FINANCIAL STATEMENT

Employer Payroll Tax Account Number:                           Business Name: 

Phone Number: Home                                        Business                                        ext. 

                                                         Fax Number: 
I. Personal Information:

 Applicant:                                              Spouse/Registered Domestic Partner:

 Name:                                                   Name: 

 Address:                                                Address: 

 Last 4 Digits of SSN:  Driver License No.:              Last 4 Digits of SSN:  Driver License No.:

 Date of Birth:                                          Date of Birth: 

Dependents:
 Name                             Age Relationship to Me          Other Monthly Income Source

All sections should include both the applicant’s and spouse’s information.
Be sure to include separate and combined assets, and information where applicable.

II. Liquid Assets

Cash on Hand                                                                                           $ 

Bank Accounts:  (Include Savings and Loans, Credit Unions, IRA and Retirement Plans, Trust Funds, etc.)

 Name of Institution              Address                               Account Number                    Balance
                                                                                                       $ 
                                                                                                       $ 

Accounts/Notes Receivable: (Anybody who owes you money)

 Name                             Address                               Payment Due Date                  Amount
                                                                                                       $ 
                                                                                                       $ 

DE 926B Rev. 18 (7-19) (INTERNET)           Page 1 of 5                                                          CU

Available Credit Sources: (Credit Unions, Lines of Credit, Charge Cards with cash advance features, etc.)

Type of Account or Card                          Name and Address                                          Credit Available

                                                                                                         $ 

                                                                                                         $ 

Securities: (Stocks, Bonds, Mutual Funds, Money Market Funds, Government Securities, etc.)

Kind           Quantity/Denomination                               Location                                Value

                                                                                                         $ 

                                                                                                         $ 

Life Insurance:

Name of Company                   Policy Number               Type          Face Amount                    Loan Value

                                                                                                         $ 

                                                                                                         $ 

III. Personal Assets (Vehicles, Boats, RVs, Motorcycles, etc.)

Year Make              Model      License Number Market Value   Balance Due Legal Owner                    Equity

                                                                                                         $ 

                                                                                                         $ 

                                                                                                         $ 

IV. Real Property Assets (Include Partnerships and Investments)

Ownership      Physical Address   County         Market Value   Mo. Payment               Balance Due      Equity

                                                                                                         $ 

                                                                                                         $ 

                                                                                                         $ 

V. Monthly Income Information

Applicant: (Attach last three months pay stubs.)              Spouse/Registered Domestic Partner:  
                                                              (Attach last three months pay stubs.)

Employer Name and Address                                     Employer Name and Address

Gross Wages/Salaries                                          Gross Wages/Salaries

$                                                             $ 

DE 926B Rev. 18 (7-19) (INTERNET)                Page 2 of 5                                                     CU

Mandatory Payroll Deductions:
               Taxes (Federal, State, FICA, SDI) $ 

               Medical Insurance                            $ 

               Retirement $ 

               Court Ordered Payments                       $ 

               Other Payroll Deductions (List)              $ 
Net Wages/Salaries $0

Net Business Income $ 

Commissions, Bonuses, Overtime $ 

Net Rental Income $ 

Interest and Dividends $ 

Alimony (Name and Address) $ 

Other Income: (Identify)

                                                      $ 

                                                      $ 

VI. Monthly Expense Information (Necessary Living Expenses)
          (Mark the appropriate box)

Support Payment:           Child                 Spousal    $ 

  Rent             Mortgage                                 $ 

Utilities (gas, electric, water, etc.)                      $ 

Phone                                                       $ 

Life Insurance                                              $ 

Vehicle Expenses:                     Payment Vehicle No. 1 $ 

                                      Payment Vehicle No. 2 $ 

                                      Insurance             $ 

                                      Fuel                  $ 

Food                                                        $ 

Clothing                                                    $ 

Medical Expenses                                            $ 

Current Liabilities:   Internal Revenue Service             $ 
                       Other Tax Agencies (List):

                                                            $ 

                                                            $ 
                                 Subtotals This Page        $           0  $                         0
                                                            (A) Expenses/Deductions  (B) Wages/Income

DE 926B Rev. 18 (7-19) (INTERNET)                           Page 3 of 5                               CU

