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2. Income for Mary Smith  

When asked for a weekly, monthly or annual value enter a value in only one field.   

Leave blank as many fields as you wish.

WAGES FOR:  Mary Smith  

Annual Wages:

NON-WAGE INCOME FOR:  Mary Smith

  Weekly Monthly Annual
Support from previous relationships:
Alimony from previous relationships:
Unemployment compensation:
Public Assistance:
Bonuses
Commissions:
Tips:
Overtime:
Disability Insurance:
Workers' compensation:
Royalties:
Rent from Spouse:
Deferred Compensation:
Monthly Social Security Income:    
Other:
Other:
Other:
Other:
Other:


3. Expenses for Mary Smith  

Enter each expense, either Weekly, Monthly or Annual amount (enter only one value). 

HOUSING:

  Weekly Monthly Annual
Rent:
Real Estate Taxes:
Condominium Charges:
Cooperative Apartment Maintenance:

UTILITIES:
  Weekly Monthly Annual
Fuel Oil:
Gas
Electricity:
Telephone:
Water:
Cell Phone:
Internet:
Other:   

FOOD:

  Weekly Monthly Annual
Groceries:
School Lunches:
Lunches at Work:
Dining Out:
Liquor / Alcohol:
Home Entertainment:
Other:   

CLOTHING:

  Weekly Monthly Annual
Husband:
Wife:
Children:
Other:   

LAUNDRY:

  Weekly Monthly Annual
Laundry at Home:
Dry Cleaning:
Tailor:
Other:   

INSURANCE:

  Weekly Monthly Annual
Life:
Homeowners / Tenant's:
Fire, Theft & Liability:
Automotive:
Umbrella Policy:
Medical Plan:
Dental Plan:
Optical Plan:
Disability:
Worker's Compensation:
Other:   

UNREIMBURSED MEDICAL:

  Weekly Monthly Annual
Medical:
Dental:
Optical:
Pharmaceutical:
Surgical Nursing, Hospital:
Therapist:
Dermatologist:
Health / Beauty:
Other:   

HOUSEHOLD MAINTENANCE:

  Weekly Monthly Annual
Repairs:
Furniture, Furnishings, Housewares:
Cleaning Supplies:
Appliances Including Maintenance:
Painting:
Sanitation / Carting:
Gardening, Lawn, Grounds Care:
Snow Removal:
Exterminator:
Water Softener:
Carpeting / Drapery / Furniture Cleaning:
Floor Waxing:
Window Cleaning:
Electrician:
Locksmith:
Flowers:
Framing:
Hardware:
Plumbing:
Security:
Other:   

Expenses continued on next page ...

 

 

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Last Update Dec 22, 2008
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