Free Individual Financial Statement - California

BOE-403-E (FRONT) REV. 7 (1-05)

STATE OF CALIFORNIA

INDIVIDUAL FINANCIAL STATEMENT
ACCOUNT NUMBER

PLEASE TYPE OR PRINT

BOARD OF EQUALIZATION

Respond By:
Please attach copies of your income tax returns for the last two years.
NAME (FIRST AND INITIAL) LAST SOCIAL SECURITY NUMBER (SSN) DATE OF BIRTH (DOB)

PRESENT HOME ADDRESS (Number and Street or Rural Route) NAME OF SPOUSE/DOMESTIC PARTNER

-

/ /
OTHER DEPENDANTS

/ /

SPOUSE/DOMESTIC PARTNER SSN

SPOUSE/DOMESTIC PARTNER DOB

CITY, TOWN, OR POST OFFICE

STATE

ZIP

HOME TELEPHONE

CHILDREN LIVING WITH YOU

(
PRESENT EMPLOYER

)
DRIVERS LICENSE NUMBER (DL) STATE EXP. DATE

EMPLOYER'S TELEPHONE

(
EMPLOYER'S ADDRESS OCCUPATION

)
MONTHLY GROSS SPOUSE/DOMESTIC PARTNER DL STATE EXP. DATE

LENGTH EMPLOYED

UNION LOCAL AND ADDRESS

BANKS, SAVINGS & LOAN, and CREDIT UNIONS

Name
SPOUSE/DOMESTIC PARTNER PRESENT EMPLOYER EMPLOYER'S TELEPHONE

Address

Type of Accounts

EMPLOYER'S ADDRESS

LENGTH EMPLOYED

MONTHLY GROSS

OCCUPATION

UNION LOCAL AND ADDRESS

MONTHLY INCOME

MONTHLY EXPENSES HOUSE / RENT PAYMENT

Monthly Take Home Pay Dates paid: Spouse/Domestic Partner Monthly Take Home Pay Dates paid: Dividends Received From Interest Received From Pensions Social Security Alimony/Child Support Received Other (please explain)

$ 1 $ $ $ $ $ $ $ $ 5 6 7 8 9 10 11 4 2 3

TOTAL MONTHLY INCOME

$

Mortgage payment or Landlord Telephone: ( ) Name: Address: City, state & zip: Food Transportation (Work related only ­ Do not include car payment) COURT ORDERED Child support Other (attachment) Alimony Payable to: Telephone: ( ) Name: Address: City, state & zip: Utilities Childcare/babysitter, paid to: Insurance expense, Car $ Life $ Home $ Union dues $ Union name/local no. Total expenses (add lines 1 through 8) Total of installments (from page 2, line 10) Total monthly expenditures (add lines 9 & 10)

$

$ $ $ $

$ $ $ $ $ $ $

BOE-403-E (BACK) REV. 7 (1-05)

STATE OF CALIFORNIA

INDIVIDUAL FINANCIAL STATEMENT

BOARD OF EQUALIZATION

SCHEDULE OF INSTALLMENT AND ANY OTHER PAYMENTS CREDITOR(S) NAME AND ADDRESS

PAYROLL DEDUCT YES NO

TYPE OF DEBT: AUTO, PERSONAL LOAN, ETC.

ORIGINAL AMOUNT OF DEBT

DATE DEBT INCURRED

BALANCE DUE

DATE FINAL PAYMENT WILL BE DUE

AMOUNT OF MONTHLY PAYMENT

1. 2. 3. 4. 5. 6. 7.
8. 9. Other ­ Please use separate sheet

Other tax liabilities. Please list agencies, year(s) and amounts 10. SUBTOTAL (Add lines 1 thru 9. Enter here and on page 1, line 10)
VEHICLE INFORMATION (AUTO, TRAILERS, VESSELS, AIRCRAFT, ETC.)

$ Do you have current Sales Tax Permit? Yes No

1. 2.
REAL PROPERTY ADDRESS

Your proposed terms to satisfy this indebtedness:

1. 2.
OTHER PARTNERSHIP(S) / CORPORATION(S) NAME ADDRESS TELEPHONE

1. 2. 3.

The information stated is true and correct to the best of my knowledge. Signed
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