Sense
of
Security
California-Financial
Information-INCOME
&
EXPENSES
NAME:
___________________________________________________________Today’s
date_________
Please
enter
CURRENT
income
(in
whole
dollars)
from
all
household
sources
in
the
blanks
below.
Monthly
Amount
One-time
gift
or
Assistance
Household
Income
(after
taxes)
Alimony/Child
Support
Additional
income-‐
including
TANF,
HUD,
SSI/SSDI,
Disability,
Etc.
Retirement/Pension
Food
Stamps
Help
from
family
members
&
friends
Help
from
other
nonprofit
organizations
and
religious/faith
communities
Any
additional
income
not
listed
above
TOTAL
CURRENT
MONTHLY
$
INCOME
ASSETS
Current
Value
Cash/Checking
Savings
Real
Estate
(not
the
house
you
live
in)
Life
Insurance
Investments/Retirement
Funds
Other
1
Sense
of
Security
California-Financial
Information-Expenses
EXPENSES-HOUSEHOLD
Please
enter
monthly
expenses
for
your
entire
household
in
the
blanks
below.
Monthly
Expense
Occasional
or
One-‐Time
Expense
(please
specify)
Rent/Mortgage
Groceries
Utilities
Child
Care
Child
Support
Paid
TV/Internet/Cable
Telephone/cell
including
long
distance
Car
payment
Gasoline
Car
insurance
Health
insurance
premium
Medical
Costs
(after
insurance)
Medication
costs
(after
insurance)
Life
insurance
Loan
payments
Credit
card
payments
Household
costs
not
listed
Other
expenses
Total
Monthly
Expenses
Have
you
sought
creditor
relief
for
any
bill
you
itemized
above?
If
so,
describe
in
detail
what
you’ve
requested,
what
has
been
approved,
and
what
is
pending.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2