General Creditors: (Credit cards, loans, etc.)           Minimum Payment

                                                $ 

                                                $ 

                                                $ 

                                                $ 

                                                $ 

Miscellaneous Expenses:

                                                $ 

                                                $ 

                                 Subtotal This Page      $              0 
                                                         (C) Expenses

               Grand Total From Pages 3 and 4            $              0 $                              0 
                                                         (A+C) Expenses/Deductions (B) Wages/Income

VII. Other Information (If yes, provide dates and explain below.)
                                                                                   Yes No
Professional/Contractor Licenses                                                                  

Court Proceedings                                                                                 

Bankruptcies                                                                                      

Repossessions                                                                                     

Participation or beneficiary to trust, estate, etc.                                               

Health considerations that will affect earning potential                                          

Explanation: 

Do you anticipate an increase in income? Or have you had a recent transfer of assets of any kind?    Yes        No 

If yes, please explain: 

Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, 
liabilities and other information is true, correct and complete. I also understand any costs incurred to verify questionable 
information may be my responsibility.

Your Signature                                                                                           Date

Additional Comments: 

DE 926B Rev. 18 (7-19) (INTERNET)                        Page 4 of 5                                               CU

                                  HOW TO PREPARE THE FINANCIAL STATEMENT

Complete all requested information. Write “N/A” (not applicable) in those areas that do not apply to you. If the 
form is incomplete and/or unsigned, we will not be able to consider your request for a payment proposal. If 
you are self-employed or a partner or officer in an active business, include all business and personal assets, and 
expenses in all the sections. The financial statement must include information on both you and your spouse. 
The areas explained below are those for which we have found to be most difficult to complete or more specific 
information is to be provided for full disclosure. You may attach additional pages if needed.

Section I. Personal Information
List all persons dependent upon you, in whole or in part, for support. Include their name, age, relationship to you, 
and any income the dependents receive along with the source of income.

Section II. Liquid Assets
Bank Account – Enter all accounts even if there is currently no balance. DO NOT enter bank loans. You may be 
requested to furnish bank statements for the last six (6) months.
Accounts/Notes Receivable – Enter requested information. Also attach a separate list describing when the receivable 
is due and how frequent (i.e., regular customer or one-time customer). Include anyone who owes you money.
Available Credit Sources – List only credit lines or cards by a bank, credit union, or savings and loan that have 
cash advance features.

Section III. Personal Assets
Enter all vehicles, boats, RVs, motorcycles, campers, etc. You may be requested to furnish a list detailing where 
the assets are located, the registered owners and lien holders, and expected payoff dates.

Section IV. Real Property Assets
List all real estate that you own or are purchasing, both as an individual or with others. Attach a list of all owners 
names and type of ownership (joint tenants, tenants in common), describe type of mortgage payments and rental 
income amounts, and what the property is used for (residence, vacation, office, or shop rental).

Section V. Monthly Income Information
Enter gross amount of wages, salary, commission, or draw amount and frequency (attach pay stubs for the last 
three [3] months). If you are self-employed, enter the NET business income (that is what you earn after you have 
paid your ordinary, necessary monthly business expenses) and attach a current profit/loss statement and balance 
sheet. Enter mandatory payroll deductions (regular withholdings for state and federal taxes, and Social Security; 
do not include insurance payments, loan payments, wage garnishments, etc.). List net rental income. Identify 
sources of other income.

Section VI. Monthly Expense Information
Necessary Living Expenses – Attach an itemized list for medical, insurance, vehicle, and other expenses. You 
may be requested to submit documentation that court ordered payments and child/spousal support payments 
have been paid for the last six (6) months and are currently being paid. You may also be requested to submit 
documentation of all wage garnishments, payment plans, estimated tax payments, and settlement offers with the 
Internal Revenue Service, other tax agencies, and general creditors.

Note: Total household income and expenses are to be listed for both you and your spouse, even if only one 
spouse has a tax liability.

Section VII. Other Information
Other Information – Mark the appropriate box. For all “yes” answers, enter full explanation. If you have any 
professional licenses, please explain the type and provide the license number.
Health/Medical Considerations – Describe disability or medical considerations that do or will affect current or 
future financial status or earning potential for either you or your spouse.

DE 926B Rev. 18 (7-19) (INTERNET)      Page 5 of 5                                              CU