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                             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



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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 



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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



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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



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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






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