Bcpc Form 523 - Affidavit Of Income And Expenses - Butler County, Ohio Page 2

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CASE NO. _______________________
7.
Household Income:
Affiant
Spouse
Other Adults
Net Wages
$ ____________
$ ____________
$ ____________
Stock Dividends
$ ____________
$ ____________
$ ____________
Interest
$ ____________
$ ____________
$ ____________
Social Security
$ ____________
$ ____________
$ ____________
Worker’s Comp.
$ ____________
$ ____________
$ ____________
VA Benefits
$ ____________
$ ____________
$ ____________
Annuity/Pension
$ ____________
$ ____________
$ ____________
Child Support
$ ____________
$ ____________
$ ____________
Spousal Support
$ ____________
$ ____________
$ ____________
0.00
0.00
0.00
TOTAL
$ ____________
$ ____________
$ ____________
0.00
TOTAL - ALL INCOME FOR HOUSEHOLD $ _________________
8.
I am unable to pay for the proposed expenditures because:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________
Affiant
On this ______ day of ______________, ________ personally appeared before me
__________________________, who being properly sworn and cautioned, did affix
his/her name hereon.
________________________________
Notary Public
BCPC FORM 523 - AFFIDAVIT OF INCOME AND EXPENSES
Page 2 OF 2
7/1/04

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