| Monthly Net Income (after taxes) |
|
| Savings |
|
| Number of persons in household |
|
Monthly Housing Expenses |
| Rent/Mortgage |
|
| Equity Loan/Second Mortgage/Land/Payment/Land Rent |
|
| Property Taxes and Insurance, Assoc. Fees/Dues if not already included in mortgage |
|
| Lawn/Garden/Pest/Pool/Security |
|
| Home Maintenance/Repairs/Cleaning |
|
| Utilities/Garbage Pickup |
|
| Utilities/Gas |
|
| Utilities/Electric |
|
| Utilities/Cable |
|
| Utilities/Sewer/Water |
|
| Phone/Local Only |
|
| Phone/Long Distance Only |
|
| Internet Fees |
|
Monthly Transportation Expenses
IF MULTIPLE VEHICLES PLEASE COMBINE INTO ONE TOTAL |
| Car Payment |
|
| Car Insurance |
|
| Gas |
|
| Oil/Lube |
|
| Car Repair |
|
| Parking/Tolls |
|
| Public Transportation/Bus/Cab/Other |
|
| Recreational Vehicles/Motorcycles/Boats/Misc/List all costs associated with |
|
Monthly Medical/Dental/Life Expenses |
| Insurance/Life |
|
| Insurance/Medical |
|
| Insurance/Dental |
|
| Insurance/Optical |
|
| Medical/Bills/Copays |
|
| Dental/Bills/Copays |
|
| Optical/Hearing/Bills/Copays |
|
Monthly Miscellaneous Expenses |
| Groceries |
|
| Household Items (cleaning supplies, paper products, diapers, toiletries, cosmetics, detergent, ect.) |
|
| Alimony/Child Support |
|
| Child/Elder Care |
|
| Laundry/Dry Cleaning |
|
| Education (tuition, books, supplies, special lessons, pictures, yearbooks) |
|
| Cell Phone/Pager |
|
| Gifts/Cards (birthdays, anniversaries/weddings, Mom's/Dad's day, holidays, etc.) |
|
| Food Away/Lunches |
|
| Dining Out |
|
| School Lunches |
|
| Beauty/Barber Shop |
|
| Clothing |
|
| Recreation (movies, video rental, entertainment, music/concerts/cds/tickets/cds/tickets, vacations, travel, family visits, hobbies, lottery, ect.) |
|
| Personal Expenses (tobacco, liquor, beer, wine) |
|
| Contributions (church, charities) |
|
| Dues (club, union, Health or sports memberships, AAA, etc.) |
|
| Magazine, News Paper Subscriptions |
|
| Pet Care |
|
| Misc. (bank charges, P.O. Box, postage, safe deposit box, allowance, storage, other) |
|
Creditor Information |
|
Your Name |
Your Phone |
|
|
|
