Form OR-SFC, Financial Statement—Page 1
150-101-159 (Rev. 01-17)
Section 1. Personal information
Revenue use only
Date received
Revenue agent
Form OR-SFC
Statement of Financial Condition
Other names or aliases used
Your rst name
Your Social Security number
Your date of birth
MI Last name
Spouse/RDP’s rst
name
Spouse/RDP’s Social Security number
Spouse/RDP’s date of birth
MI Last name
Spouse/RDP’s other names or aliases used
Your cell phone
State
Spouse/RDP’s cell phone
State
Dependent’s name (living with you)
Dependent’s name (living with you)
Dependent’s name (living with you)
Date of birth
Date of birth
Date of birth
Social Security number
Social Security number
Social Security number
Relationship
Relationship
Relationship
Your current physical address City State ZIP code County
Your home phone
Your mailing address
(if different from above) City State ZIP code
Phone
Name of your tax representative (CPA, attorney, enrolled agent)
Fax number
Address of your tax representative
Your email
Spouse/RDP’s email
Your driver license number
Spouse/RDP’s driver license no.
City State ZIP code
Complete all sections of this form. If you don’t complete all sections of this form, we can-
not process it, which will continue collection activity. This may result in garnishment, lien, or
assignment of debt to a private collection agency.
• Three months of current bank statements —personal and business (if applicable).
• Three months of current pay stubs (if applicable).
• Three months of profit and loss statements (for businesses only).
• All household income.
• Additional sheets, as needed, for additional information.
Check here if applying for suspended collection status. For suspended collection status
qualifications, visit www.oregon.gov/dor and search for “Suspended collection.”
Check here if applying for a wage garnishment modification.
Return by:
Section 2. Employment information (personal and business)
Your employer or business name
Address
Business phone
Date hired:____________________ Occupation: _______________________________ Wage earner Sole proprietor Partner Owner ofcer
Paid: Weekly Every other week Monthly Twice a month Number of allowances claimed on Form W-4:____________________
City State ZIP code
Payroll fax
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150-101-159 (Rev. 01-17)
Form OR-SFC, Financial Statement—Page 2
Section 2. (continued) Employment information (personal and business)
If self-employed: List all responsible owner(s), partner(s), ofcer(s), major shareholder(s), etc.
Identify the major responsibilities of each by circling the codes that apply: 1 = Files returns; 2 = Pays taxes; 3 = Prefers creditors; 4 = Hires and res
Name and title Effective date Home address Home phone SSN Code
1 2 3 4
1 2 3 4
1 2 3 4
Section 3. General financial information (personal and business)
Bank accounts. Include IRA and retirement plans certicates of deposit, etc. For all accounts, attach copies of your last three bank statements.
Attach additional pages as needed.
Name of institution Address Type Date opened Account number Balance
$
Total. Enter this amount on line 2, Section 4 (asset and liability analysis) ........................
Vehicles. Attach supporting documentation of current payoff. Attach additional pages as needed, and vehicles paid in full.
Available equity
(cannot be less than -0-)
Current market valueYear, make, model, license number Lender/lien holder Current payoff
$
Total. Enter this amount on line 4, section 4 (asset and liability analysis) ........................
Spouse/RDP’s employer or business name
Address
Date hired:____________________ Occupation: _______________________________ Wage earner Sole proprietor Partner Owner ofcer
Paid: Weekly Every other week Monthly Twice a month Number of allowances claimed on Form W-4:____________________
City State ZIP code
Safe deposit boxes (rented or accessed). Include location, box number, and contents. Attach additional pages as needed.
Name of institution Address Box identication Current value of assets
$
Total. Enter this amount on line 3, Section 4 (asset and liability analysis) ........................
Business phone
Payroll fax
( )
( )
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150-101-159 (Rev. 01-17)
Form OR-SFC, Financial Statement—Page 3
Real property. Include a copy of the deed and a copy of homeowners/rental insurance policy with riders and supporting documentation of loan balance.
Attach additional pages as needed.
Policy number
Life insurance. Attach additional pages as needed.
Name of insurance company Agent’s name and phone Type
$
Face amount
Loan/cash
surrender value
Owner of record
Total. Enter this amount on line 7, section 4 (asset and liability analysis) ........................
Securities. Include stocks, bonds, mutual funds, money market funds, securities, 401(k), etc. Attach additional pages as needed.
