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

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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?

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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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