Financial Declaration Form
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1
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3FINANCIAL DECLARATION
FORM CD 007
MONTHLY HOUSEHOLD BUDGET
NAME OF APPLICANT(S):……………………………………………………………………….
How much does your household earn each month?
INCOME:
1. Gross Monthly Income: ___________________________________
$ ___________
2. Less Deductions
____________________________________
$ ___________
3. Net Take Home Pay: _____________________________________
$ ___________
4. Add- Spouse’s Monthly Income (if employed full-time)__________
$ ___________
5. Add - Other Income (specify) ______________________________
$ ___________
6. Net Monthly Income _____________________________________
$ ___________
How much does your household spend each month on the following?
EXPENDITURE:
7. Shelter
(a) Mortgage (including taxes ) or Rent _____________________
$____________
(b) House Insurance ____________________________________
$____________
(c) Maintenance and Repairs to Property ____________________
$____________
(d) Gas_______________________________________________
$____________
(e) Electricity__________________________________________
$____________
(f) Telephone__________________________________________
$____________
(g) Water_____________________________________________
$____________
(h) Cable TV__________________________________________
$------------------
TOTAL
___________________________________________
$____________
8. Transportation: Do you or your family own a motor vehicle? Yes ( ) No ( )
If yes, how much is spent each month on the following:
(a) Licence ___________________________________________
$___________
(b) Insurance __________________________________________
$___________
(c) Operating Cost______________________________________
$___________
If no, how much is spent each month on:
(d) Public Transportation_________________________________
$___________
TOTAL_______________________________________________
$___________
9. Living Expenses:
(a) Food
_____________________________________________
$___________
(b) Clothing ________ ____________________________________
$___________
(c) Medical and Dental ____________________________________
$___________
(d) Life Insurance _______________________________________
$___________
(e) Other (specify) ________________________________________
$___________
TOTAL _____________________________________________
$___________
10. Installment Obligations:
(a) For Motor Vehicle __ __________________________________
$___________
(b) For Furniture, Appliances, etc. ___________________________
$___________
(c) Bank Loan (specify) ___________________________________
$___________
(d) Credit Union loan (specify)______________________________
$___________
(e) Credit Card __________________________________________
$ __________
(f) Other (specify) _______________________________________
$___________
(g) Payment on Proposed Loan _____________________________
$___________
11. Monthly Savings _________________________________________
$__________
12. Total Monthly Commitments (Add Total in Lines 7 to 11) ________
$__________
13. Balance (Line 6 minus Line 12) _____________________________
$__________
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