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Average Monthly Expenses
Please include all payroll deductions (taxes, debt-payments, insurance, retirement, etc.) under the appropriate categories. Please use combined totals if married.


Item		 Itemized
Expense		 Total Expense Item Itemized
Expense		 Total Expense

1. Giving		 8. Clothing

2. Taxes		 Adults
    Federal   Children
    State   Cleaning/Laundry  
    Social Security   9. Medical/Health

Disability Ins.

3. Saving/Investing		   Health Ins.
   Emergency Fund   Doctor Bills
   Retirement Fund   Dentist
   College Fund   Optometrist
   Other   10. Personal
4. Home Life Insurance
   First Mortgage Child Care
   Second Mortgage Barber/Beauty  
   Real Estate Taxes Education/Adult  
   Homeowners Ins. School Tuition  
   Maint./Repairs School Supplies
   Furniture Replace Child Support
  Other
   Alimony
5. Utilities
   		 Subscriptions
   Electricity Organization Dues
   Water Gifts (+Christmas)
   Gas Miscellaneous
   Phones Blow Money
   Trash Other       

Cable/Internet

 11. Recreation
6. Food Trips/Vacation    
   Grocery   Entertainment
   Eating Out    
       
         
         
         
         

7. Transportation
12. MONTHLY Debt Payments

    1st Payment
  
Credit Card

    2nd Payment
  
Credit Card

    Vehicle Insurance
 
Credit Card

    Gas & Oil 		 
Credit Card
 
    Repairs & Tires 		 

Federal Income Tax
    Tags/Taxes  

State Income Tax

    Other (Replacement) 		Student Loan

Legal Judgments


 
Other


Other
 
Other


Other


Other

  Other  

     

TOTAL EXPENSES  

     

   

     

   
   

   

     

 		        

       

  		    
 

       
           
           
           
           
           

 

 

          
           

Counselee Income and Comparison
GROSS INCOME prior to any automatic deductions (taxes, debt payments, insurance, investments, etc.)
Types of Income
Self
Spouse
 Types of Income
Self
Spouse
1. Salary 7. Other Income
     Interest/Rents/Misc
2. Social Security 8. Bonuses
3. Retirement/
     Pension 		9. Self-Employment
4. Child Support
Total Income:
5. Alimony
Less Expenses:
6. 2nd Job
AVERAGE SURPLUS/SHORT:
Financial Statement
ASSETS (at fair market value) LIABILITIES

Cash

Checking Accounts

Saving Accounts

Home

INvestment Prop

Cars

Boats/Motor home/Motorcycle

Mutual Funds

Retirement Plans

Stocks/Bonds/CDs
 

TOTAL ASSETS

1st Mortgage

2nd Mortgage

Consolidation Loans

Auto Loans

Total Credit Card Debt

Student Loans

IRS

Personal Loans

Investment Property

Boats/Motor home/Motorcycle
 

TOTAL LIABILITIES
NET WORTH
Total Assets         - Total Liabilities         =    
Client Name:  Date:

Client Signature: (if printed)__________________________________
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