SHADED AREAS ARE FOR OFFICE USE ONLY

The worksheet is 5 pages long. Click on the tabs at the bottom of the window for the additional pages.  

INCOME INSTRUCTIONS

• Your Gross Monthly Pay: Please list your gross monthly or total pay from your primary job. If you are paid twice each month, simply add your two gross or total amounts together. If you are paid weekly, simply multiply your weekly gross or total pay amount by four. If your income varies each month, please give a six month average of total pay.
• Total Monthly Deductions: Please list all payroll deductions such as taxes, credit union loan payments, employer savings or investment plan contributions, health insurance, retirement plan contributions, stock purchase plans and so on.
• Take Home Pay: Please subtract all deductions from your gross or total pay to get take home pay. This should match the amount of your paycheck.
• Your Other Income: Please list all your other monthly income from monthly bonus checks, tips, alimony, child support, dividends, interest, second or part-time job income, regular gifts from family, disability payments, business or government pensions and so on. If this income varies each month, please give a six month average. If you receive an annual bonus, divide that bonus by twelve and include the average amount.
• Co-Client’s Gross Monthly Pay, Deductions and Take Home Pay: Please complete if you are legally married, have a co-signer on a loan, or have an additional name on a credit card.

YOUR LIVING EXPENSES INSTRUCTIONS

• Housing: Please list your monthly housing expense such as rent or total mortgage payment including insurance, home owners association dues, common area maintenance fees and property taxes.
• Food: Please list all food expenses including groceries, lunches at work, school lunches, dining out, etc.
• Utilities: Please list your monthly total of electric, gas, telephone, long distance, water, garbage pick-up and similar bills. When these bills vary widely like electric or gas, please use a 12 month average.
• Transportation: Please list your monthly cost of gas, tolls, car insurance and so on. Please add the total car maintenance bills from the last six months and divide this total by six, so that these charges will be included.
• Personal: Please include estimated monthly spending for clothing, laundry, dry cleaning, hair care, prescription drugs, health and beauty products, etc.
• Family: Please list all medical expenses, child care expenses, school tuition and children's allowances. Also, list your child support and alimony payments, if any.
• Entertainment: Please include estimated monthly spending for hobbies, newspaper or magazine subscriptions, lessons, movies, cable TV, recreational activities, lottery tickets, etc.
• Other: Please list all non-recurring expenditures for holiday expenses, charitable contributions, vacations, one-time purchases for appliances or home repair and so on. Please divide this total by 12 to get a monthly average.
• Savings: Please list the amount for non-payroll deducted savings or personal investments each month.

YOUR CREDITORS INSTRUCTIONS

• Please list all your current debt obligations. Please include credit card accounts; bank, credit union and finance company loans for cars, home improvements, appliances, etc.; medical payments due to hospitals, doctors or dentists; personal loans from relatives or friends; student loans; IRS or other tax debts; etc. IMPORTANT: You must carefully list every debt obligation, even small debts. By not disclosing all debts, we may have a creditor deny cooperation with your plan.
• Please carefully include the company name (or the original creditor's name if the account is being handled by a collection agency), and account number for identification purposes. For each account, also provide the current balance, the dollar amount of the regular monthly scheduled payment and the date of the last payment you made. These figures will help us to calculate your debt management payment.