Budget Analysis Form

First Name:
Middle Name:
Last Name:
Email Address:
Phone:
Spouse Name (If Joint):
 

Employment - You

Occupation:
Employer Name:
Address:
City:
State:
Zip:
Years Employed:
Phone:
Payroll Fax #:
 

Employment - Spouse

Occupation:
Employer Name:
Address:
City:
State:
Zip:
Years Employed:
Phone:
Payroll Fax #:
 

Dependants

Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
 

Income

  Debtor Spouse
I get paid
Gross Pay per Payday
Taxes: (Federal, State, Social Security, Medicare)
Insurance: (Medical, Dental, Life)
Pension / 401(k)
401(k) Loan Repayment
Credit Union Deduction
Union Dues/Other
NET PAY
Alimony/Child Support
Social Security / Unemployment
Part-Time Employment / 2nd Job
Pension/Retirement/Annuity Income
Rental Income
Income from Operation of Business
Total Monthly Income
 

Monthly Expenses

Rent
Mortgage Payment
Second Mortgage
Third Mortgage
Taxes
Insurance
Condo Assessment
Electricity (Average)
Heating (Average)
Water/Sewer
Garbage
Phone (family use only, $75.00)
Cable (NONE in 13 unless 100% Plan)
Home Maintenance ($50.00, or more with proof)
Food ($300 for 1st person, $50 each add'l in Chapter 13 case)
Clothing: ($10-25/person)
Medical/Dental:(out of pocket expenses)
Gasoline
Tolls/Parking
Bus/Train Fees
License Plates
City Stickers
Entertainment
Newspapers/Magazines
Health Insurance:(NOT deducted from pay)
Charitable Contributions per month
Vehicle Insurance
Vehicle Payment #1
Vehicle Payment #2
Vehicle Payment #3
Vehicle Repairs
Haircuts
Postage/Bank Charges
Tuition/Books/School Supplies
Student Loan Payments
Alimony Payments:(NOT deducted from pay)
Child Support Payment:(NOT deducted from pay check)
Life Insurance:(NOT deducted from pay check)
Feminine Care/Drugstore
Eye Care/Contact Lenses
Laundry/Dry Cleaning
Babysitting/Childcare
Business Expenses: (Including telephone use)
 

Total

Income Total
Expense Total
Difference