MONTHLY EXPENSES
Rent or Home Mortgage Payment $________________
Are real Estate Taxes Included (Yes, No) $_________________
Is Property Insurance Included (Yes, No) $_________________
Utilities: Electricity and Heating Fuel $________________
Water and Sewer $________________
Telephone $________________
Other (cell, cable, internet) $________________
Home Maintenance (Repairs and Upkeep) $_________________
Food (For you and all Dependents listed) $________________
Clothing $_________________
Laundry and Dry Cleaning $_________________
Medical and Dental Expenses $_________________
Transportation (Gas, maintenance. Not including car payment) $_________________
Recreation, clubs, entertainment, newspapers, movies $_________________
Charitable Contributions $_________________
Insurance
Homeowners or Renters $________________
Life $________________
Health (Do not include the amount from paycheck) $________________
Auto $________________
Taxes (Not deducted from wages or included in mortgage Pmt.)
(Specify) $________________
Installment Payments
Automobile(s) $________________
Other $________________
Alimony or Support paid to others $________________
Payments for support of additional dependents not
living at your home $_________________
Regular Expenses from Operation of a Business
(attach detailed statement, click on “additional
information” below) $_________________
Other (Daycare, etc.) $_________________
Other $_________________
BACK SAVE SEND ADDITIONAL INFORMATION