Financial Statement-State Of California Form Page 2
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3MONTHLY INCOME AND EXPENSES ARE BASED ON ALL MEMBERS OF THE HOUSEHOLD
FTB USE ONLY
MONTHLY INCOME
Net Pay (amount you take home) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Spouse’s Net Pay (amount spouse takes home) . . . . . . . . . . . . . . . . . . . .
$
Rents Received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Pensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Disability/Social Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Commissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Other income
Dividends
Interest
Child Support
Royalties
Alimony
Other (List:
)
$
Income contributed from other people living in your home . . . . . . . . . . . . . .
$
TOTAL MONTHLY INCOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
MONTHLY EXPENSES
(Expenses must be reasonable for the size of your family, location, and circumstances)
Homeowner
Renter
Amount of payment . . . . . . . . . . . . . . . . .
$
Payments made to:
Address:
City/State/ZIP
Phone:
Alimony/Child Support (If payroll deduction, do not list) . . . . . . . . . . . . . . .
$
Groceries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Childcare/Daycare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Utilities:
Electricity, Heat, Water, Sewer . . . . . . . . . . . . . . . . . . . .
$
Telephone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Transportation (Number of miles to and from work
) . . . . . . . . .
$
Doctor and medical bills not paid by insurance (Total Due
) .
$
Insurance (not paid through payroll deduction)
Vehicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Homeowners/Renters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
IRS Payment Arrangement (Total Amount Due
) . . . . . . .
$
Quarterly Estimate Payments:
Federal
State
.
$
Vehicle Payments (List Lien Holder)
1.
$
2.
$
3.
$
CREDIT OBLIGATIONS
NAME OF
CREDIT
AMOUNT
AVAILABLE
CREDITOR/CARD
LIMIT
OWED
CASH ADVANCE
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
7.
$
OTHER EXPENSES
(List all other personal obligations not included above)
1.
$
2.
$
3.
$
TOTAL MONTHLY EXPENSES . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
MONTHLY PAYMENT PROPOSAL . . . . . . . . . . . . . . . . . . . . . . . . .
$
(Begin making payments NOW. You will be notified of our decision.)
FTB 3561 C2 (REV 7-97) PAGE 2
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