BOE-403-E (FRONT) REV. 7 (1-05)
STATE OF CALIFORNIA
INDIVIDUAL FINANCIAL STATEMENT
ACCOUNT NUMBER
PLEASE TYPE OR PRINT
BOARD OF EQUALIZATION
Respond By:
Please attach copies of your income tax returns for the last two years.
NAME (FIRST AND INITIAL) LAST SOCIAL SECURITY NUMBER (SSN) DATE OF BIRTH (DOB)
PRESENT HOME ADDRESS (Number and Street or Rural Route) NAME OF SPOUSE/DOMESTIC PARTNER
-
/ /
OTHER DEPENDANTS
/ /
SPOUSE/DOMESTIC PARTNER SSN
SPOUSE/DOMESTIC PARTNER DOB
CITY, TOWN, OR POST OFFICE
STATE
ZIP
HOME TELEPHONE
CHILDREN LIVING WITH YOU
(
PRESENT EMPLOYER
)
DRIVERS LICENSE NUMBER (DL) STATE EXP. DATE
EMPLOYER'S TELEPHONE
(
EMPLOYER'S ADDRESS OCCUPATION
)
MONTHLY GROSS SPOUSE/DOMESTIC PARTNER DL STATE EXP. DATE
LENGTH EMPLOYED
UNION LOCAL AND ADDRESS
BANKS, SAVINGS & LOAN, and CREDIT UNIONS
Name
SPOUSE/DOMESTIC PARTNER PRESENT EMPLOYER EMPLOYER'S TELEPHONE
Address
Type of Accounts
EMPLOYER'S ADDRESS
LENGTH EMPLOYED
MONTHLY GROSS
OCCUPATION
UNION LOCAL AND ADDRESS
MONTHLY INCOME
MONTHLY EXPENSES HOUSE / RENT PAYMENT
Monthly Take Home Pay Dates paid: Spouse/Domestic Partner Monthly Take Home Pay Dates paid: Dividends Received From Interest Received From Pensions Social Security Alimony/Child Support Received Other (please explain)
$ 1 $ $ $ $ $ $ $ $ 5 6 7 8 9 10 11 4 2 3
TOTAL MONTHLY INCOME
$
Mortgage payment or Landlord Telephone: ( ) Name: Address: City, state & zip: Food Transportation (Work related only Do not include car payment) COURT ORDERED Child support Other (attachment) Alimony Payable to: Telephone: ( ) Name: Address: City, state & zip: Utilities Childcare/babysitter, paid to: Insurance expense, Car $ Life $ Home $ Union dues $ Union name/local no. Total expenses (add lines 1 through 8) Total of installments (from page 2, line 10) Total monthly expenditures (add lines 9 & 10)
$
$ $ $ $
$ $ $ $ $ $ $
BOE-403-E (BACK) REV. 7 (1-05)
STATE OF CALIFORNIA
INDIVIDUAL FINANCIAL STATEMENT
BOARD OF EQUALIZATION
SCHEDULE OF INSTALLMENT AND ANY OTHER PAYMENTS CREDITOR(S) NAME AND ADDRESS
PAYROLL DEDUCT YES NO
TYPE OF DEBT: AUTO, PERSONAL LOAN, ETC.
ORIGINAL AMOUNT OF DEBT
DATE DEBT INCURRED
BALANCE DUE
DATE FINAL PAYMENT WILL BE DUE
AMOUNT OF MONTHLY PAYMENT
1. 2. 3. 4. 5. 6. 7.
8. 9. Other Please use separate sheet
Other tax liabilities. Please list agencies, year(s) and amounts 10. SUBTOTAL (Add lines 1 thru 9. Enter here and on page 1, line 10)
VEHICLE INFORMATION (AUTO, TRAILERS, VESSELS, AIRCRAFT, ETC.)
$ Do you have current Sales Tax Permit? Yes No
1. 2.
REAL PROPERTY ADDRESS
Your proposed terms to satisfy this indebtedness:
1. 2.
OTHER PARTNERSHIP(S) / CORPORATION(S) NAME ADDRESS TELEPHONE
1. 2. 3.
The information stated is true and correct to the best of my knowledge. Signed
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