Apple Law Group - Rev 030912

Income and Expense Worksheet

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

Monthly Combined Household Income*:

Other Income [Alimony, Child Support, Etc.]:

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 Co-Client’s Signature

Dental Care Date: