Interim Monthly Income And Expenses Statement Page 2

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a.
Federal withholding
$_________ $_________ $_________
b.
State withholding
$_________ $_________ $_________
c.
Estimated tax payments
$_________ $_________ $_________
d.
FICA
$_________ $_________ $_________
e.
Medicare
$_________ $_________ $_________
f.
Health insurance
$_________ $_________ $_________
g.
Life and disability insurance $_________ $_________ $_________
h.
Union dues
$_________ $_________ $_________
i.
Mandatory retirement
$_________ $_________ $_________
j.
Other_____________
$_________ $_________ $_________
4.
Total payroll deductions
$_________ $_________ $_________
(Add items in #3)
5.
Net monthly income
$_________ $_________ $_________
(Subtract Line 4 from Line 2)
4
6.
Monthly fixed expenses
:
5
a.
Residence
$_________ $_________ $_________
6
b.
Utilities
$_________ $_________ $_________
c.
Car payments
$_________ $_________ $_________
d.
Insurance premiums
$_________ $_________ $_________
(1) Car or other vehicle
$_________ $_________ $_________
7
(2) Life
$_________ $_________ $_________
7
(3) Health
$_________ $_________ $_________
8
(4) Homeowners
or renters $_________ $_________ $_________
(5) Other
$_________ $_________ $_________
9
e.
Day care
$_________ $_________ $_________
10
f.
Credit card payments
$_________ $_________ $_________
g.
Loan payments
$_________ $_________ $_________
11
h.
Child support payments
$_________ $_________ $_________
i.
Medical
$_________ $_________ $_________
j.
Other ___________
$_________ $_________ $_________
7.
Total monthly fixed expenses
$_________ $_________ $_________
12
(Add items in #6 and #7)

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