COMBINED STATEMENT OF FINANCIAL CONDITION AND INCOME AND EXPENSE DECLARATION I.TAXPAYER Name (First) (Middle) (Last) Date of Birth (Month, Day, Year) Last 4 Digits of Social Security Number Address (Number and Street) Driver License Number Phone Number (Home) (City, Town, or Post Office) (County) (State) (ZIP Code) Phone Number (Work) Spouse/Registered Domestic Partner’s Name (First) (Middle) (Last) Date of Birth (Month, Day, Year) Last 4 Digits of Social Security Number Spouse/Registered Domestic Partner’s Employer (If self-employed, list here) Spouse/Registered Domestic Partner’s Driver License Number Address (Number and Street) (City, Town, or Post Office) (County) (State) (ZIP Code) Phone Number Nearest Living Relative Not Residing in Household Relationship Address (Number and Street) (City, Town, or Post Office) (County) (State) (ZIP Code) Phone Number II.REPRESENTATIVE OF TAXPAYER (Complete this section if the taxpayer’s representative appears.) Name (If represented by a legal counsel, give name of firm and individual.) Address (Number and Street) (City, Town, or Post Office) (County) (State) (ZIP Code) Phone Number III.TAXPAYER INCOME AND EXPENSE DECLARATION A. An order assigning salary and wages for support is now in effect as to my earnings. The amount payable under that order is: $________________ (A copy of that order is attached.) B. I need the following earnings to support myself and my family: All earnings $ each pay period. C. I am willing for the following amount to be withheld from my earnings during the withholding period. I understand that the Employment Development Department can accept this offer, which will result in the following sum being withheld each pay period. None Withhold $ each pay period. I am paid: Daily Twice a month My Gross Pay is: $ ___________________ Weekly Monthly My Net Pay is : Every two weeks $ ___________________ D. The following persons depend, in whole or in part, on me for support: NAME AGE RELATIONSHIP TO ME MONTHLY INCOME SOURCE DE 9406 Rev. 5 (7-19) (INTERNET) Page 1 of 5 CU |
E. The earnings of persons listed in Item III.D. are now subject to wage assignments and earnings withholding orders as follows (specify): GROSS MONTHLY INCOME DEDUCTIONS FROM GROSS MONTHLY INCOME Total Earnings (Include commissions, bonuses, and overtime.) $ State Income Taxes $ Pensions and Retirement Federal Income Taxes Property Taxes (Not included in house Social Security Payment.) Disability and/or Unemployment Insurance Social Security (OASDI) Public Assistance (Welfare, AFDC Payments, etc.) State Disability Insurance Child and/or Support Orders (Attach any support orders.) Medical and Other Insurance Dividends and Interest Union and Other Dues Rents (Gross receipts, less cash expenditures – attach statement.) Retirement and Pension Fund Contributions to Household Expenses From Other Sources TOTAL REQUIRED DEDUCTIONS $ OTHER DEDUCTIONS FROM INCOME Income From Business or Profession Income From Partnership Savings Plan Income From Annuity Other (Itemize) Income From Estate or Trust Other Income (Itemize) GROSS MONTHLY INCOME LESS DEDUCTIONS FROM INCOME NET PERSONAL INCOME $ LESS MONTHLY EXPENSES (Page 3) TOTAL EARNINGS $ NET DISPOSABLE INCOME $ F. Withholding Information – Taxpayer Self Spouse/Registered Domestic Partner Filing Status (shown on income tax return) Number of Dependents Number of Exemptions You Claim DE 9406 Rev. 5 (7-19) (INTERNET) Page 2 of 5 |
IV.STATEMENT OF FINANCIAL CONDITION A. ASSETS LIABILITIES Cash $ Rent $ Real Estate Food Furniture and Fixtures Clothing Machinery and Equipment Utilities Motor Vehicles, Airplanes, or Boats Auto Payments Securities, Bonds or Savings Bonds Auto Expenses (Gas, oil, insurance, etc.) Installment Payments (Itemize on Cash Surrender Value of Life Insurance separate sheet, if necessary.) Accounts Receivable and/or Child and/or Support Orders Notes Receivable (Attach any support orders.) Merchandise Inventory Life Insurance Premiums Other Assets (Itemize) Medical Expenses Miscellaneous (Child care, laundry, (Attach additional pages as needed.) school, etc.) TOTAL ASSETS $ TOTAL LIABILITIES $ B. I have accounts in the following bank(s), credit union(s), or financial institution(s) Name of Bank, Credit Union, or Financial Institution Account Number Address C. I rent a safety deposit box. No Yes Box is rented in My name Another name Name of Boxholder Name of Bank Address of Bank D. Description of Real Estate (e.g., house and lot, Sacramento County): Fair Market Value Balance Due $ $ TOTAL REAL ESTATE VALUE $ $ E. I have filed a Declaration of Homestead for Real Property. No Yes DE 9406 Rev. 5 (7-19) (INTERNET) Page 3 of 5 |
F. Description of Motor Vehicles, Airplanes, or Boats (Include license, vessel, or tail number.) Fair Market Value Balance Due $ $ TOTAL VALUE $ $ G. Securities, Stocks, Bonds, and Savings Bonds Number of Units Fair Market Value Balance Due $ $ Name of Stockbroker Address H. Description of Furniture and Fixtures, Machinery and Equipment Fair Market Value Balance Due Furniture (Household) $ $ Furniture /Fixtures (Business) Machinery Equipment (Other than motor vehicles) Miscellaneous TOTAL VALUE $ $ I. Life Insurance Policies Now in Effect Right to Change Name of Company Policy Number Policy Amount Cash Surrender Value Balance Due on Loan Beneficiary (Y or N) $ $ $ $ $ $ $ $ $ $ $ $ J. Accounts or Notes Receivable (Furnish a copy of the instrument creating the Accounts or Notes Receivable.) Name Address Phone Number Fair Market Value Balance Due $ $ $ $ $ $ $ $ $ $ DE 9406 Rev. 5 (7-19) (INTERNET) Page 4 of 5 |
K. Other Assets If you have any Life Interest or Remainder Interest, either vested or contingent, in any trust or estate, or are a beneficiary of any trust, complete the following information, and furnish a copy of the instrument creating the trust or estate. Name of Trust or Estate Present Value of Trust Value of Your Interest Annual Income $ $ $ $ $ $ $ $ $ If you are the grantor or donor for any trust, or the trustee or fiduciary for any trust, complete the following information, and furnish a copy of the instrument creating the trust. Name of Corpus or Trust Value $ $ $ If you have any other assets, or interests in assets, actual or contingent, other than those listed herein, describe fully: If any foreclosure proceedings are pending at present on any real estate which you own or in which you have an interest, enter description and location of such real estate. Was the State of California named as a party to the court filings? No Yes If yes, please furnish a copy of the court filings. DECLARATION I declare, under penalty of perjury, that the foregoing instruments are true and complete to the best of my knowledge and belief. Signed on at California. (Date) (City) (County) (Signature) DE 9406 Rev. 5 (7-19) (INTERNET) Page 5 of 5 |