INCOME: (Estimate of average monthly income.)

GROSS MONTHLY WAGES and COMMISSIONS, INCLUDING OVERTIME	YOU	YOUR SPOUSE
LESS:
Payroll taxes
Insurance
Union Dues
Other
NET MONTHLY INCOME
OTHER INCOME:
NET MONTHLY INCOME FROM A BUSINESS (Attach a Monthly Operating Report)
INCOME FROM REAL PROPERTY
INTEREST AND DIVIDENDS
CHILD AND SPOUSAL SUPPORT
SOCIAL SECURITY AND OTHER GOVT. ASSISTANCE
PENSION OR RETIREMENT
OTHER MONTHLY INCOME
TOTAL MONTHLY INCOME

EXPENSES

	AMT.
RENT OR MORTGAGE PAYMENT
Are real estate taxes included? Yes No
Is property insurance included? Yes No
UTILITIES: Electric and heating fuel
Water and Sewer
Telephone
Other
HOME MAINTENANCE
FOOD
CLOTHING
LAUNDRY AND DRY CLEANING
MEDICAL AND DENTAL EXPENSE (not including insurance pmts.)
TRANSPORTATION (not including car pmts.)
RECREATION, NEWSPAPERS, AND MAGAZINES
CHARITABLE CONTRIBUTIONS
INSURANCE: Homeowner's or renter's
Life
Health
Auto
Other
TAXES (not deducted from your wages)
INSTALLMENT PAYMENTS: (Do not include Credit Card Payments) Auto
Other
CHILD OR SPOUSAL SUPPORT
CREDIT CARD PAYMENTS
GIFTS (Birthday, Wedding, etc.)
TOTAL MONTHLY EXPENSES