Free TC-805, Collection Information for Individuals - Utah

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Utah State Tax Commission
210 North 1950 West - Salt Lake City - Utah 84134 - Telephone (801) 297-2200

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TC-805 Rev. 1/09

Collection Information For Individuals
Agent s name 1. Taxpayers Names and Addresses (including county) 2. Home Telephone Number 4. Social Security number a. Taxpayer: b. Spouse:

3. Marital Status

Section One: Employment Information
5. Taxpayer s Employer or Business Name and Address 6. Business Telephone 8. Paydays 7. Occupation 9. Type

Partner Employee

Sole

10. Spouse s Employer or Business Name and Address

11. Business Telephone 13. Paydays

12. Occupation 14. Type

Partner Employee

Sole

Section Two: Personal Information
15. Name, Address and Telephone Number of Next of Kin or Other Reference

16. Age and Relationship of Dependents (excluding husband and wife in your household)

17. Number of Exemptions Claimed on W-4.

18. a. Taxpayer s Date of Birth

b. Spouse s Date of Birth

Section Three: General Financial Information
19. Latest Filed State Income Tax Return (Tax Year) 20. Adjusted Gross Income

21. Bank Accounts (including savings and loans, credit unions, IRA and retirement plans, certificates of deposit, money market accounts, savings bonds, etc.) Type of Account Account Number $ Balance

Name of Institution

Address

Total

$

DO NOT mail with your tax return. To insure proper processing, mail separately to: Taxpayer Services Division, 210 North 1950 West, SLC, UT 84134

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Section Three: General Financial Information Continued
22. Bank charge cards, credit unions, savings and loans, lines of credit, signature loan and other liabilities, including taxes. Type of Account or Card Name and Address of Financial Institution Credit Limit Credit Available

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TC-805, Page 2

Amount Owed

Monthly Payment

TOTAL from 22 23. Safe Deposit Boxes Rented or Accessed (List all locations, box numbers and contents)

24. Real Property (Brief description and type of ownership) a. b. c. 25. Life Insurance (Name of Company) Policy Number Type $

Address (Include County and State)

Face Amount $

Accumulated cash Value $

Monthly payment

TOTAL for 25

$

$

$

Section Four: Asset and Liability Analysis
26. Vehicles a. b. c. TOTAL for 26 27. Real property (from item 24) a b c TOTAL for 27 28. Other Assets (recreational vehicles, jewelry, antiques, collectible items, guns, etc.) a. b. c. TOTAL for 28 29. Asset/Payment totals (add totals from lines 22, 25, 26, 27 and 28) $ $ $ $ $ $
Description Value Amount owed Monthly payment Description Model Year License # Value Amount owed Monthly payment

$

$

$

$

$

$

Value

Amount owed

Monthly payment

$

$

$

$

$

$

$

$

$

DO NOT mail with your tax return. To insure proper processing, mail separately to: Taxpayer Services Division, 210 North 1950 West, SLC, UT 84134

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Section Five: Monthly Income and Expense Analysis
INCOME Source 30. Taxpayer s wages/salaries (attach 2 most recent check stubs) 31. Spouse s wages/salaries (attach 2 most recent check stubs) 32. Interest/Dividends 33. Net business income (from form_____) 34. Rental income 35. Pension (taxpayer) 36. Pension (spouse) 37. Child Support 38. Alimony 39. Other 46. Medical Doctor $______ Hospitals $_____ Dentist $_____ Other $______ $ Gross $ Net

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TC-805, Page 3

NECESSARY LIVING EXPENSES Type of expense 40. Rent (do not show mortgage listed in item 27) 41. Groceries (no. of people ____) 42. Payment Totals (from line 29) "Official Use Only" 43. Utilities (average of last 12 months) Gas $______ Electric $_____ Water $_______ Telephone $_____ $ Amount

44. Transportation (bus, fares, gasoline maintenance, etc.) 45. Insurance Home $____ Health $_____ Car $______

47. Payments made to IRS for delinquent taxes 48. Child support 49. Estimated tax prepayments IRS ______ State ______

50. Other expenses (specify)

TOTAL

$

$

TOTAL

$ Net difference

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$

Information contained in this document is subject to verification by the Utah State Tax Commission. You may be required to provide documentation in support of your statement(s).
Under penalties of perjury, I declare that to the best of my knowledge and belief, this statement of assets, liabilities, and other information is true, correct, and complete. Your signature: (required) Date Spouses signature (required if jointly liable) Date

If you need an accommodation under the American s with Disabilities Act, contact the Tax Commission at (801) 297-3811 or Telecommunications Device for the Deaf (801) 297-3819. Please allow three working days for a response. ** Failure to furnish ALL requested information will result in delaying the resolution of your account. DO NOT mail with your tax return. To insure proper processing, mail separately to: Taxpayer Services Division, 210 North 1950 West, SLC, UT 84134