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EDD Employment Development Department State of California Logo

PERSONAL FINANCIAL STATEMENT

(Confidential)

This personal financial information is needed to determine if you might qualify for waiver of overpayment, or to determine a fair repayment schedule. If the information is not provided waiver cannot be given even if otherwise eligible, and repayment will be calculated on amount owed and other information on hand.

Name (Last, First, MI) Blank space

Social Security Number Blank space

Telephone Blank space

Address: Number, Street Blank space City, State, ZIP code Blank space

Mail Address: P.O. Box or Street Blank space City, State, ZIP code Blank space

Date of Birth Blank space

Drivers License Number Blank space

Number of Dependents Blank space

Ages of Dependent Children Blank space

Marital Status Blank space

INCOME STATEMENT

Employer Name, Yours Blank spaceUnemployed

Employer Name, Your Spouse Blank spaceUnemployed

Address: Street Blank space City, State, ZIP code Blank space

Wage/Salary Monthly Gross Blank space

How Long Employed Blank space

Wage/Salary Monthly Gross Blank space

How Long Employed Blank space

Occupation Blank space

FAMILY INCOME FOR THE PAST SIX MONTHS: Include interest, pensions, Social Security, unemployment insurance (UI), disability insurance (DI), workers’ compensation, dividends, any other family income.

FAMILY INCOME FOR THE PAST FOUR WEEKS: Include same items as before.

Month/Year

Your Gross Monthly Income

Spouse Gross Monthly Income

Other Income

Week Ending

Your Gross Weekly Earnings

Spouse Gross Weekly Earnings

Other Income

Blank space

Total, Past Four Weeks Blank space

Additional Information Blank space

Blank space

Total, Past Six Months Blank space

ASSET STATEMENT

Home Rent

Home Own

Value $Blank space

Equity $Blank space

Automobile Make:Blank space

Year Blank space

Model Blank space

License Number Blank space

Other Real Property – Type, Address, Value Blank space

Automobile Make: Blank space

Year Blank space

Model Blank space

License Number Blank space

Other Vehicle, Specify Blank space

Value of Other Assets: Bank and Savings Accounts, Stocks, Bonds, Other Blank space

$ Blank space

Other Vehicles, Property, etc. (Use other sheet if needed) Blank space

LIABILITY STATEMENT

House Payments Month $ Blank space

Mortgage Holder(s) (Use additional sheet if needed)

Auto Payment(s) $ Blank space

Balance Due

Legal Owner(s)

Other Property Monthly Payment

Blank space

Debts Outstanding: Medical, Dental, Tax, Retail, Insurance, Loans, Utilities (Use additional sheet if needed.)

Creditors

Monthly Payments

Balance Owed

Creditors

Monthly Payments

Balance Owed

Blank Space

I certify the information on this form is true and correct to the best of my knowledge.

Signature

Blank Line

Date

Blank Line

DE 1446 Rev. 3 (6-88) (INTRANET)

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DI / DE 1446

PERSONAL FINANCIAL STATEMENT