Financial Statement California Superior Court Forms Page 3
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3Monthly Financial Statement
Monthly Income:
Assets:
Gross Salary (wages)
$
Cash (Checking, Savings, Money Market Accts:
$
Spouse’s Gross Salary (wage)
Real Estate – Market Value
Unemployment/Disability
Furniture and Fixtures
Veterans Benefits
Car(s) – Resale Value
Other Income (Itemize):
Personal Property (Boats, Cameras, etc.)
IRA’s
Stocks, Bonds, etc. – Market Value
TOTAL MONTHLY INCOME:
$
Other Assets (Itemize):
Monthly Expenses
: (include spouse)
Mandatory Payroll Deductions:
$
Voluntary Payroll Deductions:
Rent or Mortgage Payment:
Taxes and Assessments:
TOTAL ASSETS:
$
Food:
Clothing:
Liabilities:
Utilities
Balance Due on Real Estate:
$
(Gas, Electric, Water, Phone)
Car Payment(s):
Balance Due on Personal Property:
Gasoline (Transportation Expense)
Attorney Fees Due:
Insurance Premiums:
Other Creditors (itemize):
Child Support or Alimony:
Contributions:
Other expenses (itemize):
TOTAL MONTHLY EXPENSES
$
TOTAL LIABILITIES:
$
DECLARATION OF DEFENDANT
I declare under penalty of perjury that the above is a true and correct statement of my financial status. This declaration is
executed on _______________________________ , 20___ (date) at ____________________________ (city), California,
County of __________________________________.
__________________________________________
Signature of Defendant
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