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Doh 4444 form Attachment V NEW YORK STATE DEPARTMENT OF HEALTH Self- Declaration of Income Office of Health Insurance Programs Name: App Reg./Case # : Social Security Number: Address: City: State: Zip Code: Complete

Wg 026 form WG-026 ATTORNEY OR PARTY WITHOUT ATTORNEY Name State Bar number and address TELEPHONE NO FOR COURT USE ONLY FAX NO. E. The earnings of others listed in item 5 are now subject to wage assignments and Earnings Withholding Orders as follows specify Page 1 of 2 Form Adopted for Mandatory Use Judicial Council of California WG-026 Rev. January 1 2007 Wage Garnishment-State Tax Liability Code of Civil Procedure 706. ATTORNEY FOR STATE TAXPAYER/RESPONDENT NAME OF COURT STREET ADDRESS MAILING ADDRESS CITY AND ZIP CODE BRANCH NAME APPLICATION OF Name TAXPAYER/RESPONDENT CLAIM OF EXEMPTION AND FINANCIAL DECLARATION CASE NUMBER TAX AGENCY NUMBER NAME OF STATE TAX AGENCY Copy the information required above from the Application for Earnings Withholding Order for Taxes form WG-020. 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 each pay period. b. a* All earnings. me 2. Please send all papers to 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 None 4. a* I am paid Withhold daily b. My gross pay is weekly every two weeks twice a month monthly. c* My take-home pay is d. My payroll deductions are item and amount 5. The following persons depend in whole or in part on me for support Name Age Relationship to me Monthly income and its source Myself c* d. 051 706. 076 www*courtinfo*ca*gov 7. My monthly expenses are as follows a* Rent or house payment and maintenance. b. Food and household supplies. c* Utilities and telephone. d. Clothing. e. Laundry and cleaning. f* Medical and dental payments. g. Insurance life health accident etc*. h. School child care. i. Child spousal support prior marriage. 8. List payments on installment and other debts. Creditor s name 9. What do you own State value. a* Cash. b. Checking savings and credit union accounts etc* list institutions c* Cars other vehicles and boat equity list make year of each j. Entertainment and incidentals. k. Transportation and auto expenses insurance gas repair. l* Installment payments insert total and list below in item 8. m* Other specify. TOTAL MONTHLY EXPENSES add a through m. Continued on Attachment 8. For Monthly payment Balance d. Real estate equity addresses. e. Other personal property jewelry furniture furs stocks and bonds etc* List separately Total for item e. An Order Assigning Salary and Wages for support is now in effect as to my earnings. The amount payable under that order is 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 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.

Audit declaration form Please complete sign and return the Audit Declaration to the Department with the License Renewal forms and fees. I further understand that any false misleading or incomplete answers to this Audit Declaration may be construed as a violation of A. The Audit Declaration is an important report that will become a public record and be kept by the Department for at least five years. BROKER SUPERVISION CONTROL AUDIT DECLARATION The Designated Broker shall complete this Audit Declaration and return it to the Department of Real Estate concurrent with Broker s license renewal to Arizona Department of Real Estate ADRE 2910 N. 44th Street Suite 100 Phoenix Arizona 85018 Pursuant to A. R.S. 32-2108 A 32-2151. 01 A and 32-2175 H. The Department will use the information in the completed Audit Declaration when conducting any future field audit. R.S. 32-2153 A 17 and A. A. C. R4-28-303 A 2 f this Audit Declaration is required as part of the Designated/Self Employed Broker s Renewal Application or as determined appropriate by the Department s Audit Division. This Audit Declaration does not preclude an onsite or field audit of the books and records of the brokerage pursuant to A. A. R.S. 32-2173 C ADDITIONAL EXPLANATION Please provide further explanation below for any NO answers or for any answer above for which inadequate space was provided. If you require additional space to answer a question please include a further written response as part of this submission. As the Designated Broker I have personally completed or personally overseen the completion of this Audit Declaration and have personally reviewed and verified the responses in the Audit Declaration. I understand the importance of the broker s duty to exercise reasonable supervision and control in assuring broker compliance with the law and have made diligent efforts to comply in every respect. ALL NO answers require further explanation on Page 8. If you have questions relating to how to respond to any item you may submit your question to the Department s auditing staff through the Department Message Center. Statutes and rules are summarized refer to the quoted source when answering the questions. ADMINISTRATIVE-PRINT CLEARLY DESIGNATED BROKER S NAME/BUSINESS PHONE NUMBER LICENSE NUMBER BROKERAGE BUSINESS NAME/DBA BUSINESS STREET ADDRESS CITY/COUNTY/STATE/ZIP CODE Number of salespersons and associate brokers licensed to the brokerage DO NOT include the Designated Broker Number of unlicensed employees at the brokerage part-time and full-time Average number of Sales and Lease transactions handled per year The brokerage conducts check all that apply Residential Real Estate Commercial Sales and Leasing Business Brokerage Farm and Ranch Residential Property Management Other list Commercial Property Management New Home Subdivision Other Subdivision/Unsubdivided Land Timeshare Page 1 of 9 BrokerSupervisionControlAuditForm rev 10. 04. 2013 GENERAL RECORDS COMPLIANCE Yes No N/A Signage is properly affixed at the main entrance to the brokerage office and each branch office and is in clearly visible lettering.

