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Income and Expense Worksheet *Monthly Combined Household Income includes that of Client, Co-Client, Spouse, or any other contributor to the overall household income.

Monthly Income Monthly Combined Household Income*: Other Income [Alimony, Child Support, Etc.]:

$ 0.00

Income Total:

Please include all recurring monthly expenses as accurately as possible. The provided information will be utilized to determine the extent of your personal financial hardship and will assist us during the negotiations process with your creditors or collectors.

Monthly Cost of Living Expenses Housing

Personal

Mortgage/Rent

Clothing

Utilities [Gas, Electric, Water, Etc.]

Barber/Hair Salon

Homeowner’s/Renter’s Insurance

Gifts/Christmas/Birthdays

Telephone – Home/Cellular

Leisure/Recreation

Television – Cable/Satellite

Movie Theater

Maintenance

Children’s Toys/Games

Transportation

Health Club Membership Fees

Automobile Loan/Lease

CD’s, DVD’s, Books, Etc.

Automobile Insurance

Financial Obligations

Gasoline/Fuel

Current Credit Card Payments

Maintenance

Retirement [401K, IRA]

Public Parking Fees

Student Loan(s)

Public Transportation

Liens, Levy’s, Garnishment(s)

Daily Living

Miscellaneous/Other

Groceries Child Care/Day Care Laundry/Dry Cleaning Education/School Supplies

Total Expenses:

Housekeeping Expense

Funds Remaining:

Life/Health/Dental Health Insurance Life Insurance

Client’s Signature

Co-Payments/Out of Pocket Prescriptions/Medications Dental Care

Apple Law Group - Rev 030912

Co-Client’s Signature

Date:

$ 0.00 $ 0.00


ALG - Income / Expense Worksheet