Form De 9406 - Combined Statement Of Financial Condition And Income And Expense Declaration Page 3
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5IV. STATEMENT OF FINANCIAL CONDITION
A.
ASSETS
LIABILITIES
Cash ---------------------------------------------------------
$
Rent ----------------------------------------------------------
$
Real Estate ------------------------------------------------
Food ----------------------------------------------------------
Furniture and Fixtures ---------------------------------
Clothing ------------------------------------------------------
Machinery and Equipment ----------------------------
Utilities -------------------------------------------------------
Motor Vehicles, Airplanes, or
Boats -------------------------------------------------------
Auto Payments ---------------------------------------------
Securities, Bonds or Savings Bonds ---------------
Auto Expenses (Gas, oil, insurance, etc.)-----------
Installment Payments (Itemize on
Cash Surrender Value of Life Insurance ----------
separate sheet, if necessary.) -------------------------
Accounts Receivable and/or
Child and/or Support Orders
Notes Receivable ---------------------------------------
(Attach any support orders.) ---------------------------
Merchandise Inventory --------------------------------
Life Insurance Premiums -------------------------------
Other Assets (Itemize)----------------------------------
Medical Expenses ----------------------------------------
Miscellaneous (Child care, laundry,
(Attach additional pages as needed.)
school, etc.) ------------------------------------------------
TOTAL ASSETS ----------------------------------------
$
TOTAL LIABILITIES -------------------------------------
B. I have accounts in the following bank(s), credit union(s), or financial institution(s)
Name of Bank, Credit Union, or Financial Institution
Account Number
Address
C. I rent a safety deposit box.
No
Yes
Box is rented in
My name
Another name
Name of Boxholder
Name of Bank
Address of Bank
D. Description of Real Estate (e.g., house and lot, Sacramento County):
Fair Market Value
Balance Due
$
$
TOTAL REAL ESTATE VALUE -------------------------------------------------------------------------------------------------
$
$
E. I have filed a Declaration of Homestead for Real Property.
No
Yes
DE 9406 Rev. 3 (2-11) (INTERNET)
Page 3 of 5
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