Individual Financial Statement Page 2
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2BOE-403-E (BACK) REV. 8 (8-09)
STATE OF CALIFORNIA
INDIVIDUAL FINANCIAL STATEMENT
BOARD OF EQUALIZATION
PAYROLL
TYPE OF DEBT:
DATE FINAL
AMOUNT OF
DEDUCT
SCHEDULE OF INSTALLMENT AND ANY OTHER PAYMENTS
ORIGINAL AMOUNT
DATE DEBT
BALANCE
AUTO, PERSONAL
PAYMENT WILL
MONTHLY
CREDITOR(S) NAME AND ADDRESS
OF DEBT
INCURRED
DUE
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 through 9. Enter here and on
$
page 1, line 14)
Do you have a current license/permit with the BOE?
VEHICLE INFORMATION (auto, trailers, vessels, aircraft, etc.)
Yes
No
If yes, please list account number(s):
1.
2.
Your proposed terms to satisfy this indebtedness:
REAL PROPERTY ADDRESS
1.
2.
OTHER PARTNERSHIP(S) / CORPORATION(S)
NAME
ADDRESS
TELEPHONE
1.
2.
3.
Date
The information stated is true and correct to the best of my knowledge. Signed
CLEAR
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