[flowermom]

Applicant(s): Date:
Earnings
Applicant’s Salary (yearly gross) $
Other (specify): $
Spouse’s Salary (yearly gross) $
Other (specify): $
Total Earnings: $

Assets
Cash in bank (current savings) $
Cash in bank (average checking) $
Stocks (estimated value) $
Bonds (estimated value) $
Cash value of life insurance policies (not face value) $
Other $
Automobile(s):
Make Model Year Purchase Price $
Market Value
Make Model Year Purchase Price $
Market Value
Home:
Purchase date Purchase price Equity $
Market Value
Other assets and estimated value (itemize)
$
$
Total Assets: $

Liabilities Monthly Payment Outstanding Balance
Home mortgage $ $
Personal loans $ $
Installment accounts (itemize)
$ $
$ $
$ $
Real estate loans $ $
Insurance Policy Loans $ $
Automobile loans $ $
Others (specify) $ $
$ $
Total Liabilities: $
List life insurance policies by:
Spouse covered Name of Insurance Co. Face Value


List disability policies by
Spouse covered Name of Insurance Co. Face Value




Monthly Expenses
(If not monthly, pro-rate monthly amount)

1. House rent or payment, tax, and insurance $
2. House upkeep – repairs, improvements lawn
and garden expense $
3. Groceries: (Include meals purchased out and any food delivered) $

4. Utilities:
Power $
Gas $
Water $
Phone $
Garbage $ Total Utilities $

5. Clothing $
6. Medical and dental-average $

7. Car expenses:
Gas $
Tag and Tax $
Payment $
Upkeep on car $ Total Car Expenses $

8. Insurances:
Life $
Health $
Car $
Household (if not included in #1)
$
Burial $
Other $ Total Insurance: $

9. Reading materials $
10. Recreation and hobbies $
11. Church and charity contributions $
12. Installment accounts $
13. Club and membership dues; professional dues $
14. Savings and /or investments $
15. Child support/alimony if applicable $
16. Other (specify) $
TOTAL MONTHLY EXPENSES: $

Applicant’s monthly take-home pay $
Spouse’s monthly take-home pay $
Add other monthly net income $
TOTAL: $
Total monthly expenses (subtract) -
EXCESS MONTHLY INCOME* $

*Excess should be sufficient to cover needs of expected child