Illinois Boa 4 Form – Fill Out and Use This PDF

Section 1, Part A: Your information. If married, complete your spouse's information in Part B.

Enter your name, street address, city, state, ZIP, home phone and Social Security number on Lines 2 to 5.

On Line 6, check yes or no for Unemployed. If “yes,” write how long.

Enter the current or former employer's name, address, work phone and occupation on Lines 7 to 10.

On Lines 11 to 16, enter your filing status, average monthly take-home pay, amounts withheld from your paycheck (e.g., savings, bonds, deferred amounts, car payments, etc.), dates paid, length of employment and date of birth.

On Line 17, enter the name and address of next of kin (other than spouse).

Enter your spouse's name, address (if different) with city, state and ZIP, home phone (if different), Social Security number, current or former employer's name, address with city, state and ZIP, work phone, occupation, average monthly take-home pay, amounts withheld, dates paid, length of employment and date of birth on Lines 18 to 31.

Section 2: Complete the following financial information. Attach additional sheets in the same format for any of the following parts if necessary.

List your bank accounts, including savings and loans, credit unions, IRA and retirement plans, and certificates of deposit, with the Type of Account, Name of institution, Address, account number and Balance.

Add Lines 32 through 37, Column E, and write the total on Line 38 and on Part G, Line 56, Column B.

List your charge cards or credit lines from your banks, credit unions, and savings and loans with the Type of account or card, the Name and address of financial institution and the Current balance.

Add Lines 39 through 43, Column C, and write the total on Line 44 and on Part G, Line 57, Column C.

For real property you own, enter a Brief description of property, How property is titled, the Physical address and the County.

For your life and health insurance policies, enter the Insurance company, Policy number, Type, Face amount, Available loan value.

Add Lines 48 and 49, Column E, and write the total on Line 50 and on Part G, Line 60, Column B.

For your securities (e.g., stocks, bonds, annuities, mutual funds, money market funds, government securities, notes, personal, etc.), enter the Type of security, Location, Owner of record, Quantity or denomination and Present value.

Add Lines 51 and 52, Column E, and write the total on Line 53 and on Part G, Line 61, Column B.

Check Yes or No: Are foreclosure, bankruptcy, receivership, or assignment for benefit of creditors proceedings pending?

Write the bankruptcy number and the date the bankruptcy was filed. If closed, write the date.

Write amounts in all unshaded areas that apply.

Line 56 is the Total bank accounts from Section 2, Part A, Line 38. Line 57 is the Total charge cards balance from Section 2, Part B, Line 44. Line 60 is the Total cash or loan value of insurance from Section 2, Part D, Line 50. Line 61 is the Total securities from Section 2, Part E, Line 53.

Line 63 is for other liabilities not covered above (e.g., judgments, charities, tuition). Line 64 is for federal taxes owed. Line 65 is for state taxes owed: Illinois individual income tax, Illinois business income tax and other state taxes.

Income, Lines 67 through 76: 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, 76 Other (specify). Necessary monthly living expenses, Lines 78 through 87: 78 Rent (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 (monthly premiums): a life, b health, c home, d car, 84 Medical (not covered in Line 83b), 85 Estimated tax payments, 86 Court-ordered payments, 87 Other (specify). 88 Add Lines 78 through 87.

77 Add Lines 67 through 76, Column C.

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

90 Write 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.

Petitioner's signature (not representative) and Date. Spouse's signature and Date.

Section 3: Sign below. Under penalties of perjury, you state that you have examined this statement of assets, liabilities, and other information.

By signing you state that this statement of assets, liabilities, and other information is, to the best of your knowledge, true, correct, and complete.