PLEASE TYPE OR PRINT
BOE-403-E (FRONT) REV. 6 (9-96)
STATE BOARD OF EQUALIZATION
INDIVIDUAL FINANCIAL STATEMENT
ACCOUNT NUMBER
OFFICE:
Respond By
Please attach copies of your income tax returns for the last two years.
NAME (First & initial)
LAST
SOCIAL SECURITY NUMBER (See Form
DATE OF BIRTH
BOE-324-A, for SS# disclosure information.)
PRESENT HOME ADDRESS (number and street or rural route)
NAME OF SPOUSE IN FULL
SPOUSE’S SOCIAL SECURITY NUMBER
SPOUSE’S DATE OF BIRTH
CITY, TOWN OR POST OFFICE
STATE
ZIP
HOME TELEPHONE
CHILDREN LIVING WITH YOU
OTHER DEPENDENTS
Number
Age
PRESENT EMPLOYER
EMPLOYER’S TELEPHONE
DRIVERS LICENSE NUMBER
STATE
EXP. DATE
EMPLOYER’S ADDRESS
LENGTH EMPLOYED
MONTHLY GROSS
SPOUSE’S DRIVERS LICENSE NUMBER
STATE
EXP. DATE
OCCUPATION
UNION LOCAL AND ADDRESS
BANKS, SAVINGS & LOAN, and CREDIT UNIONS
Name
Address
Type of Accounts
SPOUSE’S PRESENT EMPLOYER
SPOUSE’S EMPLOYER’S TELEPHONE
SPOUSE’S EMPLOYER’S ADDRESS
SPOUSE’S LENGTH EMPLOYED
SPOUSE’S MONTHLY GROSS
SPOUSE’S OCCUPATION
SPOUSE’S UNION LOCAL AND ADDRESS
MONTHLY INCOME
MONTHLY EXPENSES
Monthly Take Home Pay
HOUSE / RENT PAYMENT
Dates paid:
$
Mortgage payment or
Landlord Telephone (
)
$
1
Name
Spouse’s Monthly Take Home Pay
Dates paid:
$
Address
City, state & zip
Dividends Received From
$
2
Food
$
3
Transportation (Work related only—Do not include car payment)
$
Interest Received From
$
COURT ORDERED
Child support
Alimony
Other (attachment)
$
Pensions
$
Payable to:
Telephone (
)
4
Name
Social Security
$
Address
City, state & zip
Alimony/Child Support Received
$
5
Utilities
$
6
Childcare/babysitter, paid to:
$
Other (please explain)
$
7
Insurance expense, Car $
Life $
Home $
$
8
Union dues $
Union name/local no.
$
$
9
Total expenses (add Lines 1 through 8)
$
10
Total of installments (from page 2, Line 10)
$
TOTAL MONTHLY INCOME
$
11
Total monthly expenditures (add Lines 9 & 10)
$