Consumer Debtor Financial Statement Template Page 4
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4Section V Monthly Income and Expenses
Total Income
Monthly Expenses
Source
Gross
Claimed
30 Gross wages/salaries (debtor)
$
41 Rent/mortgage
$
31 Gross wages/salaries (spouse)
42 Child support
32 Interest, dividends
43 Alimony
33 Net business income
44 Car payment
34 Rental income
45 Gasoline/auto repairs
35 Pension (debtor)
46 Electricity
36 Pension (spouse)
47 Natural gas
37 Child support
48 Food
38 Alimony
49 Cable/satellite TV
39 Other
50 Medical expenses (out-of-pocket)
51 Clothing
52 Trash
53 Other
40 Total income
$
54 Total expenses
$
55 (Treasury use only) Net difference
$
(income less necessary living expenses)
Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is
true, correct, and complete.
Debtor’s signature
57 Spouse’s signature (if applicable)
56
58 Date
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