Illinois Boa 4 Form PDF Details

The Illinois Department of Revenue's BOA-4 Financial Information Statement for Individuals provides a comprehensive structure for documenting personal financial status, essential for situations requiring a detailed disclosure of one's financial health. The form meticulously covers areas of personal information, including marital and employment status, alongside detailed sections on financial assets such as bank accounts, charge cards, real property, and insurance policies. Additionally, it delves into securities, a miscellany of potentially relevant financial information, and situations like bankruptcy. An analysis of assets, liabilities, and monthly income versus expenses further adds depth, ensuring that individuals can present a clear picture of their financial stability or needs. Furthermore, the form demands under penalty of perjury, the honest completion, reinforcing its legal significance. This requirement underlines the importance of accuracy in filling out the form, as it could influence legal judgments, tax considerations, or suitability for financial accommodations. By mandating a thorough disclosure, the Illinois BOA-4 form helps in creating a transparent and accountable environment for financial reporting and decision-making.

QuestionAnswer
Form NameIllinois Boa 4 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namespmts, 83b, jointly, boa 4 form

Form Preview Example

Illinois Department of Revenue

BOA-4 Financial Information Statement for Individuals

Section 1: Tell us about yourself and your employment

Part A: Your information

1

Marital status

 

single

married

separated

 

 

 

 

 

 

If married, complete your spouse’s information in Part B.

 

 

 

 

 

2

Your name ___________________________________________ 11

Filing status

single

married filing jointly

3 Street address ________________________________________

 

 

head of household

married filing separately

 

____________________________________________________ 12

Average monthly take-home pay $___________________________

 

City

 

 

State

ZIP

13

Amounts withheld from your paycheck (e.g., savings, bonds,

 

 

 

 

 

 

4

Home phone (____)____________________________________

 

deferred amounts, car payments, etc.) $______________________

5

Social Security number

___ ___ ___- ___ ___- ___ ___ ___ ___

 

______________________________________________________

6

Unemployed

yes

no If “yes,” how long. _______________ 14

Dates paid _____________________________________________

7

Current or former employer’s name ________________________ 15

Length of employment ____________________________________

8

Address _____________________________________________ 16

Date of birth

___ ___/___ ___/___ ___ ___ ___

 

 

____________________________________________________ 17

Name and address of next of kin (other than spouse)

 

 

City

 

 

State

ZIP

 

Name ________________________________________________

 

 

 

 

 

 

 

9

Work phone (_____)____________________________________

 

Street address _________________________________________

10

Occupation___________________________________________

 

______________________________________________________

 

 

 

 

 

 

 

City

 

State

ZIP

Part B: Your spouse’s information

18

Spouse’s name _______________________________________ 25

Work phone(_____)______________________________________

19

Address (if different)____________________________________ 26

Occupation ____________________________________________

 

____________________________________________________ 27

Average monthly take-home pay $___________________________

 

City

 

State

ZIP

28

Amounts withheld from your paycheck (e.g., savings, bonds,

 

 

 

 

 

20

Home phone (if different)(_____)__________________________

 

deferred amounts, car payments, etc.) $______________________

21

Social Security number

___ ___ ___-___ ___-___ ___ ___ ___

 

______________________________________________________

22

Unemployed

yes

no If “yes,” how long._______________ 29

Dates paid _____________________________________________

23

Current or former employer’s name ________________________ 30

Length of employment ____________________________________

24

Address _____________________________________________ 31

Date of birth ___ ___/___ ___/___ ___ ___ ___

 

____________________________________________________

 

 

 

City

 

State

ZIP

 

 

Section 2: Complete the following financial information

Note: Attach additional sheets in the same format for any of the following parts if necessary.

Part A: Your bank accounts (include savings and loans, credit unions, IRA and retirement plans, and certificates of deposit)

 

A

B

C

D

E

 

 

 

Type of

Account

 

 

Name of institution

Address

account

number

Balance

32

______________________

_______________________________________

___________

___________

____________

33______________________

_______________________________________

___________

___________

____________

34

______________________

_______________________________________

___________

___________

____________

35

______________________

_______________________________________

___________

___________

____________

36

______________________

_______________________________________

___________

___________

____________

37______________________

_______________________________________

___________

___________

____________

38

Add Lines 32 through 37, Column E, and write the total here and on Part G, Line 56, Column B.

