EMPLOYMENT	DEBTOR	SPOUSE	
Occupation			
Name of Employer			
Address of Employer			
			
Years Employed			
Telephone Number			
Payroll Fax Number			

 	
Dependents - Name	Age	

		

		

INCOME	DEBTOR	SPOUSE	
I Get Paid (check one)	 O  Weekly	O Bi-Weekly O 2X/Month O Monthly	O  Weekly	O Bi-Weekly O 2X/Month O Monthly	
Gross Pay per Payday	$	$	
Taxes: (Federal, State, Social Security, Medicare)	$	$	
Insurance: (Medical, Dental, Life)	$	$	
Pension / 401(k):	$	$	
401(k) Loan Repayment:	$	$	
Credit Union Deduction: WHAT FOR?	$	$	
Union Dues/Other:(Please specify)	$	$	
NET PAY:	$ 		$ 		

Alimony/Child Support:	$	$	
Social Security / Unemployment:	$	$	
Part-Time Employment / 2nd Job:	$	$	
Pension/Retirement/Annuity Income:	$	$	
Rental Income (from property):	$	$	
Income from Operation of Business:	$	$	
TOTAL MONTHLY INCOME:	$	$	

MONTHLY EXPENSES	Clothing: ($10-25/person)	$ 	
_	Haircuts (# of persons x $20):	
$	
Rent:	
$ 		Medical/Dental:
(out of pocket expenses)	
$ 		Postage/Bank Charges:	
$	
Mortgage Payment:	
$ 		Gasoline ($ 	/wk. x 4.33):	
$ 		Tuition/Books/School Supplies:	
$	
Second Mortgage:	
$ 		Tolls/Parking:
($ 	/wk. x 4.33)	
$ 		Student Loan Payments:	
$	
Third Mortgage:	
$ 		Bus/Train Fees (Monthly):	
$ 		Alimony Payments:
(NOT deducted from pay)	
$	
Are Taxes Included?
YES NO (if no, how much)	
$ 		License Plates ($ 	x 	)	
$ 		Child Support Payment:
(NOT deducted from pay check)	
$	
Is Insurance Included?
YES NO (if no, how much)	
$ 		City Stickers ($ 	x 	)	
$ 		Life Insurance:
(NOT deducted from pay check)	
$	
Condo Assessment:	
$ 		Entertainment ($10-$20/person):	
$ 		Feminine Care/Drugstore:	
$	
Electricity (Average) :	
$ 		Newspapers/Magazines:	
$ 		Eye Care/Contact Lenses: (per month)	
$	
Heating (Average):	
$ 		Health Insurance:
(NOT deducted from pay)	
$ 		Laundry/Dry Cleaning ($20-$40):	
$	
Water/Sewer:	
$ 		Charitable Contributions per month: For the last 	months	
$ 		Babysitting/Childcare (monthly):	
$	
Garbage:	
$ 		Vehicle Insurance:	
$ 		Business Expenses: (Including telephone use)	
$	
Phone (family use only, $75.00)	
$ 		Vehicle Payment #1	
$ 		TOTAL:	
$	
Cable (NONE in 13 unless 100% Plan):	
$ 		Vehicle Payment #2	
$ 		A) Income Total:	
$	
Home Maintenance ($50.00, or more with proof)	 	
$	Vehicle Payment #3	 	
$	B) Expense Total:
(subtract B from A)	$	0	
Food ($300 for 1st person, $50 each add’l in Chapter 13 case)	
$ 		Vehicle Repairs (# of cars x $50):	
$ 		C)	Difference:	$ 0.00