Settlement Offer Application Form - Oregon Department Of Revenue Page 12
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Section 5. Monthly income and expense analysis (continued)
Monthly personal expenses (actually paid).
Amount
52
. Rent/mortgage
If renting, landlord’s name, address, phone number
53. Real estate taxes (if not included in your mortgage payment)
54. Homeowner’s/renter’s insurance
55. Homeowner or neighborhood association fees
+
=
56. Utilities:
Electric/gas/oil: (
)
Phone/internet/cable: (
)
+
=
Water/sewer: (
)
Garbage: (
)
57. Household expenses (food, clothing, personal products, etc) No. of people:
Ages:
58. Auto payments (purchase or lease)
59. Auto insurance
60. Auto maintenance, fuel, or other transportation costs (parking, etc)
61. Life or health insurance (if not deducted from your paycheck)
62. Out-of-pocket medical expenses
63. Estimated tax payments (provide proof)
64. Court-ordered payments (alimony, child support, restitution, etc., not deducted from your paycheck)
65. Garnishments (wages)
66. Delinquent tax payments, other than Oregon state taxes (federal, other state, local, property, etc)
67. Work-related child care expenses
68. Other expenses: explain (don’t include unsecured debt)
$
69. Total monthly personal expenses ...................................................................................................
Amount
Monthly business expenses (actually paid). Provide current general ledger and profit/loss statement.
70. Materials and supplies
71. Installment and monthly payments
72. Rent/mortgage
73. Insurance (liability, malpractice, etc)
+
=
74. Utilities:
Electric/gas/oil: (
)
Phone/internet/cable:
(
)
+
=
Water/sewer: (
)
Garbage:
(
)
75. Net wages and salaries
76. Payroll and business taxes
77. Other expenses: explain (don’t include unsecured debt)
78. Total monthly business expenses ...................................................................................................
$
79. Enter net dollar amount from line 51
80. Add lines 69 and 78; enter total dollar amount
81. Net disposable income (subtract line 80 from line 79) ..................................................................... $
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