Monthly Expense Form Page 3
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1
2
3
4
5G.
CLOTHING EXPENSES:
1.
You
____________
2.
Children
____________
3.
Other
____________
TOTAL CLOTHING EXPENSES:
____________
H.
MEDICAL / DENTAL / OPTICAL EXPENSES:
1.
Insurance premiums:
Medical – Adult
a.
____________
Dental – Adult
b.
____________
Medical – Children
c.
____________
Dental – Children
d.
____________
2.
Uninsured medical, dental, optical,
prescriptive and other uninsured
health care expenses – Adult
____________
3.
Uninsured medical, dental, optical,
prescriptive and other uninsured
health care expenses – Children
____________
TOTAL MEDICAL / DENTAL / OPTICAL EXPENSES:
____________
I.
INSURANCE: LIFE / DISABILITY:
1.
Life
____________
2.
Disability
____________
TOTAL INSURANCE: LIFE / DISABILITY:
____________
J.
DRYCLEANING:
____________
K.
HAIRDRESSER / BARBER:
____________
L.
REQUIRED DUES:
____________
M.
RECREATION / ENTERTAINMENT:
____________
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