Wage Assignment Reduction Request Page 2
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1
2Please indicate both separate and combined assets and expenses.
Balance
Name and address of institution
Financial Institutions
Checking Account
$
Savings Account
$
Other (IRA, CD,
$
Money Market, etc.)
Cash
Balance Due
Life Insurance Policies
Company
Beneficiary
Amount
Value
on Loan
$
$
$
$
$
$
$
$
$
Have premiums been paid to date?
Yes
No
Motor Vehicles
Make
Model
Year
Fair Market Value $
Balance Due $
License Plate #
Lien Holder
Address
Make
Model
Year
Fair Market Value $
Balance Due $
License Plate #
Lien Holder
Address
Other personal property (boat, motorcycle, snowmobile, etc.):
R
eal Estate (If you rent, list name and address of landlord)
Location
Fair Market Value $
Balance Due $
Mortgage Holder
Address
Expenses
Monthly
Please note any payments you
Payment
Balance Due
are behind in and by how much
Mortgage or Rent
$
$
Property tax escrow
$
$
Auto payments
$
$
Gasoline/oil
$
$
Utilities: Home Heating
$
$
Electrical
$
$
Telephone
$
$
Water
$
$
Cable / internet access
$
$
Loans (list) 1.
$
$
2.
$
$
3.
$
$
Credit Cards . . . . . . . Is card still in use?
VISA . . . . . . . . . . .
No
Yes
$
$
MasterCard . . . . . .
No
Yes
$
$
Discover . . . . . . . .
No
Yes
$
$
Other:
No
Yes
$
$
Food
$
$
Entertainment
$
$
Insurance (all)
$
$
IRS – Delinquent Payment
$
$
Other (list)
$
$
Total Monthly Expenses. . . . . . . . . . . . . . . . $
Total Net Monthly Income . . . . . . . . . . . . . . $
Net Difference . . . . . . . . . . . . . . . . . . . . . . . $
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Parent category: Business