Type Where located
$
Quantity or denomination Current value
Total. Enter this amount on line 8, section 4 (asset and liability analysis) ........................
Current market value
Personal property. Include water craft, RVs, air craft, business equipment, and/or machinery. Attach additional pages as needed.
Year, make, model, license number Lender/lien holder Current payoff
$
Total. Enter this amount on line 6, section 4 (asset and liability analysis) ........................
Available equity
(cannot be less than -0-)
Section 3. (continued) General financial information (personal and business)
A. Physical address
Type
(single- or multi-family dwelling,
lot, rental, etc.)
Mortgage lender’s name and address
Parcel number:_______________
How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________
Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________
B. Physical address
Type
(single- or multi-family dwelling,
lot, rental, etc.)
Mortgage lender’s name and address
Parcel number:_______________
How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________
Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________
C. Physical address
Type
(single- or multi-family dwelling,
lot, rental, etc.)
Mortgage lender’s name and address
Parcel number:_______________
How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________
Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________
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150-101-159 (Rev. 01-17)
Form OR-SFC, Financial Statement—Page 4
Section 3. (continued) General financial information (personal and business)
Credit cards and lines of credit. Credit cards and unsecured lines of credit may only be allowed with three months of statements showing they are used
for living expenses.
Type of account Name and address of creditor Monthly payment Credit limit Credit available
Amount owed
$
Total. Enter this amount on line 28, Section 4 (asset and liability analysis) . . . . . . . . .
$
Total
Other financial information. Please provide the following information relating to your nancial conditions. If you check “Yes” in any box, provide dates,
an explanation, and documentation. Attach additional pages as needed.
Court proceedings ............................................. No Yes _______________________________________________________________________________
Repossessions .................................................. No Yes _______________________________________________________________________________
Anticipated increase in income ......................... No Yes _______________________________________________________________________________
Bankruptcies/receiverships ............................... No Yes _______________________________________________________________________________
Recent transfer of assets .................................. No Yes _______________________________________________________________________________
Beneciary to trust, estate, prot sharing, etc. ... No Yes _______________________________________________________________________________
Last Oregon income tax return led .................. Year:_______ _______________________________________________________________________________
Total number of exemptions claimed ................ ___________ ________________________________________________________________________________
Adjusted gross income from return ................... $__________ ________________________________________________________________________________
List any vehicles, equipment, or property sold, given away, or repossessed during the past three years. Attach additional pages as needed.
Year, make, model of vehicle, or property address Who took possession Value
D. Physical address
Type
(single- or multi-family dwelling,
lot, rental, etc.)
Mortgage lender’s name and address
Parcel number:_______________
How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________
Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________
Total Equity. Enter this amount on line 9, Section 4 (asset and liability analysis) . . . . . . . . .
$
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150-101-159 (Rev. 01-17)
Form OR-SFC, Financial Statement—Page 5
1. Cash
2. Bank accounts / balance (from section 3)
3. Safe deposit box value of contents (from section 3)
4. Enter vehicles equity (from section 3)
5. Vehicle equity formula (line 4 - $3000, if less than -0-, enter -0-) This line for use on form 150-101-157, Settlement Offer Application only.
6. Personal property (from section 3)
7. Loan / cash surrender value for life insurance (from section 3)
8. Securities (from section 3)
9. Current real estate equity (from section 3)
10. Notes
11. Accounts receivable
12. Judgements / settlements received or pending
13. Interest in trusts
14. Interest in estates
15. Partnership interests
16. Major machinery / equipment, etc.
17. Business inventory
18. Other assets: (specify): (Example: $1,000 guns / $200 jewelry / $800 gold)
19. Other assets (specify):
20. Total assests ....................................................................................................................................................................................
Immediate assets. Totals
Section 4. Assets and liability analysis
$
21. Property 1:
22. Property 2:
23. Property 3:
24. Total equity from properties listed on additional sheet (if applicable)
25. Total of all real property equity (add the Equity column from lines 21 thru 24)
26. Enter dollar amount from line 20
27. Total value of all immediate assets and real property equity (line 25 plus line 26) .............................
Real property equity. From Section 3. Liens or cost of sale don’t reduce equity (can’t be less than -0-).
Address or location
$
28. Amount owed to credit cards and lines of credit (from Section 3)
29. Taxes owed to IRS (provide a copy of recent notices)
30. Other liabilities (specify):
31. Other liabilities (specify):
32. Other liabilities (specify):
33. Total liabilities .................................................................................................................................................................................
