Personal Data Form And Social Study Information Sheet - Tarrant County Family Court Services Page 7
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16Food:
1.
Groceries
$______________
2.
School and work lunches
$______________
Medical:
1.
Doctors
$______________
2.
Dentists
$______________
3.
Medications (prescription and over the counter)
$______________
Education:
1.
School Supplies, fees and other costs
$______________
Personal:
1.
Grooming (barber, hair dresser)
$______________
2.
Clothing
$______________
3.
Cleaning and Laundry
$______________
4.
Uniforms for work
$______________
Child Care:
1.
Daycare/babysitter
$______________
Entertainment:
___________________________________
1.
$______________
2.___________________________________________
$______________
3.___________________________________________
$______________
Dues:
1.
Union, professional, etc.
$______________
Other Payments:
1.____________________________________________
$______________
2.____________________________________________
$______________
3.____________________________________________
$______________
4.____________________________________________
$______________
TOTAL EXPENSES:
$______________
HEALTH INSURANCE:
NAME OF YOUR HEALTH INSURANCE COMPANY____________________________________________________________
NAME OF PRIMARY POLICY
HOLDER_______________________________________________________________________
NAME OF CHILD(REN)’S HEALTH INSURANCE
COMPANY____________________________________________________
NAME OF PRIMARY POLICY HOLDER_______________________________________________________________________
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