| Employed by:______________________
City/State: ______________________ Occupation: ______________________ Pay Period: ______________________ Salary/Annual:____________________ Next Payday:______________________ # Exemptions: __________ |
Children in Household
Name DOB ___________________ ___________________ ___________________ ___________________ ___________________ |
Avg Gross Pay/MONTH:__________
LESS IncomeTaxes-Fed: __________ IncomeTaxes-St: __________ Medicare/FICA: __________ Health Insurance: __________ Life Insurance: __________ Required Retirement:__________ Avg MONTHLY NET PAY:__________ Other Income: __________ |
| Household | Clothing | |||
| Mortgage or Rent * | _________ | New (excluding children) | _________ | |
| Real Estate Prop. Tax | _________ | Cleaning/Laundry | _________ | |
| Personal Property Tax | _________ | Uniforms | _________ | |
| Homeowner's Insurance | _________ | Health Expenses | ||
| Repairs/Maintenance | _________ | Doctor | _________ | |
| Furniture/Furnishings | _________ | Dentist | _________ | |
| Utilities | _________ | Orthodontist | _________ | |
| Electricity | _________ | Therapist | _________ | |
| Gas/Heating Oil | _________ | Eyeglasses | _________ | |
| Water/Sewage | _________ | Hospital | _________ | |
| Telephone | _________ | Medicines | _________ | |
| Trash Collection | _________ | Other | _________ | |
| Cable TV | _________ | Dues | _________ | |
| Food | Professional Association | _________ | ||
| Groceries | _________ | Social Associations | _________ | |
| Meals Out | _________ | Homeowner's Association | _________ | |
| Automobile | Miscellaneous | _________ | ||
| Payment | _________ | Gifts (Xmas, Birthday) | _________ | |
| Gasoline | _________ | Church/Charity | _________ | |
| Repair Maintenance | _________ | Entertainment(w/chdn) | _________ | |
| Auto Insurance | _________ | Vacations | _________ | |
| Parking/Transportation | _________ | Hobbies | _________ | |
| Tags/Inspection, etc. | _________ | Personal Grooming | _________ | |
| Children Expenses | Newspapers/Publication | _________ | ||
| Child care | _________ | Disability Insurance | _________ | |
| School Tuition | _________ | Life Insurance | _________ | |
| Lunch Money | _________ | Legal Expenses | _________ | |
| School Supplies | _________ | Other: | _________ | |
| Lessons/Sports | _________ | Totals Per Month | _________ | |
| New Clothing | _________ | Subtotal Expenses | _________ | |
| Personal Grooming | _________ | Subtotal Debt Payments | _________ | |
| Other - Allowances | _________ | TOTAL EXPENSES | _________ | |
| Debt
Payments,total
(itemize below) |
_________ | TOTAL NET INCOME | _________ | |
| ________________________ | _________ | BALANCE (Shortfall) | _________ | |
| ________________________ | _________ | |||
| ________________________ | _________ | Liquid Assets on Hand | ||
| ________________________ | _________ | Cash/Checking/Savings | _________ | |
| ________________________ | _________ | Other Liquid Assets | _________ | |
| ________________________ | _________ | TOTAL LIQUID ASSETS | _________ |