Form Fs-H - Financial Statement For Claim For Hardship Page 2
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4Schedule 1
Monthly Income Information
Your net pay ..............................................................................................................................$ _____________
Your spouse’s net pay ...............................................................................................................$ _____________
Rents paid to you (list property rent is being derived from) .....................................................$ _____________
Pensions ....................................................................................................................................$ _____________
Social Security Benefits ............................................................................................................$ _____________
Social Security Disability .........................................................................................................$ _____________
Profit from your business
...$ _____________
(must attach Federal Schecule C, E, F or any other pertinent schedules)
Commissions .............................................................................................................................$ _____________
Alimony/Child support received ...............................................................................................$ _____________
Welfare/Food Stamp assistance ................................................................................................$ _____________
Other income (please list source) .............................................................................................$ _____________
Total Monthly Income ...........................................................................................................$ _____________
Schedule 2
Monthly Expenses Information
Rent ..........................................................................................................................................$ _____________
Mortgage ..................................................................................................................................$ _____________
Alimony/Child support paid ....................................................................................................$ _____________
Groceries ..................................................................................................................................$ _____________
Electricity .................................................................................................................................$ _____________
Heat (oil, gas, etc.) ...................................................................................................................$ _____________
Water/Sewer .............................................................................................................................$ _____________
Telephone .................................................................................................................................$ _____________
Transportation (gasoline, bus fare, etc.) ...................................................................................$ _____________
Medical Expenses (physician’s bills, medication not paid by insurance) ...............................$ _____________
Insurance Cost -
Automobile .................................................................................... $________________
Health/Hospitalization ................................................................... $________________
Life ................................................................................................. $________________
Homeowner’s/Renter’s .................................................................. $________________
Total cost of insurance (auto, health, life, home, rental, etc.) ...................................................$ _____________
Total cost of credit card payments (list card information on Schedule 3) ................................$ _____________
Total loan payments (list loan information on schedule 4) .......................................................$ _____________
Other expenses (please itemize and explain below) .............................................................$ _____________
Total Monthly Expenses ........................................................................................................$ _____________
Other Expenses
Itemized Monthly Expenses and Explanations (attach additional sheets as needed)
Page 4
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Parent category: Financial