Sworn Financial Statement Page 2
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72. Monthly Deductions (Mandatory and Voluntary)
Mandatory Deductions
Cost Per
Cost Per
Month
Month
Federal Income Tax
$
State/Local Income Tax
$
PERA/Civil Service
Social Security Tax
Medicare Tax
Other - ___________________
Total Mandatory Deductions
$
Voluntary Deductions
Cost Per
Cost Per
Month
Month
Life and Disability Insurance
$
Stocks/Bonds
$
Health, Dental, Vision Insurance Premium
Retirement & Deferred Compensation
Total number of people covered on Plan
Child Care (deducted from salary)
Other - ____________________
Flex Benefit Cafeteria Plan
Other - ____________________
$
Total Voluntary Deductions
$
Total Monthly Deductions
3.
Monthly Expenses
Note:
List regular monthly expenses below that you pay on an on-going basis and that are not identified
in the deductions above.
A. Housing
Cost Per
Cost Per
Month
Month
st
nd
1
Mortgage
$
2
Mortgage
$
Insurance (Home/Rental) & Property
Condo/Homeowner’s/Maintenance
Taxes
Fees
(not included in mortgage payment)
Rent
Other - ________________
Total Housing
$
B. Utilities and Miscellaneous Housing Services
Cost Per
Cost Per
Month
Month
Gas & Electricity
$
Water, Sewer, Trash Removal
$
Telephone
Property Care
(local, long distance, cellular &
(Lawn, snow removal,
pager)
cleaning, security system, etc.)
Internet Provider, Cable & Satellite TV
Other - ____________________
Total Utilities and Miscellaneous Housing Services
$
C. Food & Supplies
Cost Per
Cost Per
Month
Month
Groceries & Supplies
$
Dining Out
$
Total Food & Supplies
$
D. Health Care Costs (Co-pays, Premiums, etc.)
Cost Per
Cost Per
Month
Month
Doctor & Vision Care
$
Dentist and Orthodontist
$
Medicine & RX Drugs
Therapist
Premiums (if not paid by employer)
Other - ____________________
Total Health Care
$
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2
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