Rolling Thunder Inc Indiana Veterans Fund Application Page 4

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Asset & Liability Worksheet
Name:__________________________________________________date:____________
Type/Print
Monthly Income
Monthly Expenses
Type/Print
Amount
Type/Print
Monthly payment
Wages
$_________
Rent
$_________
Veteran
Wages
$_________
Mortgage
$_________
Spouse
Social Security
$_________
Food
$_________
Vet.
Social Security
$_________
Heating/ Gas
$_________
Spouse
SSI Benefits
$_________
Auto Payment(s) $_________
VA Compensation
$_________
Electricity
$_________
Military Retirement $_________
Telephone
$_________
VA Pension
$_________
Water
$_________
Civilian Pension
$_________
Prop. Taxes
$_________
Investments
$_________
Home Insurance $_________
Unemployment
$_________
Auto Insurance
$_________
ADC
$_________
Medical
$_________
Food Stamps
$_________
Child Support
$_________
Other
$_________
Gasoline
$_________
Other
$_________
Credit Cards
$_________
Other
$_________
Other
$_________
TOTAL
$_________
TOTAL
$_________
All Items must be verifiable with receipt upon request
Attach additional sheet as needed
Assets (Annotate Totals)
Savings
$________
Bonds/CDs
$________
Real Estate
$________
Auto
$________
IRAs
$________
Auto
$________
Other/Real estate $________
Other
$________
Total______________
Liabilities (Balances)
Mortgage Balance
$________
Personal Loan Balance $________
Credit Card Balance $________
Medical Balance
$________
Total______________
I hereby certify that there are no other financial resources within my household. All statements are true, and an accurate representation of
my financial status. Any attempt at fraud will be fully prosecuted.
_______________________________________________________________________
Signature of Applicant
Date
Page 1 of 1
Form Date: November 3rd, 2015

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