Financial satatement - State of California
SHORT TITLE:
LEVYING OFFICER FILE NO.
COURT CASE NO.
FINANCIAL STATEMENT
(Wage Garnishment—Enforcement of Judgment
NOTE: If you are married, this form must be signed by your spouse unless you and your spouse are living separate and
apart. If this form is not signed by your spouse, check the applicable box on the reverse in item 9.
1. The following persons other than myself depend, in whole or in part, on me or my spouse for support:
MONTHLY TAKE-HOME
INCOME & SOURCENAME AGE RELATIONSHIP TO ME
a. Spouse
b.
c.
d.
e.
2. My monthly income
a. My gross monthly pay is:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a. $
b. My payroll deductions are (specify purpose and amount):
(1 ) Federal and state withholding, FICA, and SDI. . . . . . . . .
$
(2)
$
(3)
$
$
(4)
My TOTAL payroll deduction amount is (add (1) through (4)): ................................................
b. $
c. $c. My monthly take-home pay is (a minus b): ..................................................................................
d. Other money I get each month from (specify source):
is .........................
d. $
e. $e. TOTAL MONTHLY INCOME (c plus d) ..................................................................................
3. I, my spouse, and my other dependents own the following property:
a. Cash ..........................................................................................................................................
3a. $
b. Checking, savings, and credit union accounts (list banks):
(1) $
(2) $
(3) b. $$
c. Cars, other vehicles, and boat equity (list make, year of each):
(1)
(2) $
(3) c. $
d. Real estate equity ...................................................................................................................... d. $
e. Other personal property (jewelry, furniture, furs, stocks, bonds, etc.) (list separately):
e. $
Form Adopted by the Judicial Council
of California
WG-007/EJ-165 [Rev. January 1, 2007]
FINANCIAL STATEMENT
(Wage Garnishment—Enforcement of Judgment)
Code of Civil Procedure, §§ 706.124, 703.530
www.courtinfo.ca.gov
$
$
WG-007/EJ-165
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