Form Dwsp-2443 - Household Budget Worksheet For Wisconsin Works (W-2)

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STATE OF WISCONSIN
WBW
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Family and Economic Security
HOUSEHOLD BUDGET WORKSHEET FOR WISCONSIN WORKS (W-2)
Name: ______________________________________
Household Size: ________
RFA/Case Number: ____________________________
Date: ___/___/___
Resource Specialist: ____________________________
Monthly Income
Assets
Salary/Wages (Net)
$__________
Checking Accounts
$__________
Tips
+ $__________
Savings Accounts
+ $__________
Self-Employment Income
+ $__________
Life Insurance Cash Value
+ $__________
Unemployment Insurance
+ $__________
Certificates of Deposit
+ $__________
Child Support
+ $__________
Stocks or Bonds
+ $__________
Alimony
+ $__________
Land/Buildings other than
Social Security (SSI/SSDI)
+ $__________
Homestead
+ $__________
Veterans
+ $__________
Farm Equipment/Livestock
+ $__________
Railroad Retirement
+ $__________
Notes/Contracts of Value
+ $__________
Sick or Disability Payments + $__________
Retirement Accounts
+ $__________
School Grants or Loans
+ $__________
Burial Accounts
+ $__________
Money received regularly
Own Land Contract/Mortgage
+ $__________
from relatives, friends, etc.
+ $__________
Trust Funds
+ $__________
Charitable Organizations
+ $__________
Other
+ $__________
Dividends/Interest
+ $__________
Total Assets
= $__________
FoodShare
+ $__________
Other
+ $__________
Total Income
= $__________
Monthly Household Expenses
Vehicles
Rent/Mortgage
$__________
Vehicle #1 Equity
$__________
Real Estate Taxes
+ $__________
(Fair Mkt. - Loan Value)
Home Owner’s Insurance
+ $__________
Vehicle #2 Equity
+ $__________
Utilities
+ $__________
(Fair Mkt. - Loan Value)
Uniform Expense
+ $__________
Vehicle #3 Equity
+ $__________
Child Care Expenses
+ $__________
(Fair Mkt. - Loan Value)
Vehicle Payment
+ $__________
Total Vehicle Equity
= $__________
Vehicle Maintenance
+ $__________
Vehicle Insurance
+ $__________
Public Transportation
+ $__________
Child Support
+ $__________
Food
+ $__________
Clothing
+ $__________
Personal Care
+ $__________
Health Insurance
+ $__________
Medical Expenses
+ $__________
Personal Loans
+ $__________
Life Insurance
+ $__________
Education
+ $__________
Entertainment
+ $__________
Total Expenses
= $__________
NET HOUSEHOLD BUDGET: $__________
(Income Minus Expenses)
DWSP-2443 (R. 02/2009)

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