Bankruptcy Questionnaire Template Page 24
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26M. Do you, your spouse, or your dependents receive any regular contributions to your household expenses from any
source not listed above? YES _____ NO _____. If YES, list:
Source of Contribution
To Whom Payable
Amount per Month
N.
Is your family eligible for food stamps? YES _____ NO _____.
If YES, how much in food stamps do you receive per month? $
O. Expenses. (Give realistic estimates. If your expenses add up to more than the income you have listed, or less than
your income, be prepared to explain why.)
List below your average monthly expenses for you and your family. If you pay any of these expenses weekly, bi-
weekly, quarterly, semi-annually, or annually, you will need to adjust the amount to show it as a monthly amount
(for example, if you pay the expense weekly, you can show that as a monthly expense by multiplying the weekly
amount by 4.3). If you are not sure how to do this, let us know of any expenses you do not pay monthly.
List Any Increase or
Average Monthly
Decrease You Expect
Expenses
for Item in Next Year
Rent or mortgage
$
Are real estate taxes included? ___
Is property tax included? ___
Condo or homeowners association fees
$
Trash pickup
$
Electricity
$
Heat
$
Water
$
Telephone
Home
$
Cell
$
Other utilities
Internet
$
Cable T.V.
$
Other
$
Personal care (haircuts, etc.)
$
Home maintenance (repairs and upkeep)
$
Food (cash you spend on food)
$
Amount of food stamps you spend
$
Clothing
$
Laundry and cleaning
$
Medications
$
Other medical and dental expenses (co-pays,
eye care, etc.)
$
Public transportation
$
Auto maintenance (repairs and upkeep)
$
Auto registration and license fees
$
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