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Under the penalties of perjury, I hereby certify that for the calendar year ended December 31, 19___, the following income was received by me: Wages and salaries: $______________ Commissions: $______________ Bonuses: $______________ Overtime: $______________ Dividends $______________ Severance Pay $______________ Pension: $______________ Interest: $______________ Trust Income: $______________ Annuities: $______________ Capital Gains: $______________ Title II benefits: $______________ Workers' Comp: $______________ Judgments: $______________ Unemployment: $______________ Gifts, prizes, etc.: $______________ Alimony: $______________ Self-employment: $______________ Other:___________: $______________
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[Signature]
State of ________________ ) County of ______________ )
Sworn to and subscribed before me this _____ day of ____________, 19___.
_________________________________
[Notary]
My Commission Expires:________________ |
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