Real estate transfer declarati... COOK COUNTY REAL ESTATE TRANSFER DECLARATION The following is required by the Cook County Real Property Tax Ordinance effective September 1 1993. Any transferor of transferee who fails to file with the Recorder a real property transfer declaration as required by Section 7 of this ordinance or a supplemental transfer declaration as required by Section 10 of this ordinance or willfully falsifies the value of transferred real estate shall be subject to a penalty equal to the amount of the applicable tax and shall be fined an amount not to exceed 1000. Sec 2 COMPUTATION OF TAX Twp. Range use additional sheet If necessary Full actual consideration Less amount of personal property included in purchase Net consideration for real estate property remains subject Net taxable consideration Amount of tax stamps. 25 per 500 or part thereof ATTESTATION OF PARTIES we hereby declare the full actual consideration and above facts contained in the declaration to be true and correct. Name and Address of Seller Please Print Signature Seller or Agent Buyer or Agent Use space below for tax mailing address if different from above Cook County Transfer Declaration FASTDoc 09/2005 EXEMPT TRANSFERS Check the Appropriate Box Exempt transfers are subject to the requirement contained in subsection 7 c of this ordinance. 00 or imprisoned for a period not to exceed six months or both. Except as to Exempt Transactions the Recorder is prohibited by law from accepting any deed assignment or other instrument of transfer for recordation unless it is accompanied by Recorder s Valuation a declaration containing all of the information requested therein. PROPERTY IDENTIFICATION Address of Property City Street or Rural Route Permanent Real Estate Index No. Zip Code Township Date of Deed Type of Deed TYPE OF PROPERTY INTEREST TRANSFERRED Single Family Commercial Fee title Condo co-op Industrial Beneficial interest in a land trust 4 or more units residential Vacant Land Lessee interest in a ground lease Mixed use commer. Name and Address of Seller Please Print Signature Seller or Agent Buyer or Agent Use space below for tax mailing address if different from above Cook County Transfer Declaration FASTDoc 09/2005 EXEMPT TRANSFERS Check the Appropriate Box Exempt transfers are subject to the requirement contained in subsection 7 c of this ordinance. 7 c No transfer shall be exempt from the tax imposed by this ordinance unless the declaration describes the facts supporting the exemption and is accompanied by such supporting documentation as the Recorder may reasonably require. A. Transfers of real property made prior to May 21 1979 where the deed was recorded after that date or assignments of beneficial interest in real property dated prior to August 1 1985 where the assignment was delivered on or after August 1 1985 B. 25 per 500 or part thereof ATTESTATION OF PARTIES we hereby declare the full actual consideration and above facts contained in the declaration to be true and correct. Name and Address of Seller Please Print Signature Seller or Agent Buyer or Agent Use space below for tax mailing address if different from above Cook County Transfer Declaration FASTDoc 09/2005 EXEMPT TRANSFERS Check the Appropriate Box Exempt transfers are subject to the requirement contained in subsection 7 c of this ordinance. 7 c No transfer shall be exempt from the tax imposed by this ordinance unless the declaration describes the facts supporting the exemption and is accompanied by such supporting documentation as the Recorder may reasonably require. 7 c No transfer shall be exempt from the tax imposed by this ordinance unless the declaration describes the facts supporting the exemption and is accompanied by such supporting documentation as the Recorder may reasonably require. A. Transfers of real property made prior to May 21 1979 where the deed was recorded after that date or assignments of beneficial interest in real property dated prior to August 1 1985 where the assignment was delivered on or after August 1 1985 B. Transfers involving real property acquired by or from any governmental body or acquired by any corporation society association foundation or institution organized and operated exclusively for charitable religious or educational purposes or acquired by any international organization not subject to local taxes under applicable law Copy of IRS granting tax exempt status must be attached C. Transfers in which the deed assignment or other instrument of transfer secures debt or other obligation confirms corrects modifies or supplements a deed assignment or other instrument of transfer previously recorded or delivered E. F. other obligations its undivided interest in the real property then such party shall be liable for tax computed upon any consideration paid for the excess I. Transfers between a subsidiary corporation and its parent or between subsidiary corporations of a common parent either pursuant to a plan of merger or consolidation or pursuant to an agreement providing for the sale of substantially all of the seller s assets J. Transfers from a subsidiary corporation to its parent for no consideration other than the cancellation or surrender of the subsidiary s stock and transfers from a parent corporation to its subsidiary for no consideration other than the issuance or delivery to the parent of the subsidiary s stock K. Transfers made pursuant to a confirmed plan of reorganization as provided under section 1146 c of Chapter 11 of the U.S. Bankruptcy Code of 1978 as amended Provided bankruptcy court docket number L. Deeds representing transfers subject to the imposition of a documentary stamp tax imposed by the government of the United States except that such deeds shall not be exempt from filling the declaration and pursuant to a mortgage or security interest foreclosure proceeding or sale or pursuant to a transfer in lieu of foreclosure.

