. Name of company
Number of shares or units
Current value
Used as loan collateral? Loan balance
Yes
No
f. Name of company
Number of shares or units
Current value
Used as loan collateral? Loan balance
Yes
No
16. Do you have life insurance (not term life insurance) with a cash value?
Yes
No
a. Name of insurance company
Policyholder
Policy number
Current cash value
Outstanding loan balance
b. Name of insurance company
Policyholder
Policy number
Current cash value
Outstanding loan balance
c. Name of insurance company
Policyholder
Policy number
Current cash value
Outstanding loan balance
17. List all lines of credit, including credit cards. Provide a copy of a current statement for each account. Use additional pages if necessary.
a. Name of credit institution
Credit limit
Amount owed
Available credit (credit limit less amount owed)
b. Name of credit institution
Credit limit
Amount owed
Available credit (credit limit less amount owed)
c. Name of credit institution
Credit limit
Amount owed
Available credit (credit limit less amount owed)
d. Name of credit institution
Credit limit
Amount owed
Available credit (credit limit less amount owed)
e. Name of credit institution
Credit limit
Amount owed
Available credit (credit limit less amount owed)
f. Name of credit institution
Credit limit
Amount owed
Available credit (credit limit less amount owed)
Page 5
18. List all business assets and encumbrances, including Uniform Commercial Code (UCC) filings. Tools used in trade or business include the basic tools
or books used to conduct your business, excluding motor vehicles. Use additional pages if necessary.
a. Tools used in trade or business
Current value
Loan balance
Lender
Monthly payment
Date of final payment
b. Machinery
Current value
Loan balance
Lender
Monthly payment
Date of final payment
c. Equipment
Current value
Loan balance
Lender
Monthly payment
Date of final payment
d. Merchandise or inventory
Current value
Loan balance
Lender
Monthly payment
Date of final payment
e. Other
Current value
Loan balance
Lender
Monthly payment
Date of final payment
f. Other
Current value
Loan balance
Lender
Monthly payment
Date of final payment
19. Enter your total of all accounts receivable, and then list your three largest accounts receivable, including contracts awarded but not started.
Total of all accounts receivable
a. Name of account
Amount due
Due date
Business street address (not PO box)
City/Town
State
Zip
Age of account (in days)
0–30
31–60
61–90
91+
b. Name of account
Amount due
Due date
Business street address (not PO box)
City/Town
State
Zip
Age of account (in days)
0–30
31–60
61–90
91+
c. Name of account
Amount due
Due date
Business street address (not PO box)
City/Town
State
Zip
Age of account (in days)
0–30
31–60
61–90
91+
20. Enter your total of all notes receivable, and then list your three largest notes receivable, including contracts awarded but not started.
Total of all notes receivable
a. Name of account
Amount due
Due date
Business street address (not PO box)
City/Town
State
Zip
Age of account (in days)
0–30
31–60
61–90
91+
b. Name of account
Amount due
Due date
Business street address (not PO box)
City/Town
State
Zip
Age of account (in days)
0–30
31–60
61–90
91+
c. Name of account
Amount due
Due date
Business street address (not PO box)
City/Town
State
Zip
Age of account (in days)
0–30
31–60
61–90
91+

Download Form M-433-OIS Statement of Financial Condition and Other Information - Massachusetts

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