Fill a Valid Illinois Boa 4 Form

The Illinois BOA-4 form is a Financial Information Statement designed for individuals to report their financial status to the Illinois Department of Revenue. It collects essential details about personal and employment information, as well as financial assets and liabilities. Completing this form accurately is crucial for proper assessment of your financial situation, so be sure to fill it out by clicking the button below.

Open Illinois Boa 4 Editor

Example - Illinois Boa 4 Form

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,
						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 ________________________________________________
							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,
					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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Fact Name	Description
Form Purpose	The Illinois BOA-4 form is used to collect financial information from individuals for tax assessment purposes.
Governing Law	This form is authorized under the Illinois Income Tax Act.
Marital Status Options	Individuals must indicate their marital status, selecting from options such as single, married, separated, or head of household.
Employment Information	Section 1 of the form requires details about the individual's employment, including current or former employer's name and length of employment.
Financial Disclosure	Part 2 requires individuals to disclose bank accounts, charge cards, real property, and various insurance policies.
Next of Kin	Individuals must provide the name and address of a next of kin, other than a spouse, for contact purposes.
Income and Expenses	Part H analyzes monthly income and expenses, requiring individuals to detail sources of income and necessary living expenses.
Signature Requirement	The form must be signed by the petitioner and, if applicable, by the spouse, under penalties of perjury.
Penalties for Non-Disclosure	Failure to provide required information may result in the form not being processed by the Illinois Department of Revenue.
Form Version	The current version of the BOA-4 form is R-4/01, as indicated on the document.

Fill a Valid Illinois Boa 4 Form

Example - Illinois Boa 4 Form

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