CDTFA-403-E (FRONT) REV. 12 (3-18)                                                                                                                               STATE OF CALIFORNIA 
INDIVIDUAL FINANCIAL STATEMENT                                   PLEASE TYPE OR PRINT                  CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION 
ACCOUNT NUMBER 
                                                                                                                  Respond By: 
                Please attach copies of your income tax returns for the last two years. Documentation is required to support your income and expenses. 
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                      SPOUSE/DOMESTIC PARTNER (SSN)     SPOUSE/DOMESTIC PARTNER (DOB) 
                                                                                                                        -             -                     /          / 
CITY, TOWN, OR POST OFFICE               STATE          ZIP HOME TELEPHONE                  CELL PHONE           CHILDREN LIVING WITH YOU          OTHER DEPENDENTS  

PRESENT EMPLOYER                                            EMPLOYER’S TELEPHONE                                 DRIVER LICENSE NUMBER (DL)        STATE             EXP. DATE 

EMPLOYER’S ADDRESS                                          LENGTH EMPLOYED                 MONTHLY GROSS INCOME SPOUSE/DOMESTIC PARTNER (DL)      STATE             EXP. DATE 

OCCUPATION                                                  PERSONAL EMAIL ADDRESS                               BANKS, CREDIT UNIONS, and OTHER FINANCIAL INSTITUTIONS 
                                                                                                                 Name                      Address               Type of Accounts 
SPOUSE/DOMESTIC PARTNER PRESENT EMPLOYER                    EMPLOYER’S TELEPHONE 

EMPLOYER’S ADDRESS                                          LENGTH EMPLOYED                 MONTHLY GROSS INCOME 

OCCUPATION                                                  BUSINESS EMAIL ADDRESS 

                                   MONTHLY INCOME                                                                       MONTHLY EXPENSES 
Monthly take-home pay                                                                                  MORTGAGE / RENT PAYMENT 
Dates paid:                                             $                          Mortgage or          Rent payment - Landlord telephone:                       $  
                                                                            1 
Spouse/domestic partner monthly take-home pay                                      Name: 
Dates paid:                                             $                          Address: 
                                                                            2      Food:                                                                         $  
Dividends received from: 
                                                        $                   3      Housekeeping supplies:                                                        $  
                                                                            4      Apparel and services:                                                         $  
Interest received from: 
                                                        $                   5      Personal care products and services:                                          $  
                                                                            6      Transportation (work related only – do not include car payment):              $  
Pensions                                                $                                                        COURT ORDERED 
                                                                                     Child support              Alimony               Other (attachment) 
Social Security                                                             7 
                                                        $                          Payable to:                             Telephone: 
                                                                                   Address:                                                                      $  
Alimony/child support received: 
                                                        $                   8      Utilities (electric/gas, water, trash, telephone):                            $  
                                                                            9      Childcare/dependent care, paid to:                                            $  
Other (please explain) 
                                                        $                   10     Health care expenses (not paid by insurance):                                 $  
                                                                            11                                INSURANCE EXPENSE* 
                                                                            11 
                                                                                   Car  $              Life $     Home $                      Health $           $  
                                                                            12     Miscellaneous (please explain)                                                $  
                                                                            13     Total expenses (add lines 1 through 12)                                       $  
                                                                            14     Total of recurring monthly payments  (from page 2, line 10)                   $  
TOTAL MONTHLY INCOME 
                                                        $                   15     Total monthly expenditures (add lines 13 and 14)                              $  

                                                                                                                                              *Not paid through payroll deductions

CDTFA-403-E (BACK) REV. 12 (3-18)                                                                                                                                                             STATE OF CALIFORNIA 
INDIVIDUAL FINANCIAL STATEMENT                                                                                                   CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION 
 
                                                                 PAYROLL 
          OTHER RECURRING MONTHLY PAYMENTS                       DEDUCT     TYPE: AUTO,                                     ORIGINAL AMOUNT INCURRED                BALANCE      DATE FINAL      AMOUNT OF 
            CREDITOR(S) NAME AND ADDRESS                                    PERSONAL LOAN,                                       DUE        DATE                        DUE      PAYMENT WILL    MONTHLY 
                                                                 YES  NO    ETC.                                                                                                   BE DUE        PAYMENT 

1.                                                                                                                                                                                                   

2.                                                                                                                                                                                                   

3.                                                                                                                                                                                                   
4.                                                                                                                                                                                                   

5.                                                                                                                                                                                                   

6.                                                                                                                                                                                                   
7.                                                                                                                                                                                                   

8.  Other – Please use separate sheet                                                                                                                                                                

9.  Other taxes owed. Please list agencies, year(s) and amounts                                                                                                                                      
10. SUBTOTAL (Add lines 1 thru 9.  Enter here and on 
    page 1, line 14)                                                                                                                                                                           $ 
                                                                                                                             
VEHICLE INFORMATION (Please include the make, model, year and plate number for autos, trailers, vessels, aircraft, etc.).   Do you have a current license/permit with CDTFA?       Yes           No                
                                                                                                                            If yes, please list the account number(s):                                                                                           
1.                                                                                                                           
                                                                                                                              
2.                                                                                                                          Have you filed bankruptcy in the past year?     Yes    No 
                                                                                                                            If yes, list court and case number.                                                                                              
                                  REAL PROPERTY ADDRESS                                                                      
                                                                                                                              
1.                                                                                                                           Your proposed terms to satisfy this amount due:                                        
                                                                                                                            Your proposed terms to satisfy this amount due:                                 
2.                                                                                                                           
                                                                                                                             
                                                                      OTHER PARTNERSHIP(S) / CORPORATION(S) 
                     NAME                                                        ADDRESS                                                                                         TELEPHONE 

1.                                                                                                                                                         

2.                                                                                                                                                         

3.                                                                                                                                                         
 
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.  Signed                                                       Date                      
 
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.  Signed                                                       Date                      

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