Fill and Sign the California Claim Exemption Form

CLAIM OF EXEMPTION AND FINANCIAL DECLARATION C AS E NUM BE R: NAME OF STATE TAX AGENCY: TA X AG EN CY NUM BE R:––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––– –– ––– –– ––––– ––– –– ––– –– ––– –– ––– –– ––––– ––––– ––––– ––– –– ––– –– ––––– ––– –– ––– –– ––– –– ––– –– ––– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––– –– ––––– ––––– ––––– ––––– W G - 02 6ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address): FOR COU RT US E ON LY TELEPHONE NO.: FAX NO.: ATTOR NE Y FOR S TAT E TA X PAY E R /R E S P ON DE N T NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: C I TY A N D Z I P CODE BRANCH NAME. APPLICATION OF (Name): TAXPAYER/RESPONDENT (Copy the information required above from the Application for Earnings Withholding Order for Taxes (form 982.5(1 1)). The top left space is for your or your attorney's name and address.) 1. I need the following earnings to support myself or my family (check and complete item a or b): a . All earnings. b . $ each pay period. 2. Please send all papers to m e my attorney at the address shown above following (specify): 3. In addition to the 25 percent minimum withholding, I am willing for the following amount to be withheld from my earnings during the withholding period: a . Non e b . Withhold: $ each pay period. 4. a. I am p ai d dail y weekl y every two weeks twice a month monthly . b. My gross pay is: $ per pay period. c. My take-home pay is: $ per pay period. d. My payroll deductions are (item and amount): 5. The following persons depend, in whole or in part, on me for support: Nam e Ag e Relationship to me MonthIv income and its source a . Myse lf b . C . d . e . 6 . The earnings of others listed in item 5 are now subject to wage assignments and Earnings Withholding Orders as follows (specify) : (Continued on reverse)Form Adopted for Mandatory Use Judicial Council of California WG-026 [Rev. January 1, 2007] C L A I M O F E X E M P T I O N A N D F I N A N C I A L D E C L A R AT I O N (Wage Garnishment-State Tax Liability) Code of Civil Procedure, §§ 706.051, 706.076electronic form ã 1999-2007 WWW.LawCA.com Law Publishers Page 1 of 2 ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––– –– ––––– ––– –– ––––– ––––– –––––APPLICATION OF (Name): CASE NUMBER, TAXPAYER/RESPONDENT 7. My monthly expenses are as follows: a. Rent or house payment and J. Entertainment and incidentals $ maintenanc e $ k. Transportation and auto expenses b. Food and household supplies $ (insurance, gas, repair) $ c. Utilities and telephone $ 1. Installment payments (insert d. Clothing $ total and list below in item 8) $ e. Laundry and cleaning $ m. Other (specify): $ f. Medical and dental payments $ g. Insurance (life, health, accident, etc.) $ h. School, child care $ i. Child, spousal support TOTAL MONTHLY EXPENSES (prior marriage) $ (add a through m) $ 8. List payments on installment and other debts. Continued on Attachment 8. Creditor's name F o r Monthly payment Balan ce 9. What do you own? (State value.) a. Cash $ d. Real estate equity (addresses): . . . $ b. Checking, savings and credit union accounts, etc. (list institutions): ( 1 )( 2 ) $ $ $ $ e. Other personal property J ewelry, ( 3 ) ( 4 ) furniture, furs, stocks and bonds, etc. List separately): c. Cars, other vehicles, and boat equity (list make, year of each): ( 1 )( 2 ) ( 3 ) $ $ $ Total for item e- $ 1 0 . An Order Assigning Salary and Wages (for support) is now in effect as to my earnings. The amount payable under that order is: $ monthl y. 11. Other facts that support this Claim of Exemption are (describe unusual medical needs, school tuition, expenses for recent family emergencies, or other unusual expenses to help the judge understand your budget): Continued on Attachment 11. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dat e: (TYPE OR PRINT NAME) (SIGNATURE OF TAXPAYER) File this form with the clerk of the court and mail a copy to the tax agency as soon as possible. Keep a copy and take it with you to the court hearing. If you wish to obtain the advice of an attorney, you should do so at once. WG-026 [Rev. January 1, 2007] CLAIM OF EXEMPTION AND FINANCIAL DECLARATION (Wage Garnishment-State Tax Liability) Page 2 of 2