Form Boe-403-E - Individual Financial Statement Page 2
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2BOE-403-E (BACK) REV. 6 (9-96)
STATE BOARD OF EQUALIZATION
INDIVIDUAL FINANCIAL STATEMENT
TYPE OF DEBT:
DATE FINAL
AMOUNT OF
PAYROLL DEDUCT
SCHEDULE OF INSTALLMENT AND ANY OTHER PAYMENTS
ORIGINAL AMOUNT
DATE DEBT
AUTO, PERSONAL
PAYMENT WILL
MONTHLY
BALANCE DUE
CREDITOR(S) NAME AND ADDRESS
OF DEBT
INCURRED
LOAN, ETC.
BE DUE
PAYMENT
YES
NO
1.
2.
3.
4.
5.
6.
7.
8. Other — Please use separate sheet
9. Other tax liabilities. Please list agencies, year(s)
and amounts
10. SUBTOTAL (Add Lines 1 thru 9. Enter here and on
$
Page 1, Line 10)
VEHICLE INFORMATION (AUTO, TRAILERS, VESSELS, AIRCRAFT, ETC.)
Do you have a current Sales Tax Permit?
Yes
No
1.
Your proposed terms to satisfy this indebtedness:
2.
REAL PROPERTY ADDRESS
1.
2.
OTHER PARTNERSHIP(S) / CORPORATION(S)
NAME
ADDRESS
TELEPHONE
1.
2.
3.
The information stated is true and correct to the best of my knowledge. Signed
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