Download - ALG - Income / Expense Worksheet
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: