Form Boe-403-E - Individual Financial Statement - 2014 Page 2
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2BOE-403-E (BACK) REV. 10 (12-14)
STATE OF CALIFORNIA
INDIVIDUAL FINANCIAL STATEMENT
BOARD OF EQUALIZATION
PAYROLL
TYPE:
DATE FINAL
AMOUNT OF
DEDUCT
OTHER RECURRING MONTHLY PAYMENTS
ORIGINAL AMOUNT
INCURRED
BALANCE
AUTO, PERSONAL
PAYMENT WILL
MONTHLY
CREDITOR(S) NAME AND ADDRESS
DUE
DATE
DUE
LOAN, ETC.
BE DUE
PAYMENT
YES
NO
1.
2.
3.
4.
5.
6.
7.
8. Other – Please use separate sheet
9. Other taxes owed. 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?
Yes
No
VEHICLE INFORMATION (Please include the make, model, year and plate numbers for autos, trailers, vessels, aircraft, etc.)
If yes, please list account number(s):
1.
2.
Have you filed bankruptcy in the past year?
Yes
No
REAL PROPERTY ADDRESS
If yes, please list court and case number.
1.
Your proposed terms to satisfy this amount due:
2.
OTHER PARTNERSHIP(S) / CORPORATION(S)
NAME
ADDRESS
TELEPHONE
1.
2.
3.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signed
Date
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signed
Date
CLEAR
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