FINANCIAL STATEMENT

Employer Payroll Tax Account Number: __________________         Business Name: ___________________________

Phone Number: Home (              )  __________________________ Business (    )  ___________________________
                                                             Fax Number: (    )  ___________________________
I. Personal Information:

 Applicant:                                            Spouse/Registered Domestic Partner:

 Name:                                                 Name:

 Address:                                              Address:

 SSN:                  Driver License No.:             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. 17 (2-19) (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 Bal. 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. 17 (2-19) (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:        o Child            o Spousal        $ ____________________

o Rent         o 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. 17 (2-19) (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. 17 (2-19) (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. 17 (2-19) (INTERNET)      Page 5 of 5                                              CU