United Way Cummunity Partner

416 College Street, Beloit, WI 53511

Phone: 608-365-1244
Toll Free: 866-925-CCCS
FAX: 608-365-4097

Personal Profile

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

Creditor Name
(or collection agency
currently holding account)
Balance
(use most recent)
Interest Rate Payment

Your Name

Your Phone