Current liabilities. Include judgements, notes, and other charge accounts. Do not include vehicle or home loans.
$
Totals
Mortgage payoff amount
Equity
RMV from property tax statement
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150-101-159 (Rev. 01-17)
Form OR-SFC, Financial Statement—Page 6
34. Wages / salaries / tips (yours)
35. Social Security income (yours)
36. Pension / annuities (yours)
pension
annuities
both
37. Disability (yours)
38. Wages / salaries / tips (spouse/RDP’s)
39. Social Security income (spouse/RDP’s)
40. Pension / annuities (spouse/RDP’s)
pension
annuities
both
41. Disability (spouse/RDP’s)
42. Interest / dividends / royalties (average monthly)
Income. Attach copies of all income sources that contribute to household expenses (minimum three months).
Section 5. Monthly income and expense analysis
Totals
List Net Income
$
55. Rent / mortgage / real estate secured line(s) of credit
56. Real estate taxes (Is this included in your mortgage payment? No Yes)
57. Personal home owners / renters insurance: ( ) Assoc. fees: ( )
58. Personal utilities: Electric: ( )
Natural gas / oil: ( ) Phone, internet, & cable: ( )
Garbage: ( ) Water / sewer: ( )
59. Food / clothing / other Items: No. of people: ( ) Their ages: ( )
60. Auto payments / lease
61. Auto insurance
62. Auto maintenance / fuel / other transportation
63. Medical payments (not covered by insurance) (provide proof)
64. Estimated tax payments (provide proof)
65. Court ordered payments (alimony, child support, restitution, not deducted from your paycheck)
Personal expenses (actually paid). (May be limited by federal standards.)
Amount
If renting—name, address, and phone number of landlord
43. Payments from trust / partnerships / entities
44. Unemployment
45. Other income (specify)
46. Other income (specify)
47. Other income (specify)
List Gross Income
48. Business income (yours)
49. Business income (spouse/RDP’s)
50. Rental income
51. Child support
52. Alimony
53. Seller carried contracts / sales
54. Total income ...........................................................................................................................................................................
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150-101-159 (Rev. 01-17)
Form OR-SFC, Financial Statement—Page 7
66. Garnishments (specify)
67. Delinquent tax payments (other than Oregon state taxes, IRS, etc.)
68. Work related child care expenses
69. Other expenses (do not include unsecured debt) (specify)
70. Total personal expenses .......................................................................................................................................................
Personal expenses (actually paid). (continued) (May be limited by federal standards.)
Amount
$
Business expenses (actually paid). Provide current general ledger and prot / loss.
71. Materials purchased (specify)
72. Supplies (specify)
Amount
73. Installment payments (specify)
74. Monthly payments (specify)
75. Rent / mortgage
76. Insurance
77. Business utilities: Electric: ( )
Natural gas / oil: ( ) Phone, internet, & cable: ( )
Garbage: ( ) Water / sewer: ( )
78. Net wages and salaries paid to employees
79. Current taxes (payroll / business)
80. Other: Specify: (do not include unsecured debt)
81. Total business expenses .....................................................................................................................................................
82. Net disposable income (line 54 minus lines 70 and 81)........................................................................................................
$
$
If renting—name, address, and phone number of landlord
Please provide any additional information not already included. Attach additional pages as needed. All household income must be included.
Section 6. Additional information
Section 5. (continued) Monthly income and expense analysis
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150-101-159 (Rev. 01-17)
Form OR-SFC, Financial Statement—Page 8
Please provide any additional information not already included. Attach additional pages as needed. All household income must be included.
Section 6. (continued) Additional information
Section 7. Authorization to disclose
Under penalties of perjury, I declare that I have examined this statement of assets, liabilities, and other information, and to the best
of my knowledge and belief, it is true, correct, and complete. I (we) authorize the Oregon Department of Revenue to verify any
information on this nancial statement which may include credit reports.
Sign
here
X
X
Your signature Date
DateSpouse’s signature (if applying jointly, both must sign even if only one had income)
Return your completed form to: Oregon Department of Revenue
PO Box 14725
Salem OR 97309-5018
Your proposed monthly payment ..................................................................................................................... $
Your proposed payment date
...........................................................................................................................................
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