Monthly Income and Expense Worksheet

Monthly Net Income (* Includes that of Client and Co-Client)
Monthly Combined Household Net Income*:
Other Income [Alimony, Child Support, Etc.]:
Additional Financial Assistance Per Month:
Source Of Additional Financial Assistance:
Total Monthly Net Income:
Monthly Cost of Living Expenses
Housing
Mortgage/Rent:
Utilities [Gas, Electric, Water, Etc.]:
Homeowner's/Renter's Insurance:
Telephone – Home/Cellular:
Television – Cable/Satellite:
Maintenance:
Total Housing:
Transportation
Automobile Loan/Lease:
Automobile Insurance:
Gasoline/Fuel:
Maintenance:
Public Parking Fees:
Public Transportation:
Total Transportation:
Daily Living
Groceries:
Child Care/Day Care:
Laundry/Dry Cleaning:
Education/School Supplies:
Housekeeping Expense:
Total Daily Living:
Life/Health/Dental
Health Insurance:
Life Insurance:
Co-Payments/Out of Pocket:
Prescriptions/Medications:
Dental Care:
Total Life/Healty/Dental:
Personal
Clothing:
Personal Care:
Entertainment:
Membership Dues:
Gifts:
Household Items:
Total Personal:
Financial Obligations
Plan Payment:
Other Unsecured Debt Payment(s):
Student Loan(s):
Liens, Levy's, Garnishment(s):
Retirement [401K, IRA]:
Alimony/Child Support:
Total Financial Obligations:
Miscellaneous/Other
Total Miscellaneous/Other:
Total Expenses:
Funds Remaining:
Client's Name
Co-Client's Name
Date: MM/DD/YYYY
Important Note
Send To:
BBB - Better Business Bureau
TASC Best Practice Standards
TASC
American Debt Services is a member of (TASC)
The Association of Settlement Companies.
This trade association has developed a
standardized industry disclosure for consumers.
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