Form Boe-403-E - Individual Financial Statement - 2014
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2BOE-403-E (FRONT) REV. 10 (12-14)
STATE OF CALIFORNIA
INDIVIDUAL FINANCIAL STATEMENT
PLEASE TYPE OR PRINT
BOARD OF EQUALIZATION
ACCOUNT NUMBER
Respond By:
Please attach copies of your income tax returns for the last two years. Documentation is required to support your income and expenses.
NAME (first and initial)
LAST
SOCIAL SECURITY NUMBER (SSN)
DATE OF BIRTH (DOB)
/
/
PRESENT HOME ADDRESS (number and street or rural route)
NAME OF SPOUSE/DOMESTIC PARTNER
SPOUSE/DOMESTIC PARTNER (SSN)
SPOUSE/DOMESTIC PARTNER (DOB)
/
/
CITY, TOWN, OR POST OFFICE BOX
STATE
ZIP
HOME TELEPHONE
CELL PHONE
CHILDREN LIVING WITH YOU
OTHER DEPENDENTS
(
)
(
)
PRESENT EMPLOYER
EMPLOYER’S TELEPHONE
DRIVER LICENSE NUMBER (DL)
STATE
EXP. DATE
(
)
EMPLOYER’S ADDRESS
LENGTH EMPLOYED
MONTHLY GROSS INCOME
SPOUSE/DOMESTIC PARTNER (DL)
STATE
EXP. DATE
BANKS, CREDIT UNIONS, AND OTHER FINANCIAL INSTITUTIONS
OCCUPATION
PERSONAL EMAIL ADDRESS
Name
Address
Type of Accounts
SPOUSE/DOMESTIC PARTNER PRESENT EMPLOYER
EMPLOYER’S TELEPHONE
(
)
EMPLOYER’S ADDRESS
LENGTH EMPLOYED
MONTHLY GROSS INCOME
OCCUPATION
BUSINESS EMAIL ADDRESS
MONTHLY INCOME
MONTHLY EXPENSES
MORTGAGE / RENT PAYMENT
Monthly take-home pay
$
Dates paid:
Mortgage or
Rent payment - Landlord telephone: (
)
$
1
Name:
Spouse/domestic partner monthly take-home pay
$
Dates paid:
Address:
2
Food
$
Dividends received from:
$
3
Housekeeping supplies
$
4
Apparel and services
$
Interest received from:
$
5
Personal care products and services
$
6
Transportation (work related only – do not include car payment)
$
Pensions
$
COURT ORDERED
Child support
Alimony
Other (attachment)
Social Security
7
$
Payable to:
Telephone: (
)
$
Address:
Alimony/child support received:
$
8
Utilities (electric/gas, water, trash, telephone)
$
9
Childcare / dependent care, paid to:
$
Other (please explain)
$
10
Health care expenses (not paid by insurance)
$
INSURANCE EXPENSE *
11
$
Car $
Life $
Home $
Health $
$
12
Miscellaneous (please explain)
$
$
13
Total expenses (add lines 1 through 12)
$
14
Total of recurring monthly payments (from page 2, line 10)
$
TOTAL MONTHLY INCOME
$
15
Total monthly expenditures (add lines 13 and 14)
$
* Not paid through payroll deductions
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