COMBINED STATEMENT OF FINANCIAL CONDITION 
                                           AND INCOME AND EXPENSE DECLARATION 
I.TAXPAYER
Name  (First)                                       (Middle)                              (Last)            Date of Birth (Month, Day, Year)            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)            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.   4 (2-19) (INTERNET)                                                        Page       1of5                                                                                 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.   4 (2-19) (INTERNET)                                         Page       2of 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.   4 (2-19) (INTERNET)                                                     Page     3of 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.   4 (2-19) (INTERNET)                                       Page     4of 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.   4 (2-19) (INTERNET)                                                 Page5of     5