Form CDTFA-403-E "Individual Financial Statement" - California

What Is Form CDTFA-403-E?

This is a legal form that was released by the California Department of Tax and Fee Administration - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the California Department of Tax and Fee Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CDTFA-403-E by clicking the link below or browse more documents and templates provided by the California Department of Tax and Fee Administration.

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Download Form CDTFA-403-E "Individual Financial Statement" - California

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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)
DATE OF BIRTH (DOB)
-
-
/
/
PRESENT HOME ADDRESS (number and street or rural route)
NAME OF SPOUSE/DOMESTIC PARTNER
SPOUSE/DOMESTIC PARTNER (SSN)
SPOUSE/DOMESTIC PARTNER (DOB)
-
-
/
/
OTHER DEPENDENTS
CHILDREN LIVING WITH YOU
CITY, TOWN, OR POST OFFICE
STATE
ZIP
HOME TELEPHONE
CELL PHONE
EMPLOYER’S TELEPHONE
PRESENT EMPLOYER
DRIVER LICENSE NUMBER (DL)
STATE
EXP. DATE
EMPLOYER’S ADDRESS
LENGTH EMPLOYED
MONTHLY GROSS INCOME
SPOUSE/DOMESTIC PARTNER (DL)
STATE
EXP. DATE
PERSONAL EMAIL ADDRESS
BANKS, CREDIT UNIONS, and OTHER FINANCIAL INSTITUTIONS
OCCUPATION
Name
Address
Type of Accounts
EMPLOYER’S TELEPHONE
SPOUSE/DOMESTIC PARTNER PRESENT EMPLOYER
EMPLOYER’S ADDRESS
LENGTH EMPLOYED
MONTHLY GROSS INCOME
BUSINESS EMAIL ADDRESS
OCCUPATION
MONTHLY INCOME
MONTHLY EXPENSES
MORTGAGE / RENT PAYMENT
Monthly take-home pay
Dates paid:
$
Mortgage or
Rent payment - Landlord telephone:
$
1
Name:
Spouse/domestic partner monthly take-home pay
Dates paid:
Address:
$
2
Food:
$
Dividends received from:
$
3
Housekeeping supplies:
$
4
Apparel and services:
$
Interest received from:
5
Personal care products and services:
$
$
Transportation (work related only – do not include car payment):
6
$
Pensions
$
COURT ORDERED
Child support
Alimony
Other (attachment)
Social Security
7
Payable to:
Telephone:
$
Address:
$
Alimony/child support received:
8
Utilities (electric/gas, water, trash, telephone):
$
$
9
Childcare/dependent care, paid to:
$
Other (please explain)
10
Health care expenses (not paid by insurance):
$
$
11
INSURANCE EXPENSE*
11
Car $
Life $
Home $
Health $
$
12
Miscellaneous (please explain)
$
Total expenses (add lines 1 through 12)
13
$
14
Total of recurring monthly payments (from page 2, line 10)
$
TOTAL MONTHLY INCOME
15
Total monthly expenditures (add lines 13 and 14)
$
$
*Not paid through payroll deductions
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)
DATE OF BIRTH (DOB)
-
-
/
/
PRESENT HOME ADDRESS (number and street or rural route)
NAME OF SPOUSE/DOMESTIC PARTNER
SPOUSE/DOMESTIC PARTNER (SSN)
SPOUSE/DOMESTIC PARTNER (DOB)
-
-
/
/
OTHER DEPENDENTS
CHILDREN LIVING WITH YOU
CITY, TOWN, OR POST OFFICE
STATE
ZIP
HOME TELEPHONE
CELL PHONE
EMPLOYER’S TELEPHONE
PRESENT EMPLOYER
DRIVER LICENSE NUMBER (DL)
STATE
EXP. DATE
EMPLOYER’S ADDRESS
LENGTH EMPLOYED
MONTHLY GROSS INCOME
SPOUSE/DOMESTIC PARTNER (DL)
STATE
EXP. DATE
PERSONAL EMAIL ADDRESS
BANKS, CREDIT UNIONS, and OTHER FINANCIAL INSTITUTIONS
OCCUPATION
Name
Address
Type of Accounts
EMPLOYER’S TELEPHONE
SPOUSE/DOMESTIC PARTNER PRESENT EMPLOYER
EMPLOYER’S ADDRESS
LENGTH EMPLOYED
MONTHLY GROSS INCOME
BUSINESS EMAIL ADDRESS
OCCUPATION
MONTHLY INCOME
MONTHLY EXPENSES
MORTGAGE / RENT PAYMENT
Monthly take-home pay
Dates paid:
$
Mortgage or
Rent payment - Landlord telephone:
$
1
Name:
Spouse/domestic partner monthly take-home pay
Dates paid:
Address:
$
2
Food:
$
Dividends received from:
$
3
Housekeeping supplies:
$
4
Apparel and services:
$
Interest received from:
5
Personal care products and services:
$
$
Transportation (work related only – do not include car payment):
6
$
Pensions
$
COURT ORDERED
Child support
Alimony
Other (attachment)
Social Security
7
Payable to:
Telephone:
$
Address:
$
Alimony/child support received:
8
Utilities (electric/gas, water, trash, telephone):
$
$
9
Childcare/dependent care, paid to:
$
Other (please explain)
10
Health care expenses (not paid by insurance):
$
$
11
INSURANCE EXPENSE*
11
Car $
Life $
Home $
Health $
$
12
Miscellaneous (please explain)
$
Total expenses (add lines 1 through 12)
13
$
14
Total of recurring monthly payments (from page 2, line 10)
$
TOTAL MONTHLY INCOME
15
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
CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION
PAYROLL
TYPE: AUTO,
DATE FINAL
AMOUNT OF
DEDUCT
OTHER RECURRING MONTHLY PAYMENTS
ORIGINAL AMOUNT
INCURRED
BALANCE
PERSONAL LOAN,
PAYMENT WILL
MONTHLY
CREDITOR(S) NAME AND ADDRESS
DUE
DATE
DUE
ETC.
BE DUE
PAYMENT
YES
NO
1.
2.
3.
4.
5.
6.
7.
Other – Please use separate sheet
8.
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?
Yes
No
If yes, please list the account number(s):
1.
2.
Have you filed bankruptcy in the past year?
Yes
No
If yes, list court and case number.
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
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