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              $