Name: 

E-mail:

Monthly Income

   DEBTOR’S MONTHLY
   TAKE-HOME PAY:

$

   SPOUSE’S MONTHLY
   TAKE-HOME PAY:

$

   OTHER MONTHLY INCOME :

$

   SOURCE OF OTHER INCOME:

Total Monthly Income:

$

Estimated Monthly Expenses

   MORTGAGE PAYMENT - 1st:

$

   MORTGAGE PAYMENT - 2nd:

$

   ELECTRIC BILL:

$

   HEATING BILL:

$

   WATER BILL:

$

   TELEPHONE BILL:

$

   CABLE TELEVISION:

$

   AUTOMOBILE #1:

$

   AUTOMOBILE #2:

$

   TRANSPORTATION / GASOLINE:

$

   AUTO INSURANCE:

$

   OTHER INSURANCE:

$

   PAST DUE TAXES DUE TO IRS or
   STATE:

$

   ALIMONY, MAINTENANCE or
   CHILD SUPPORT:

$

   CHILD CARE, COLLEGE, or
   SCHOOL:

$

   CLOTHING PURCHASES:

$

   DRY CLEANING:

$

   RELIGIOUS and/or CHARITY:

$

   FOOD:

$

   CREDIT CARD #1:

$

   CREDIT CARD #2:

$

   CREDIT CARD #3:

$

   HOMEOWNERS ASSOC FEE or
   CONDO FEE:

$

   SPENDING MONEY:

$

   ENTERTAINMENT:

$

  OTHER:

$

Total Monthly Expenses:

$