MONTHLY INCOME DATA by iAuERAV

VIEWS: 2 PAGES: 11

									                                FINANCIAL INFORMATION WORKSHEET

                                  INTAKE WORK OUT SHEET
                                  JOINT      INDIVIDUAL
# Family Members: ___________________________

BORROWER INFORMATION

CLIENT NAME:
SOCIAL SECURITY#:              DOB:
ADDRESS:
CITY:                           STSTE:     ZIP:          COUNTY:
Mailing Address: _______________________________________________________________________________

Home #: ___________________________________         Work #: ___________________________________


SPOUSE NAME:
SOCIAL SECURITY#:              DOB:
ADDRESS:
CITY:                           STSTE:     ZIP:          COUNTY:
Mailing Address: _______________________________________________________________________________

Home #: ___________________________________         Work #: ___________________________________


   (1) A detailed letter explaining your circumstances/hardship. 50 WORDS OR LESS
MONTHLY INCOME DATA
Optional information which will assist in debt relief settlement (*) means required information

Description                     Mortgagor               Co-Mortgagor                    Total


Net Salary (*)                  $____________           $____________                   $____________



Net O/T                         $____________           $____________                   $____________



Commission                      $____________           $____________                   $____________



Bonus                           $____________           $____________                   $____________



SSI                             $____________           $____________                   $____________



Alimony/Child Support           $____________           $____________                   $____________



Other Income                    $____________           $____________                   $____________



TOTAL                           $____________           $____________                   $____________
EMPLOYMENT INFORMATION
Optional information which will assist in debt relief settlement



                                 Place of Employment                          How Long?



Debtor (*)              ___________________________________            _____________



        Address                  ___________________________________



Co-Debtor                        ___________________________________          _____________



        Address                  ___________________________________
EXPENSES
Optional information which will assist in debt relief settlement

Monthly Obligations              Monthly Payment         Balance Due     Past Due? # months


Mortgage / Rent (*)              $____________           $____________   _____________

Other Mtg/Rent                   $____________           $____________   _____________
 nd
2 Lien                           $____________           $____________   _____________

Alimony/Child Support            $____________           $____________   _____________

Child Care                       $____________           $____________   _____________




Loans
Optional information which will assist in debt relief settlement

Automobile                       $____________           $____________   _____________

Furniture/Appliance              $____________           $____________   _____________

Finance Company                  $____________           $____________   _____________

Finance Company                  $____________           $____________   _____________

Installment                      $____________           $____________   _____________
Type Card / Account # Credit Limit Balance Monthly pmt Avail Credit
1
2
3
4
5
6
7
8
9
10
TOTALS

Utilities
Optional information which will assist in debt relief settlement

Electricity                      $____________           $____________   _____________

Heating/Gas                      $____________           $____________   _____________

Telephone                        $____________           $____________   _____________

Water/Sewer                      $____________           $____________   _____________




Insurance
Optional information which will assist in debt relief settlement

Homeowners                       $____________           $____________   _____________

Automobile                       $____________           $____________   _____________

Health                           $____________           $____________   _____________

Life                             $____________           $____________   _____________

Dental                           $____________           $____________   _____________
Donations
Optional information which will assist in debt relief settlement

Church                           $____________           $____________   _____________

Charity                          $____________           $____________   _____________




Subtotal                         $____________           $____________
EXPENSES (cont’d)

Optional information which will assist in debt relief settlement

Dues                                 Monthly Payment     Balance Due     Past Due? # months


Union                                $____________       $____________   _____________

HOA                                  $____________       $____________   _____________

Club                                 $____________       $____________   _____________

Other                                $____________       $____________   _____________




Medical (not covered by insurance)

Optional information which will assist in debt relief settlement

Doctor/Dentist                       $____________       $____________   _____________

Hospital                             $____________       $____________   _____________

Drugs                                $____________       $____________   _____________




Car


Gasoline                             $____________       $____________   _____________

Maintenance                          $____________       $____________   _____________

Monthly Parking                      $____________       $____________   _____________
Food
Optional information which will assist in debt relief settlement

Family                           $____________           $____________          _____________

School/Work Lunches              $____________           $____________          _____________




Clothing
Optional information which will assist in debt relief settlement

New Clothes                      $____________           $____________          _____________

Dry Cleaning                     $____________           $____________          _____________

Uniforms                         $____________           $____________          _____________




Miscellaneous
Optional information which will assist in debt relief settlement

Spending Money                   $____________           $____________          _____________

Cable TV                        $____________            $____________          _____________

Clubs/Sports/Hobbies             $____________           $____________          _____________

Entertainment                    $____________           $____________          _____________

Vacations                        $____________           $____________          _____________

Gifts                            $____________           $____________          _____________

IRS Liens                       $____________            $____________          _____________

____________________             $____________           $____________          _____________




Subtotal                $____________            $____________           _____________
IRS Liens           $____________          $____________          _____________




Subtotal            $____________          $____________

Subtotal (page 2)   $____________          $____________



TOTAL                      $____________          $____________
BANKING INFORMATION



Checking Account                                       Savings Account


Bank Name ________________________________             ___________________________________________



Account #: _________________________________           ___________________________________________



Balance $___________________________________ ___________________________________________



IRA      $___________________________________ ___________________________________________



401K     $___________________________________ ___________________________________________




RECAP


Total Income                  $___________
Total Expenses                $___________

Difference                    $___________ This number might be negative if in ( brackets )




ASSETS
                              Monthly Payment          Amount Owed               Net Value
Home                          $____________            $____________             $____________

Other Real Estate             $____________            $____________             $____________

Automobile                    $____________            $____________             $____________

Make/Model                    $____________            $____________             $____________

Automobile                    $____________            $____________             $____________
Make/Model                          $____________              $____________               $____________

Checking Accounts                   $____________

Savings Accounts                    $____________

Boat                                $____________              $____________               $____________

Cash Value Life Ins.                $____________              $____________               $____________

Collections                         $____________              $____________               $____________

Computers                           $____________              $____________               $____________

Jewelry                             $____________              $____________               $____________

IRA                                 $____________              $____________               $____________

401K                                $____________              $____________               $____________

Stocks/Bonds/CDs                    $____________              $____________               $____________

Other Investments                   $____________              $____________               $____________




I agree that the financial information provided is an accurate statement of my financial status. I understand that the
Lender may verify this information at its option, by ordering a credit report, and I agree that the Lender has my
permission to do so.


I understand that any legal action already taken will not be canceled until an approved work out is completed.



Submitted this __________ day of __________ 2000.



___________________________________________                    ___________________________________________

DEBTOR                                                         Co-DEBTOR



Final Instructions: Review the worksheet and make sure it is correct. Sign and date the form. Make copies of
everything you have submitted and keep them for your records.

								
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