Free TR01A - California

FINANCIAL DECLARATION - Traffic Petition
Docket Number: ________________

Full Name: __________________________________________ Age: ________ Date of Birth: ___________________ Address: ________________________________________________________ Telephone: _____________________
Street City

Marital Status:

Single ______

Married ______

Divorced ______

Separated ______

Widowed ______

Name of wife/husband: ___________________________________ Children:

Number ______ Ages ___________

Social Security Number: _________________________________ Driver's License No. _______________________

EMPLOYMENT RECORD

SPOUSE EMPLOYMENT

Employer: Address: City: Type of Job: Gross Salary: Take Home:

_______________________________ _______________________________ _______________________________ _______________________________ $__________________ (Week/Month) $__________________ (Week/Month)
OTHER INCOME

Employer: Address: City: Type of Job: Gross Salary: Take Home:

_______________________________ _______________________________ ___________________________ _______________________________ $__________________ (Week/Month) $__________________ (Week/Month)

LIST YOUR MONTHLY EXPENSES

Unemployment & Disability Social Security Welfare, AFDC Veterans Benefits Workers Compensation Child Support Payments Support from parents All Other Income

$ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________

Rent or House Payment Car Payments Medical Payments Loan Payments Clothing & laundry Food Other Payments

$ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________

WHO DO YOU OWE? WHAT DO YOU OWN? LIST VALUE

Name

Monthly Payment

Balance Owed

Cash House:

$ _______________________ $ _______________________

____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________

Cars & Other Vehicles $ _______________________ Life Insurance Bank Accounts
Name of Bank

$ _______________________ $ _______________________
Branch

____________________________________________

I declare under penalty of perjury that the foregoing Financial Declaration is true and correct and if sworn as a witness, I could testify competently thereto. Executed at ____________________, this ______ day of _____________, 200___ .

___________________________________________ Signature of Petitioner
Local form TR01a (0511)