Financial Statement
STATE OF CALIFORNIA
FRANCHISE TAX BOARD
INFORMATION WILL BE VERIFIED (FILL OUT FINANCIAL STATEMENT COMPLETELY)
Taxpayer:
Phone Numbers (Circle best daytime number):
Address:
Home:
Work:
City:
State:
ZIP:
Spouse’s Work:
Driver License Number:
Personal Fax:
Spouse:
Social Security Numbers:
Date of Birth:
Address:
Taxpayer:
Taxpayer:
City:
State:
ZIP:
Spouse:
Spouse:
Driver License Number:
LIST ALL DEPENDENTS AND NON-RELATIVES LIVING WITH YOU If additional space is needed, attach a separate sheet.
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
EMPLOYMENT INFORMATION
EMPLOYMENT INFORMATION
TAXPAYER
SPOUSE
Employer/Business Name:
Employer/Business Name:
Address:
Address:
City:
State:
ZIP:
City:
State:
ZIP:
Employer/Business Phone Number:
Employer/Business Phone Number:
Employer/Business Fax Number:
Employer/Business Fax Number:
Occupation/Profession:
Occupation/Profession:
How long employed:
How long employed:
Marital status on your W-4:
Single
Married
Marital status on your W-4:
Single
Married
Number of exemptions you claim:
Number of exemptions you claim:
BANK ACCOUNTS Include Savings & Loans, Credit Unions, CD’s, IRA’s. If additional space is needed, attach separate sheet.
Type of Account
Name of Institution
Address
Account No.
Balance
(Checking/Savings)
(Joint/Separate)
REAL ESTATE If additional space is needed, attach separate sheet.
Address/County of Property
Date Purchased
Current Value
Mortgage Balance
Paid to: (Lender Name)
MOTOR VEHICLES If additional space is needed, attach a separate sheet.
Year, Make, and License Number
Date Purchased
Current Value
Loan Balance
Date Loan Will Be Paid Off
1.
2.
3.
LIFE INSURANCE If additional space is needed, attach a separate sheet.
Amount You Can
Amount You Can
Name of Company
Name of Company
Borrow on Policy
Borrow on Policy
OTHER ASSETS Things you own or are buying, such as stocks, bonds, boats, etc. If additional space is needed, attach a separate sheet.
Description
Current Value
Loan Balance
Date Loan Will Be Paid Off
FTB 3561 C2 (REV 7-97) PAGE 1