SUPPLEMENTARY EXAMINATION

 

NAME                                                          SPOUSE                                                     

(Last)        (First)         (Middle)

 

Soc. Sec. #                                   D.O.B.                Spouse S.S.#                D.O.B.        

 

Drivers Lic.#                                            Spouse Drivers Lic.#                                        

 

Address                                                                               Phone                                  

 

Renting   (   )         Buying  (  )        Amount per month                   Date due                  

 

Landlord                                                         Address                                                    

 

Do you have an interest in

any real property?                                   Where (any county)                                          

 

California                                         Out of State                                                              

 

Who holds first T.D.                                     Address                                                         

 

Second T.D.                                                 Address                                                         

 

Balance on first                                    Mo. Pmts.                                 Date due              

 

Balance on second                              Mo. Pmts.                                  Date due              

 

Purchase price on prop.                          Taxes                       Paid to what date              

******************************************************************************************************

 

Employer Name                                                                                                                

Employer Address                                                                                                            

 

Employer phone                                                                                                              

 

Position or Dept.                                                 How long employed                             

 

Rate of pay                            Pay dates                                   

 

If you are not employed, what was last date worked?                                                      

 

For whom                                                                                                                         

(Address)                                         (Phone)

Other Income:     Child Support                      Social Security                 Pension_______              

Disability                               Welfare                               Rent                  Other________               

 

Remarks                                                                                                                               ****************************************************************************************************

Where do you bank?                                                                                                                      

(Name)                                    (Branch)                          (City)                    (St)

 

Type of Account:    Checking                 Savings                Account No.                          

 

How are checks signed?                                                                                                   

****************************************************************************************************

 

Number of cars and/or trucks owned or buying                         Leasing                         

 

Car #1.  Make                                        Year                         Lic.#                            

Balance Owing                                       Mo. Pmt.                        

Registered Owner                                                                                                              

Financed by                                                                                                                       

 

Car #2. Make                                          Year                          Lic.#                            

Balance Owing                                        Mo. Pmt.                                                               Registered Owner                                                                                                              

Financed by                                                                                                                       

 

If leasing, from whom?                                                          Mo pmt.                                

Year                          Make                                                    Lic.#                                     

 

Number of motorcycles owned or buying?                                                                        

Make                                Year                                      Lic.#                                            

 

Number of boats, motor homes, airplanes, vacation trailer, camper – owned or buying?

                                                                                                                                          

 

Does anyone owe you any money.  (Give Detailes)  

                                                     

                                                                                                                                         

 

If self employed or in business, what is value of accounts receivables?                        

Are they assigned?                        If so, to whom?                                                         

Gross income as reported to the Department of Internal Revenue:                                

Last year                                                             Year before                                           

Number of children under 18 living with you                                                                    

Spouse’s former name(s)                                                                                                  

Does spouse own prop. in other name?  (Give Details)                                                                                                                                                                                                 

Does spouse receive child support?                  If so, how much per month?________               

 

Do you belong to a union?                 Which one?                                                           

Do you have union insurance?                                                                                        

Do you belong to a credit union?                                                                                     

 

I declare under penalty of perjury that the foregoiing is true and correct.

                                                                                                                                             Executed at Fairfield, California on                                                                                                                                                                                                                                  **************************************************************************************************

                          Household Expenses                            Contractual Obligations           

 

Rent                                              $                                              $         @                

Telephone                                                                                     $         @                

Other Utilities                                                    _                          $         @               

Groceries                                                                                      $          @               

Drugs                                                                                            $          @               

Doctors & Dentists                                                                        $          @               

School Lunches                                                                            $          @               

Car Expenses                                                                               $          @               

Child Support                                                                                $          @               

Union Dues                                                                                   $          @               

Misc.                                                                                              $         @                

Sub Total #1                            $                             Sub Total #2                                 

 

Income:         Wages                $                      Expenses:      Sub Total #1  $              

Child Support                                                    Sub Total #2                  

Other                                           Total Expenses                    $             

Total Income                            $                        Balance of Income              $              

 

 

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