Declaration Of Income And Expenses Page 2

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9 I receive this much per month from government
Source of Income
Monthly income
programs. (Include such sources as social security
from government
benefits, worker’s compensation, housing, food,
programs
other living allowances, etc.)
$_______________
9 I share a household with others, some of whom
Monthly pay, before
Monthly pay after
have jobs and share the cost of household
deductions, of others in
deductions of others
expenses. The names of these household members
household:
in household:
are listed in this box:
Name:________________________
$_________________
$_______________
Name:________________________
$_________________
$_______________
Assets:
9 I have this much money in cash, in the bank, in stocks or bonds, and in other
$____________
available sources:
9 Other people or organizations owe me this much money:
$____________
9 I own or am buying a home, land, other real property, vehicles, other personal property, or business
interests as listed below.
Property (home, land, vehicles, etc.) and location
Balance owed
Value
Home
$_______________
Land and other real property
$_______________
Cars, trucks, or other vehicles
$_______________
Other personal property
$_______________
Business interests
$_______________
2
May 6, 2006

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