Fill and Sign the Offer in Compromise Ohio Attorney General Form

CLA IM O F E XEM PTIO N A ND F IN ANCIA L D EC LA RATIO N CAS E N UM BE R :N AM E O F S TA TE T A X A G EN CY:TA X A G EN CY N UM BER : W G-0 26ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):FO R C O URT U SE O NLYTELEPHONE NO.:FAX NO.:ATTO RNEY F O R S TA TE T A XPAYER /R ESPO NDEN TNAME OF COURT:STREET ADDRESS:MAILING ADDRESS:CIT Y A N D Z IP C O DEBRANCH NAME.APPLIC ATIO N O F ( N am e):T A XPAYER /R ESPO NDEN T(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 . P le ase s e nd a ll p apers tomemy attorneyat the addressshown abovefollowing (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.Noneb.Withhold: $each pay period.4 . a . I a m p aiddailyweeklyevery two weekstwice a monthmonthly.b. M y g ro ss p ay is : $per pay period.c . M y ta ke -h om e p ay is : $per pay period.d. My payroll deductions are (item and amount):5. The following persons depend, in whole or in part, on me for support:Nam eAgeRelationship to meMonthIv income and its sourcea.Myselfb.C.d.e.6 .The earnings of others listed in item 5 are now subject to wage assignments and Earnings Withholding Orders as follows(s p ecif y ):(C ontin ued o n r e ve rs e )Form Adopted for Mandatory Use Judicial Council of California WG-026 [Rev. January 1, 2007]C LA IM O F E XEM PTIO N A ND F IN ANCIA L D EC LA RATIO N (W ag e G arn is h m en t-S ta te T ax L ia b ilit y )Code of Civil Procedure,§§ 706.051, 706.076electronic form 1999-2007 WWW.LawCA.com Law PublishersPage 1 of 2 APPLIC ATIO N O F ( N am e):CASE NUMBER,TAXPAYER/RESPONDENT7. M y m onth ly e xp en ses a re a s f o llo w s: a. R en t o r h ouse p aym en t a n dJ. E nte rta in m en t a n d in cid en ta ls$m ain te n an ce$k. T ra n sp orta tio n a n d a u to e xp en sesb . F o od a n d h ouse h old s u pplie s$(in su ra n ce, g as, r e p air )$c . U tilit ie s a n d t e le p hone$1. Installment payments (insertd. C lo th in g$to ta l a nd lis t b elo w in it e m 8 )$e. Laundry and cleaning$m . O th er ( s p ecif y ):$f. Medical and dental payments$g. In su ra n ce ( lif e , h ealt h ,accid en t, e tc .)$h . S ch ool, c h ild c a re$i. Child, spousal supportTOTAL MONTHLY EXPENSES(p rio r m arria g e)$(a dd a th ro u gh m )$8. L is t p aym en ts o n in sta llm en t a n d o th er d eb ts .C ontin ued o n A tta ch m en t 8 .C re d it o r's n am eForM onth ly p aym en tB ala n ce9. What do you own? (State value.)a . C ash$d. Real estate equity (addresses):...$b . C heckin g, s avin gs a n d c re d it u nio n acco un ts , e tc . ( lis t in stit u tio ns):(1 )(2 )$ $$$e. O th er p ers o nal p ro perty J e w elr y ,(3 )(4 )furniture, furs, stocks and bonds, etc. List separately):c. Cars, other vehicles, and boat equity (list make, year of each):(1 )(2 )(3 )$ $$Total for item e-$10.An Order Assigning Salary and Wages (for support) is now in effect as to my earnings. The amount payable under that orderis: $monthly.11. Other facts that support this Claim of Exemption are (describe unusual medical needs, school tuition, expenses for recent familyemergencies, 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.Date :(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