EJ-165 - Financial Statement

Summary

Financial Statement

Text

Form ID: EJ-165
Title: Financial Statement
Effective Date: 2007-01-01
Mandatory Form: no
Info Page: https://selfhelp.courts.ca.gov/jcc-form/EJ-165
Primary Download URL: https://www.courts.ca.gov/documents/ej165.pdf
Form Detail Page:
Financial Statement
(EJ-165)
Describes your financial situation if you claim property is exempt from collection based on your financial status. Is attached to form EJ-160.
Get form EJ-165
Effective: January 1, 2007
Go to
How-to instructions for Debt Collection
PDF Text:
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:
MONTHLY TAKE-HOME 
INCOME & SOURCENAME AGE RELATIONSHIP TO ME
a. Spouse
b.
c.
d.
e.
2.   My monthly income
a.  My gross monthly pay is:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a. $
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. $c.  My monthly take-home pay is  (a minus b): ..................................................................................
d.  Other money I get each month from  (specify source):
is ......................... d. $
e. $e.  TOTAL MONTHLY INCOME  (c plus d) ..................................................................................
3.   I, my spouse, and my other dependents own the following property:
a.  Cash .......................................................................................................................................... 3a. $
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, stocks, bonds, etc.) (list separately):
e. $
Form Adopted by the Judicial Council
of California 
WG-007/EJ-165 [Rev. January 1, 2007]
FINANCIAL STATEMENT
 (Wage Garnishment—Enforcement of Judgment)
Code of Civil Procedure, §§ 706.124, 703.530
www.courtinfo.ca.gov
$
$
WG-007/EJ-165
Page 1 of 2

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.  Clothing ...................................................................................................................................... d. $
e.  Medical and dental payments ..................................................................................................... e. $
f.  $f.   Insurance (life, health, accident, etc.) ........................................................................................
g.  School, child care ....................................................................................................................... g. $
h.  Child, spousal support (prior marriage) ...................................................................................... h. $
i.  $ I.   Transportation & auto expenses (insurance, gas, repair) (list car payments in item 5) ..............
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: OWED BY
FOR MO. PAYMENTS BALANCE OWED (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.)
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):
7.
A wage assignment for support is now in effect with respect to my earnings or those of my spouse or dependents named in8.
item 1 (specify each person's name and monthly amount):
My spouse has signed below.9.
I 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)
(TYPE OR PRINT NAME OF SPOUSE) (SIGNATURE OF SPOUSE)
FINANCIAL STATEMENT 
(Wage Garnishment—Enforcement of Judgment)
WG-007/EJ-165 [Rev. January 1, 2007]
SHORT TITLE: LEVYING OFFICER FILE NO. COURT CASE NO.
CREDITOR'S NAME
Page 2 of 2
WG-007/EJ-165

Retrieval chunks

• #1

  Form ID: EJ-165 Title: Financial Statement Effective Date: 2007-01-01 Mandatory Form: no Info Page: https://selfhelp.courts.ca.gov/jcc-form/EJ-165 Primary Download URL: https://www.courts.ca.gov/documents/ej165.pdf Form Detail Page: Financial Statement (EJ-165) Describes your financial situation if you claim …

• #2

  Form Adopted by the Judicial Council of California WG-007/EJ-165 [Rev. January 1, 2007] FINANCIAL STATEMENT (Wage Garnishment—Enforcement of Judgment) Code of Civil Procedure, §§ 706.124, 703.530 www.courtinfo.ca.gov $ $ WG-007/EJ-165 Page 1 of 2 4. The monthly expenses for me, my spouse, and my other dep…

• #3

  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.) 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 per…