HOUSEHOLD FINANCIAL INFORMATION
INCOME BUDGET FOR HOUSEHOLD
SOURCE OF INCOME LAST MO. ACTUAL THIS MO. EXPECTED THIS MO. ACTUAL ADJUSTED MONTHLY
Employment $ $ $ $
Overtime ________________________________________
Child Support/Alimony _____________________________________
Pension _______________________________________
Interest ______________________________________
Public Benefits _____________________________________
Dividends
Trust Payments ______________________________________
Royalties ______________________________________
Rents Received ______________________________________
Other (List) ______________________________________
TOTAL (MONTHLY) $ $ $ $
NOTES/ANTICIPATED CHANGES:________
EXPENSE BUDGET FOR HOUSEHOLD
TYPE OF EXPENSE LAST MO. ACTUAL THIS MO. EXPECTED THIS MO. ACTUAL ADJUSTED MONTHLY
Payroll Deductions $ $ $ $
Income Tax Withheld ____________________________
Social Security ___________________________
FICA ___________________________
Wage Garnishments _______________________ Credit Union ___________________________________
Other _____________________
Home Related Expenses
Mortgage or Rent ___________________________________
Second Mortgage ___________________________________
Third Mortgage ___________________________________
Real Estate Taxes ___________________________________
Insurance __________________________________
Condo Fees & Assessments __________
Mobile Home Lot Rent ________
Home Maintenance/ Upkeep ________________
Utilities _________________________________
Gas __________________________________________________
Electric ___________________
Oil ___________________
Water/Sewer _______________
Telephone:
Land Line ____________
Cell ____________
Cable TV ____________
Internet
Other ___________
Food
Eating Out ________________
Groceries ________________
Clothing _______________________
Laundry and Cleaning _____________________
Medical _______________________
Current Needs _______________________
Prescriptions _______________________
Dental _______________________
Insurance Co-Payments or Premiums
Other _________________________________
Transportation _________________________
Auto Payments _________________________________
Car Insurance _________________________________
Gas and Maintenance _________________________
Public Transportation _______________________
Life Insurance _________________________
Alimony or Support Paid _________________________
School Expenses _________________________
Student Loan Payments _________________________
Entertainment _________________________
Newspapers/Magazines _________________________
Charity/Church _________________________
Pet Expenses _________________________
Amounts Owed on Debts _________________________
Credit Card_______________________________________
___________________
Credit Card
___________________
Credit Card
___________________
Medical Bill
___________________
Medical Bill
___________________
Other Back Bills (List)
___________________
Cosigned Debts
Business Debts (List)
___________________
___________________
Other Expenses (List)
___________________
___________________
Miscellaneous
TOTAL
Other Important Debt Issues:
Wage Garnishments Yes______ No______
Pending Court Cases Yes______ No______
Pending Utility Shut-offs Yes _____ No _____
Car Loan Defaults or Repossessions Tax Debts Yes ____ No____
Student Loan Debts Yes_____ No_____
Other:
Notes/Anticipated Changes:
Describe Assets and Other Resources:
Savings Yes______ No______ Amount $______________
Court Cases Pending Against Others Yes______ No__________
Value $______________
Anticipated Tax Refunds Yes______ No____________
Amount $______________
Assets Which Can Be Sold Yes ______ No______ Value $______________
Pension or Retirement Funds Yes______ No______ Value $______________
Other Assets and Notes:
INCOME AND EXPENSE TOTALS
Last Mo. Actual This Mo. Expected This Mo. Actual Adjusted Expected
A. Total Projected Monthly Income
B. Total Projected Monthly Expenses
Excess Income or Shortfall (A minus B)
Notes:
OTHER INFORMATION
1. Have you made an effort to arrange a workout on their own? What result?
2. Have you filed bankruptcy? If so when? Current status of case if still pending? If bankruptcy is over, what result?
3. Other issues which came up during this time.
4. Questions and open issues that must be resolved.