California Individual Financial Statement (California Department of Tax and Fee Administration)

Individual Financial Statement (California Department of Tax and Fee Administration)
CDTFA-403-E
CDTFA-403-E (FRONT) REV. 12 (3-18)

STATE OF CALIFORNIA

INDIVIDUAL FINANCIAL STATEMENT

PLEASE TYPE OR PRINT CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION

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)

PRESENT HOME ADDRESS (number and street or rural route)

STATE

ZIP

SPOUSE/DOMESTIC PARTNER (SSN)

HOME TELEPHONE

CHILDREN LIVING WITH YOU

CELL PHONE

PRESENT EMPLOYER

EMPLOYER’S TELEPHONE

EMPLOYER’S ADDRESS

LENGTH EMPLOYED

OCCUPATION

PERSONAL EMAIL ADDRESS

SPOUSE/DOMESTIC PARTNER PRESENT EMPLOYER

EMPLOYER’S TELEPHONE

EMPLOYER’S ADDRESS

LENGTH EMPLOYED

OCCUPATION

BUSINESS EMAIL ADDRESS

MONTHLY GROSS INCOME

Interest received from:
Pensions
Social Security
Alimony/child support received:
Other (please explain)

TOTAL MONTHLY INCOME

-

/

/

OTHER DEPENDENTS

STATE

EXP. DATE

SPOUSE/DOMESTIC PARTNER (DL)

STATE

EXP. DATE

BANKS, CREDIT UNIONS, and OTHER FINANCIAL INSTITUTIONS

Address

Type of Accounts

MONTHLY GROSS INCOME

MONTHLY INCOME

Dividends received from:

/

SPOUSE/DOMESTIC PARTNER (DOB)

DRIVER LICENSE NUMBER (DL)

Name

Monthly take-home pay
Dates paid:
Spouse/domestic partner monthly take-home pay
Dates paid:

/

NAME OF SPOUSE/DOMESTIC PARTNER

CITY, TOWN, OR POST OFFICE

DATE OF BIRTH (DOB)

-

MONTHLY EXPENSES

$

1

$
$
$

2
3
4
5
6

$
$
$
$

$

7
8
9
10
11
11
12
13
14
15

MORTGAGE / RENT PAYMENT
Rent payment - Landlord telephone:

Mortgage or
Name:
Address:
Food:
Housekeeping supplies:
Apparel and services:
Personal care products and services:
Transportation (work related only – do not include car payment):
COURT ORDERED
Child support
Alimony
Other (attachment)
Payable to:
Telephone:
Address:
Utilities (electric/gas, water, trash, telephone):
Childcare/dependent care, paid to:
Health care expenses (not paid by insurance):
INSURANCE EXPENSE*
Car $
Life $
Home $
Health $
Miscellaneous (please explain)
Total expenses (add lines 1 through 12)
Total of recurring monthly payments (from page 2, line 10)
Total monthly expenditures (add lines 13 and 14)

$

$
$
$
$
$

$
$
$
$
$
$
$
$
$

*Not paid through payroll deductions

CDTFA-403-E (BACK) REV. 12 (3-18)

STATE OF CALIFORNIA

INDIVIDUAL FINANCIAL STATEMENT

OTHER RECURRING MONTHLY PAYMENTS
CREDITOR(S) NAME AND ADDRESS

CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION

PAYROLL
DEDUCT
YES

NO

TYPE: AUTO,
PERSONAL LOAN,
ETC.

ORIGINAL AMOUNT
DUE

INCURRED
DATE

BALANCE
DUE

DATE FINAL
PAYMENT WILL
BE DUE

AMOUNT OF
MONTHLY
PAYMENT

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 thru 9. Enter here and on
page 1, line 14)

$

VEHICLE INFORMATION (Please include the make, model, year and plate number for autos, trailers, vessels, aircraft, etc.).

Do you have a current license/permit with CDTFA?
If yes, please list the account number(s):

Yes

1.
2.

Have you filed bankruptcy in the past year?
If yes, list court and case number.

Yes

No

REAL PROPERTY ADDRESS

1.

Your proposed terms to satisfy this amount due:
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

PRINT

No