Form De 9406 - Combined Statement Of Financial Condition And Income And Expense Declaration Page 2
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5E. 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
DEDUCTIONS FROM GROSS MONTHLY INCOME
Total Earnings (Include commissions, bonuses,
and overtime.) --------------------------------------------
$
State Income Taxes ----------------------------------
$
Pensions and Retirement -----------------------------
Federal Income Taxes -------------------------------
Property Taxes (Not included in house
Social Security -------------------------------------------
Payment.) ------------------------------------------------
Disability and/or Unemployment Insurance ------
Social Security (OASDI) -----------------------------
Public Assistance (Welfare, AFDC
State Disability Insurance ---------------------------
Payments, etc.) -------------------------------------------
Child and/or Support Orders
(Attach any support orders.) --------------------------
Medical and Other Insurance ----------------------
Dividends and Interest ---------------------------------
Union and Other Dues --------------------------------
Rents (Gross receipts, less cash expenditures –
attach statement.) ---------------------------------------
Retirement and Pension Fund ---------------------
Contributions to Household Expenses From
Other Sources --------------------------------------------
TOTAL REQUIRED DEDUCTIONS --------------
$
OTHER DEDUCTIONS FROM INCOME
Income From Business or Profession --------------
Income From Partnership ------------------------------
Savings Plan -------------------------------------------
---------------------------
Income From Annuity
Other (Itemize) -----------------------------------------
Income From Estate or Trust -------------------------
Other Income (Itemize) --------------------------------
GROSS MONTHLY INCOME ----------------------
LESS DEDUCTIONS FROM INCOME ----------
NET PERSONAL INCOME -------------------------
$
LESS MONTHLY EXPENSES (Page 3) --------
$
TOTAL EARNINGS -------------------------------------
NET DISPOSABLE INCOME ----------------------
$
F. Withholding Information – Taxpayer
Self
Spouse/Registered
Domestic Partner
Filing Status (shown
on Income Tax Return)
No. of Dependents
No. of Exemptions You Claim
DE 9406 Rev. 3 (2-11) (INTERNET)
Page 2 of 5
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