Printable income disclosure fo... Name Address City State Zip Code Phone Number PETITIONER/ RESPONDENT PRO SE MONTANA JUDICIAL DISTRICT COURT COUNTY In re the Marriage of: Cause No.: , Petitioner, and , Respondent. Petitioner s/ Respondent

Bc hydro underground declarati... CUSTOMER REFERENCE GUIDE - UNDERGROUND RESIDENTIAL SERVICES The Canadian Electrical Code specifies that the supply end of a service shall be installed in a location satisfactory to both the Electrical

Cayman islands customs forms s... CAYMAN ISLANDS Department ofFinance Development and DECLARATION CUSTOMS Everypassengeror the head of a familytravellingtogetheris requiredto give the following information: ''RNAME...... iii;;;;;ilii

Financial declaration for rest... My Name Address City, State, Zip Phone Email In the ? District ? Justice Court of Utah, County Court Address Prosecutorial Jurisdiction Financial Declaration for Restitution v. Case Number Defendant

Declaration form by the applic... Declaration Form by the Applicant D e t I hereby decla that I hav read the in are ve nstruction car refully and I have submitt ted all docum ments according to HAAD equirements. re will nsible for any delay that ma incur if I su ay ubmit an inco omplete applic cation or re-su ubmit any doc cuments at a I w be respon later stage. understand th completing the verifica hat ation process does not gua arantee obtaiining a licens if I do not meet HAAD se Iu cr riteria* Pe ersonal Deta ails Fu Name ull First Name Middle Name Last Nam me Signature Date d dd/mm/yyyy. re will nsible for any delay that ma incur if I su ay ubmit an inco omplete applic cation or re-su ubmit any doc cuments at a I w be respon later stage. understand th completing the verifica hat ation process does not gua arantee obtaiining a licens if I do not meet HAAD se Iu cr riteria* Pe ersonal Deta ails Fu Name ull First Name Middle Name Last Nam me Signature Date d dd/mm/yyyy.

Declaration facility form Declaration Form by the Sponsoring Facility We hereby declare that is applying for HAAD licensure under our sponsorship and that we undertake to comply with and fulfill the licensing requirements for the above mentioned healthcare professionals. Please note that by signing this application I acknowledged the responsibility held by our facility to ensure that all information given to HAAD is true and correct Personal Details Full Name First Name Middle Name Last Name Official Title/Position Signature Date dd/mm/yyyy.

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