Fillable Printable Combined Statement Of Financial Condition And (De 9406)

Combined Statement Of Financial Condition And (De 9406)

DE 9406 Rev. 3 (2-11) (INTERNET) Page 1 of 5 CU

COMBINED STATEMENT OF FINANCIAL CONDITION And

INCOME AND EXPENSE DECLARATION

I. TAX PAYER

Name (first) (middle) (last) Date of Birth (mo., day, year) Social Security Number

Address (number and street)

Driver’s License Number

Telephone Number (home)

(City, Town or Post Office) (County) (State) (ZIP Code)

Telephone Number (work)

Spouse/Registered Domestic Partner’s Name (first) (middle) (last)

Date of Birth (mo., day, year)

Social Security Number

Spouse/Registered Domestic Partner’s Employer (If self-employed, list here)

Spouse/Registered Domestic

Partner’s Driver’s License Number

Address (Number and Street) (City, Town, or Post Office) (County) (State) (ZIP Code)

Telephone Number

Nearest Living Relative Not Residing in Household

Relationship

Address (Number and Street) (City, Town, or Post Office) (County) (State) (ZIP Code)

Telephone Number

II. REPRESENTATIVE OF TAXPAYER (Complete this section if Taxpayer’s repr esentative 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)

Telephone Number

III. TAX PAYER INCOME AND EXPENSE DECLARATION

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.)

I need the following earnings to support mys elf and my family:

All earnings $ each pay period.

I am willing for the following amount to be withheld from my earnings during the withholding peri od. I understand that the Employment

Development Department can accept t his off er which will result i n the followi ng sum being withheld each pay period.

None Withhold $ each pay period.

I am paid: Weekly Twice a month

Daily Every two weeks Monthly

My Gross Pay is :

$ ___________________

My Net Pay is:

$ ___________________

The following persons depend, in whole or in part, on me for support:

NAME AGE RELATIONSHIP T O ME MONTHLY I NCOME SOURCE

DE 9406 Rev. 3 (2-11) (INTERNET) Page 2 of 5

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 DEDUCTIO NS FRO M GROSS MONTHLY INCOME

Total Earnings (Include commissions, bonuses,

and overtime.) --------------------------------------------

State I nco me Taxe s -----------------------------------

Pensions and Retirement -----------------------------

Federal Income Taxes --------------------------------

Social Security -------------------------------------------

Property Taxes (Not included i n house

Payment.) -------------------------------------------------

Disability and/ or Unem ployment Insuranc e ------

Socia l Securi ty (OASDI) ------------------------------

Public Assistance (Wel f are, AFDC

Payments, etc.) -------------------------------------------

State Disabili ty Insuranc e ----------------------------

Child and/or Support Orders

(Attach any support orders.) --------------------------

Medical and Other Insurance -----------------------

Dividends and Interest ---------------------------------

Union and Other Dues ---------------------------------

Rents (Gross receipts, l ess cas h expenditures –

attach statement.) ---------------------------------------

Retirement and Pension Fund ----------------------

Contributions t o Household Expens es From

Other Sources --------------------------------------------

TOTAL REQUIRED DEDUCTIONS ---------------

Income From Business or Profession --------------

OTHER DEDUCTI O NS FROM INCOME

Income From Partnership ------------------------------

Savings Plan --------------------------------------------

Income From Annuity ---------------------------

Other (Itemize) ------------------------------------------

Income From Estate or Trust -------------------------

Other Income (Itemize) --------------------------------

GROSS MONTHLY INCOME -----------------------

LESS DEDUCTI O NS FRO M I NCOME -----------

NET PERSONAL INCOM E --------------------------

LESS MO N THLY EXPENSES (Page 3) ---------

TOTAL EARNINGS -------------------------------------

NET DISPOSABLE INC O ME -----------------------

F. Withholding Informat i on – Taxpayer

Self

Spouse/Registered

Domestic Part ner

Filing Status (shown

on Income Tax Return)

No. of Dependents

No. of Exemptions You Claim

DE 9406 Rev. 3 (2-11) (INTERNET) Page 3 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.) -----------

Cash Surrender Value of Life Insurance ----------

Installm ent Payments (Item iz e on

separate sheet, if necessary.) -------------------------

Accounts Receiv able and/or

Notes Receivable ---------------------------------------

Child and/or Support Orders

(Attach any support orders.) ---------------------------

Merchandis e Inventory --------------------------------

Life Insurance Premiums -------------------------------

Other Assets (Itemiz e) ----------------------------------

Medical Expens es ----------------------------------------

(Attach additional pages as needed.)

Miscell aneous (Chil d care, laundry,

school, etc.) ------------------------------------------------

TOTAL ASSETS ----------------------------------------

TOTAL LIABILITIES -------------------------------------

B. I have accounts in the following bank(s), credit union(s), or financi al 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. 3 (2-11) (INTERNET) Page 4 of 5

F. Description of Motor Vehicles, Airplanes, or Boats (Include License, Vessel, or Tail Nmber.)

Fair Market Value Balance Due

TOTAL VALUE ------------------------------------------------------------------------------------------------------------------------

G. Securities, Stocks, Bonds, and Savings B onds

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 (Househol d) -----------------------------------------------------------------------------------------------------------

Furniture /Fixtures (B usiness) -------------------------------------------------------------------------------------------------

Machinery ---------------------------------------------------------------------------------------------------------------------------

Equipment (Other than motor vehicles) -------------------------------------------------------------------------------------

Miscellaneous ----------------------------------------------------------------------------------------------------------------------

TOTAL VALUE -------------------------------------------------------------------------------------------------------------------

I. Life Insurance Policies Now in Effect

Name of Company

Policy Number

Policy Amount

Cash Surrender Value

Balance Due on Loan

Right to Change

Beneficiary (Y or N)

J. Accounts or Notes Receivable (Furnis h a copy of the instrument creating the Accounts or Notes Receivable.)

Name

Address

Phone Number

Fair Market Value

Balance Due

DE 9406 Rev. 3 (2-11) (INTERNET) Page 5 of 5

K. Other Assets

If you have any Life Interest or Remainder Interest, either vested or cont i ngent, in any trust or estat e, or are a beneficiary of any trust, complete the

following i nformation, and furnish a copy of the instrument creati ng 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 fiduci ary for any trust, complete t he 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 foregoin g in struments are true and complete to the best of my knowledge and belief.

Signed on at California.

(Date) (City) (County)

(Signature)