Form Cd Lo-14b - Statement Of Financial Condition For Individuals Page 4

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CD LO-14B (Rev. 02/03)
Page 4
SECTION VIII – INCOM E & EXPENSE ANALYSIS
42. Monthly Household Disposable Income
Gross Monthly Incom e
Monthly Living Exp enses
Sour ce
Taxp ayer
Spouse
Sour ce
Amount
Salar y, W ages, Commissions, Tip s
$
$
House or Rent Payment
$
Self-Emplo yment In come
Income Taxes (Fed eral, Stat e, FIC A)
Pen sions, Disabilit y & Social Secur it y
Estim ated Tax (If Applicab le)
Dividends & Inter est
Groceries
Gift or Loan Proceeds
Med ical Expenses & Prescr iptions
Rental Income
Utilities:
Est ate, Trust & Ro yalt y Income
Electric $_______ +
Gas $________
W orkers’ Comp. & Unemp lo yment
+ W ater $________+ Phone $_______=
Alimon y & Child Support
Insuran ce:
Other (Sp ecif y)
Lif e
$_______+ Health $ _______
+ Auto $_______+ Home $________=
Court Ord ered Payment
Per sonal Lo an Payment
R eligious & Charitable Donations
Clothing & Person al Grooming
Entertainm ent & Recr eation
L egal F ees
Tr ansportation Expense
Vehicle Loan Paym ent
Vehicle Lease Payment
Propert y & Ad Valor em Taxes
Child Care
Installment & Credit Card Payments
Tuition Payment
Other (Specif y)
Subtotal
$
$
Combined Monthly Income $
Total Monthly L iving Expen ses
$
43. Net Monthly Household Disposable In come (“Combined Monthly In come” Minus “Total Monthly Living Exp enses”) $
I/we h ave examin ed this Statement of Finan cial Condition for Individuals and her eb y affirm that to the best of m y/our kno wledge
and belief, it is true, correct and complete.
Taxpayer’s Signature
_______________________________________________________ Date __________________________
Spouse’s Sign ature
_______________________________________________________ D ate __________________________
POA Signature
_______________________________________________________ Date __________________________
(Attach Po wer of Attorney - Use Department of Revenue Form RD-1061 Only)

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