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Average Monthly Expenses
Please list 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		 9. Entertainment & Recreation

2. Taxes
      Activities & Trips

    Federal		  
      Eating Out

    State		  
      Health Club/Spas 		 

    Social Security		  
      Country Club Fees 		 

3. Child Support Alimony
      Entertainment

4. Housing		  
      Vacations

    Rent		  
      Other

    1st Mortgage		  
10. Clothing

    2nd Mortgage		  
11. Medical Expenses

    Real Estate Taxes 		 
      Doctor

    Home Insurance 		 
      Dentist

    Renters Insurance
      Optometrist

    Association Fees
      Drugs/Prescriptions		  

    Electricity
      Chiropractor		  

    Gas
      Other		  

    Water
12. Savings

    Trash
13. Miscellaneous

    Telephone/cell
      Toiletries

    Internet
      Cosmetics

    Cable/Satellite
      Hair Care

    Pest Control
      Laundry

    Lawn Care
      Subscriptions

    Maintenance/Repairs
      Organizational Dues

    Other
       Gifts
       (Include Christmas)

5. Food		  
      Pet Care 		 

    Groceries		  
      Professional
      (Atty, CPA, etc.) 		 
   
      Other
         
         
         
         
         
         

6. Transportation
14. School/Child Care

    1st Payment
  
      Tuition

    2nd Payment
  
      Room/Board

    Vehicle Insurance
 
      School Supplies

    Gas & Oil 		 
      Day Care
 
    Repairs & Tires 		 
      Babysitter

    Tags/Taxes 		 
      Transportation

    Other
      Other

7. Insurance


15. Investments

    Life		  
      401k or 403

    Medical/Health
      IRA

    Disability
      Stocks/Bonds

    Longterm Care
      Retirement Plan

    Other
      Other

8. Other Debts 		     

    Credit Card		      

    Collection		    

    Student Loans		      

    Federal Income Tax 		   

    State/Co Income Tax		      

    Property Tax 		   

    Line of Credit 		 

   Personal Loans 		   

    Motorcycle		      

    Boat		        

    Timeshare		        

    Liens/Judgments		    
Total Expenses: 		 

    Other		        
           
           
           
           
           
           
           

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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