38

____________

BOA-4 (R-4/01)

Page 1 of 4

Part B: Your charge cards or credit lines from your banks, credit unions, and savings and loans

 

A

B

C

 

Type of account

 

Current

 

or card

Name and address of financial institution

balance

39

_________________

_______________________________________________________________________

___________

40

_________________

_______________________________________________________________________

___________

41

_________________

_______________________________________________________________________

___________

42

_________________

_______________________________________________________________________

___________

43

_________________

_______________________________________________________________________

___________

44

Add Lines 39 through 43, Column C, and write the total here and on Part G, Line 57, Column C.

44 ___________

Part C: Real property you own

 

A

B

C

D

 

Brief description

How property

 

 

 

of property

is titled

Physical address

County

45

_____________________________

__________________

_______________________________________

___________

46

_____________________________

__________________

_______________________________________

___________

47

_____________________________

__________________

_______________________________________

___________

Part D: Your life and health insurance policies

 

A

B

C

D

E

 

 

Policy

 

Face

Available

 

Insurance company

number

Type

amount

loan value

48

__________________________________________________

___________

___________

___________

___________

49

__________________________________________________

___________

___________

___________

___________

50

Add Lines 48 and 49, Column E, and write the total here and on Part G, Line 60, Column B.

 

50 ___________

Part E: Your securities (e.g., stocks, bonds, annuities, mutual funds, money market funds, government securities, notes, personal, etc.)

 

A

B

C

D

E

 

Type

 

 

Quantity or

 

 

of security

Location

Owner of record

denomination

Present value

51

_________________

______________________________

_________________________

___________

___________

52

_________________

______________________________

_________________________

___________

___________

53

Add Lines 51 and 52, Column E, and write the total here and on Part G, Line 61, Column B.

 

53 ___________

Part F: Miscellaneous information

54a Are foreclosure, bankruptcy, receivership, or assignment for benefit of creditors proceedings pending? b What is the bankruptcy number? ______________________

Yes

No

c What date was the bankruptcy filed? ___ ___/___ ___/___ ___ ___ ___

If closed, what was the date? ___ ___/___ ___/___ ___ ___ ___

Month

Day

Year

Month

Day

Year

Page 2 of 4

BOA-4 (R-4/01)

Part G: Analyze your assets and liabilities

Note: Write amounts in all unshaded areas that apply

 

A

B

 

 

Fair market

 

Description

value

55

Cash

___________

56

Total bank accounts

 

 

from Section 2, Part A,

 

 

Line 38

___________

57Total charge cards balance from Section 2, Part B,

Line 44

___________

58Vehicles (model, year)

a ___________________

___________

b ___________________

___________

c ___________________

___________

59

Real property listed

 

 

in Section 2,

 

 

Part C, (Line 45)

___________

 

(Line 46)

___________

 

(Line 47)

___________

60

Total cash or loan value

 

 

of insurance from

 

 

Section 2, Part D,

 

 

Line 50

___________

61

Total securities from

 

 

Section 2, Part E,

 

 

Line 53

___________

62

Other assets (specify)

 

C

Liabilities

balance due

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

D

Equity

(Column B minus

Column C)

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

E

Monthly payment amount

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

F

Pledgee or obligee

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

G

Date of

final

payment

____________

____________

____________

____________

____________

____________

____________

____________

____________

____________

____________

a___________________

b___________________

c___________________

63 Other liabilities not covered above (e.g., judgments, charities, tuition)

a___________________

b___________________

c___________________

64 Federal taxes owed

65 State taxes owed a Illinois individual

income tax

b Illinois business income tax

c Other state taxes

66Total

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

____________

____________

____________

____________

____________

____________

____________

____________

____________

____________

____________

BOA-4 (R-4/01)

Page 3 of 4

Part H: Analyze your monthly income and expenses

Income

 

A

B

C

 

Source

Gross

Net

67

Your wages or salary

___________________

___________________

68

Your spouse’s

 

 

 

wages or salary

___________________

___________________

69

Interest or dividends

___________________

___________________

70

Business income

___________________

___________________

71

Rental income

___________________

___________________

72

Your pension

___________________

___________________

73

Your spouse’s pension

___________________

___________________

74

Child support

___________________

___________________

75

Alimony

___________________

___________________

76Other (specify)

________________ ___________________ ___________________

________________ ___________________ ___________________

________________ ___________________ ___________________

________________ ___________________ ___________________

________________ ___________________ ___________________

________________ ___________________ ___________________

________________ ___________________ ___________________

________________

___________________

___________________

________________

___________________

___________________

________________

___________________

___________________

________________

___________________

___________________

________________

___________________

___________________

77 Add Lines 67 through 76, Column C.

 

This amount is your total net income.

____________________

Necessary monthly living expenses

A

B

Expense

Amount

78Rent (not included

 

in Part G, Line 59)

___________________

79

Groceries

 

 

 

 

(number of people____)

___________________

80

Installment pmts. from

 

 

Part G, Line 66, Col. E

___________________

81

Utilities

a

gas

___________________

 

 

b

water

___________________

 

 

c

electric

___________________

 

 

d

telephone

___________________

82

Transportation

___________________

83

Insurance

a

life

___________________

 

(monthly

b

health

___________________

 

premiums) c

home

___________________

 

 

d

car

___________________

84Medical (not covered

 

in Line 83b above)

___________________

85

Estimated tax payments

___________________

86

Court-ordered payments

___________________

87Other (specify)

__________________ ___________________

__________________ ___________________

__________________ ___________________

88Add Lines 78 through 87. This amount is your

total expenses.

___________________

89 Subtract Line 88 from Line 77. This amount is your net income after expenses.

89 ___________________

Part I: Complete any additional asset or income information

90Write any additional information you have about your assets or income that was not included in any of the preceding parts. Be sure to include a statement regarding the prospect of any increase in the value of your assets or your present income.

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Section 3: Sign below

Under penalties of perjury, I state that I have examined this statement of assets, liabilities, and other information and, to the best of my knowledge, it is true, correct, and complete.

______________________________________________/___/_____ ______________________________________________/___/_____

Petitioner’s signature (not representative)

Date

Spouse’s signature

Date

Page 4 of 4

This form is authorized as outlined by the Illinois Income Tax Act. Disclosure of this information is REQUIRED. Failure to provide information

 

could result in this form not being processed. This form has been approved by the Forms Management Center.

IL-492-3683

BOA-4 (R-4/01)

 

 

 

 

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1. To start with, once filling in the obligee, start in the area containing subsequent blank fields:

boa 4 conclusion process detailed (step 1)

2. Immediately after this part is completed, proceed to enter the suitable details in these: Spouses name Work phone, State, ZIP, Amounts withheld from your, Home phone if different Social, deferred amounts car payments etc, yes, City, State, ZIP, Section Complete the following, Note Attach additional sheets in, Part A Your bank accounts include, Name of institution, and Address.

Part number 2 in completing boa 4

3. The next section is normally quite uncomplicated, Add Lines through Column E and, and Page of - all of these fields needs to be completed here.

boa 4 completion process clarified (part 3)

Always be really careful when filling in Add Lines through Column E and and Page of, since this is where many people make some mistakes.

4. The subsequent subsection needs your involvement in the subsequent areas: Type of account, or card, Name and address of financial, Current balance, Add Lines through Column C and, Part C Real property you own, Brief description, of property, How property, is titled, Physical address, County, Part D Your life and health, Insurance company, and Policy number. Just be sure you enter all requested info to go onward.

Step # 4 of submitting boa 4

5. To finish your document, the last area incorporates some additional blanks. Completing Add Lines and Column E and, Part E Your securities eg stocks, Type, of security, Location, Quantity or, Owner of record, denomination, Present value, Add Lines and Column E and, Part F Miscellaneous information, a Are foreclosure bankruptcy, Yes, b What is the bankruptcy number, and c What date was the bankruptcy will certainly conclude everything and you're going to be done in a short time!

Present value, b What is the bankruptcy number, and Add Lines  and  Column E and of boa 4

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