Financial satatement - State of California
4. The monthly expenses for me, my spouse, and my other dependents
a. Rent or house payment and maintenance ................................................................................. 4 a. $
b. Food and household supplies .................................................................................................... b. $
c. Utilities and telephone ............................................................................................................... c. $
d. Clothing ...................................................................................................................................... d. $
e. Medical and dental payments ..................................................................................................... e. $
f. $f. Insurance (life, health, accident, etc.) ........................................................................................
g. School, child care ....................................................................................................................... g. $
h. Child, spousal support (prior marriage) ...................................................................................... h. $
i. $ I. Transportation & auto expenses (insurance, gas, repair) (list car payments in item 5) ..............
j. Installment payments (insert total and itemize below in item 5) .................................................. j. $
k. Laundry and cleaning ................................................................................................................. k. $
l. Entertainment ............................................................................................................................. l. $
m. Other (specify):
m. $
n. TOTAL MONTHLY EXPENSES (add a through m): .................................................................... n. $
5. I, my spouse, and my other dependents owe the following debts:
OWED BY
FOR MO. PAYMENTS BALANCE OWED (State person's name)
6. Other facts which support this Claim of Exemption (i.e., unusual medical needs, school tuition, expenses for recent family
emergencies, or other unusual expenses to help your creditor and the judge understand your budget) (describe): (If more space is
needed, attach page labeled Attachment 6.)
An earnings withholding order is now in effect with respect to my earnings or those of my spouse or dependents named in
item 1 (specify each person's name and monthly amount):
7.
A wage assignment for support is now in effect with respect to my earnings or those of my spouse or dependents named in
8.
item 1 (specify each person's name and monthly amount):
My spouse has signed below.9.
I have no spouse.
My spouse and I are living separate and apart.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE)
(TYPE OR PRINT NAME OF SPOUSE)
(SIGNATURE OF SPOUSE)
FINANCIAL STATEMENT
(Wage Garnishment—Enforcement of Judgment)
WG-007/EJ-165 [Rev. January 1, 2007]
SHORT TITLE:
LEVYING OFFICER FILE NO.
COURT CASE NO.
CREDITOR'S NAME
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WG-007/EJ-165
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