Total Primary Tax Payer's Income =
Total Spouse's Income =
Additional sources of income used to support the household, e.g., non-liable spouse, or anyone else who may contribute to the household income, etc.
Interest, dividends, and royalties
Distributions (e.g., income from partnerships, sub-S Corporations, etc.)
Net rental income
Net business income (if any)
Child support received
Alimony received
Total Household Income
Food, clothing and miscellaneous
Housing and utilities
Home Insurance, Maintenance, Dues, Fees and Utilities (including electricity, gas, other fuels, trash collection, water, cable television and internet, telephone, and cell phone)
No of Vehicles You Own.
Max 2 Allowed by IRS
Vehicle Loan and/or Lease Payment(s)
For Max 2 Cars
Vehicle operating costs (e.g., average monthly cost of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, tolls, etc.). A reasonable estimate of these expenses may be used
Public transportation costs (e.g., average monthly cost of fares for mass transit such as bus, train, ferry, taxi, etc.). A reasonable estimate of these expenses may be used
Health insurance premiums
Out-of-pocket health care costs (e.g. average monthly cost of prescription drugs, medical services, and medical supplies like eyeglasses, hearing aids, etc.)
Court-ordered payments (e.g., monthly cost of any alimony, child support, etc.)
Child/dependent care payments (e.g., daycare, etc.)
Life Insurance
Life Insurance Total Policy Amount
Total of Life Insurance Premiums:
Current monthly taxes(e.g., monthly cost of federal, state, and local tax, personal property tax, etc.)
Secured debts/Other(e.g., any loan where you pledged an asset as collateral not previously listed, government guaranteed student loan, employer required retirement or dues)
Enter the Amount of your Monthly Delinquent State and/or Local Tax Payment(s)
Total Household Expenses
Remaining Monthly Income
