Fill and Sign the Ej 165 Form

SHORT TITLE: ––––– LEVYING OFFICER FILE NO.: ––––– COURT CASE NO.: ––––– FINANCIAL STATEMENT (Wage Garnishment  Enforcement of Judgment) NOTE: If you are married, this form must be signed by your spouse unless you and your spouse are living separate and apart. If this form is not signed by your spouse, check the applicable box on the reverse in item 9. 1. The following persons other than myself depend, in whole or in part, on me or my spouse for support: NAME AGE RELATIONSHIP TO ME MONTHLY TAKE-HOME INCOME & SOURCE a. ––––– ––––– Spouse ––––– ––––– b. ––––– ––––– ––––– ––––– ––––– c. ––––– ––––– ––––– ––––– ––––– d. ––––– ––––– ––––– ––––– ––––– e. ––––– ––––– ––––– ––––– ––––– 2. My monthly income a. My gross monthly pay is: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 a. $ ––––– b. My payroll deductions are (specify purpose and amount ) : (1) Federal and state withholding, FICA, and SDI . . . . . . . . . . . . . . . . . $ ––––– (2) ––––– $ ––––– (3) ––––– __________________________________ $ ––––– (4) ––––– __________________________________ $ ––––– My TOTAL payroll deduction amount is (add (1) through (4)) :. . . . . . . . . . . . . . . . . . . . . . . . . . b. $ = ––––– c. My monthly take-home pay is (a minus b) :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. $ = ––––– d. Other money I get each month from (specify source) : ––––– is:. d. $ ––––– . . . . . . e. TOTAL MONTHLY INCOME (c plus d) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. $ = ––––– 3. I, my spouse, and my other dependents own the following property: a. Ca sh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 a. $ ––––– b. Checking, savings, and credit union accounts (list banks) : (1) ––––– $ ––––– (2) ––––– $ ––––– (3) ––––– $ ––––– b. $ ––––– c. Cars, other vehicles, and boat equity (list make, year of each) : (1) ––––– $ ––––– (2) ––––– $ ––––– (3) ––––– $ ––––– c. $ ––––– d. Real Estate equity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. $ ––––– e. Other personal property (jewelry, furniture, furs, stock, bonds, etc.) (list separately) : ––––– ––––– ––––– ––––– ––––– ––––– e. $ ––––– (Continued on reverse) WG-007/EJ-165 Form Adopted by the Judicial Council of California WG-007/EJ-165 [Rev. January 1, 2007] FINANCIAL STATEMENT (Wage Garnishment  Enforcement of Judgment) CCP 703.530, 706.124 electronic form ã 1997, 2001-07 WWW.LawCA.com Law Publishers SHORT TITLE: ––––– LEVYING OFFICER FILE NO.: ––––– COURT CASE NO.: ––––– 4. The monthly expenses for me, my spouse, and my other dependents a. Rent or house payment and maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 a. $ ––––– b. Food and household supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. $ ––––– c. Utilities and telephone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. $ ––––– d. d. $ ––––– e. Medical and dental payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. $ ––––– f. Insurance (life, health, accident, etc.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f. $ ––––– g. School, child care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g. $ ––––– h. Child, spousal support (prior marriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h. $ ––––– i. Transportation & auto expenses (insurance, gas, repair) (list car payments in item 5) . . . . . . . . i. $ ––––– j. Installment payments (insert total and itemize below in item 5) . . . . . . . . . . . . . . . . . . . . . . . . . . j. $ ––––– k. Laundry and cleaning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . k. $ ––––– l. Entertainment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l. $ ––––– m. Other (specify) : ––––– ––––– ––––– ––––– ––––– m. $ ––––– n. TOTAL MONTHLY EXPENSES (add a through m): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n. $ = ––––– 5. I, my spouse, and my other dependents owe the following debts: CREDITOR'S NAME FOR MO. PAYMENTS BALANCE OWED OWED BY (State person's name) ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– 6. Other facts which support this Claim of Exemption (i.e., unusual medical needs, school tuition, expenses for recent family emergencies, or other unusual expenses to help your creditor and the judge understand your budget) (describe) : (If more space is needed, attach page labeled Attachment 6.) ––––– ––––– ––––– 7. An earnings withholding order is now in effect with respect to my earnings or those of my spouse or dependents named in item 1 (specify each person's name and monthly amount) : ––––– ––––– 8. A wage assignment for support is now in effect with respect to my earnings or those of my spouse or dependents named in item 1 (specify each person's name and monthly amount) : ––––– ––––– 9. My spouse has signed below. have no spouse. My spouse and I are living separate and apart. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) Date: ––––– ––––– ( TYPE OR PRINT NAME OF SPOUSE ) ( SIGNATURE OF SPOUSE ) WG-007/EJ-165 WG-007/EJ-165 [Rev. January 1, 2007] FINANCIAL STATEMENT (Wage Garnishment  Enforcement of Judgment) =