Fillable Printable Financial Statement (De 926B)
Fillable Printable Financial Statement (De 926B)
Financial Statement (De 926B)
FINANCIAL STATEMENT
Employment Development Department
Employer Account Number:Business Name:
Phone Number: Home () Business ()
Fax Number: ()
I.Personal Information:
Applicant:Spouse:
Name:
Name
Address:
Address:
SSN:Driver License No.:
SSN: Driver License No.:
Date of Birth:
Date of Birth:
Dependents:
NameAgeRelationship to MeOther Monthly IncomeSource
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 andLoans, Credit Unions, IRA and Retirement Plans, Trust Funds, etc.)
Name of InstitutionAddressAccount NumberBalance
$
$
Accounts/Notes Receivable: (Anybody who owes you money)
NameAddressPayment Due DateAmount
$
$
DE 926BRev. 16 (5-15) (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 CardName andAddressCredit Available
$
$
Securities:(Stocks, Bonds, Mutual Funds, Money Market Funds, Government Securities, etc.)
KindQuantity/DenominationLocationValue
$
$
Life Insurance:
Name of CompanyPolicy NumberTypeFace AmountLoan Value
$
$
III.Personal Assets(Vehicles, Boats, RVs,Motorcycles, etc.)
Year MakeModelLicense NumberMarket ValueBalance DueLegal OwnerEquity
$
$
$
IV.Real Property Assets(Include Partnerships and Investments)
OwnershipPhysical AddressCountyMarket ValueMo. PaymentBal. DueEquity
$
$
$
V.Monthly Income Information
Applicant:
(Attach last threemonths pay stubs.)
Employer Name andAddress
Spouse:
(Attach last threemonths pay stubs.)
Employer Name andAddress
Gross Wages/Salaries
$
Gross Wages/Salaries
$
DE 926BRev. 16
(5-15) (INTERNET)Page 2 of 5
Mandatory Payroll Deductions:
Taxes (Federal, State, FICA, SDI)$
Medical Insurance$
Retirement$
Court Ordered Payments$
Other Payroll Deductions (List)$
Net Wages/Salaries$
Net Business Income$
Commissions, Bonuses, Overtime$
Net Rental Income$
Interest andDividends$
Alimony (Name andAddress)$
Other Income:(Identify)
$
$
VI.Monthly Expense Information(Necessary Living Expenses)
(Mark the appropriate box)
Support Payment: Child Spousal $
Rent 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$ $
(A) Expenses/Deductions(B) Wages/Income
DE 926BRev. 16 (5-15) (INTERNET)Page 3 of 5
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General Creditors:(Credit cards, loans, etc.)Minimum Payment
$
$
$
$
$
Miscellaneous Expenses
$
$
Subtotal This Page$
(C)Expenses
Grand Total From Pages 3 and 4$ $
(A+C) Expenses/Deductions(B)Wages/Income
VII.Other Information(If yes, provide dates andexplain below.)YesNo
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?YesNo
If yes, please explain:
CertificationUnder 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 SignatureDate
Additional Comments:
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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 dependentsreceive 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
InternalRevenue 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 926BRev. 16 (5-15) (INTERNET)Page 5 of 5
