Budget Form
 
 
Client Name: Counselor Code:
 
Please note all creditors required this form be itemized for accuracy
 
Monthly Income Sources
Net Monthly Salary:
Net Spouse Salary:
Part-Time Income:
Social Security:
Retirement:
Pension:
Military:
Annuity:
Child Support:
Alimony:
Food Stamps:
Disability:
Other:
 
Total Monthly Income

Monthly Utilities
Gas/Oil:
Electric:
Telephone:
Water/Sewage:
Cable:
Internet:
 
Monthly Sub-total

Monthly Insurance
Life:
Auto:
Medical/Health:
Medication:
Homeowners:
Flood:
 
Monthly Sub-total

Budget Form (Continued)
   
 
   
Monthly Household Expenses
Mortgage:
Second Mortgage:
Rent:
Condo Fee:
Taxes:
Car Payment:
Second Car Payment:
Car Expenses/Maintenance:
Union Dues:
Alimony/Child Support:
Transportation:
Groceries/Food:
Day Care:
Education:
Clothing:
Charitable Donations:
Dry Cleaning/Laundry:
Gifts:
Cellular/Pager:
House Maintenance:
Entertainment:
Other:
 
Monthly Sub-total
Monthly Revolving Debts
Credit Cards:
Personal Loans:
Installment Loans:
Other Secured Debts:
 
Monthly Sub-total

Monthly Household Expense To Income:
Monthly Total Expense to Income:
Monthly Debt-To-Income Ratio (AFDC):

   
Client Information Form
   
 
   
Client Profile
SSN:
First Name:
Last Name:
Middle Initial:
Mother's Maiden Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State:  
Zip:
Country:
Home Phone:
Work Phone:
Mobile Phone:
Fax Number:
E-mail:
Preferred method of contact Mail  Email  Fax
Co-Client Profile (if-applicable)
SSN:
First Name:
Last Name:
Middle Initial:
Mother's Maiden Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State:
Zip:
Country:
Home Phone:
Work Phone:
Mobile Phone:
Fax Number:
E-mail:
Preferred method of contact Mail  Email  Fax
 

For Agency Use Only

Number of Creditors  EFT Client  POA

Special Notes:
 
Creditor Information Form
 
 
Account Number:  - - - -
Issuer / Creditor: 
  Address: 
City:  St: Zip: 
Phone: 
Balance:  Original Payment: Original APR:
Issuer Type:  Credit Card/Store Card  Bank Loan  Student Loan  Dr./Hospital
Coll. Agency  Debt Buyer   
Primary Acct Holder:  Primary  Co-Client
Original Acct Number: 
Original Issuer: 

Account Number:  - - - -
Issuer / Creditor: 
  Address: 
City:  St: Zip: 
Phone: 
Balance:  Original Payment: Original APR:
Issuer Type:  Credit Card/Store Card  Bank Loan  Student Loan  Dr./Hospital
Coll. Agency  Debt Buyer   
Primary Acct Holder:  Primary  Co-Client
Original Acct Number: 
Original Issuer: 
 
Creditor Information Form (Continued)
 
 
Account Number:  - - - -
Issuer / Creditor: 
  Address: 
City:  St: Zip: 
Phone: 
Balance:  Original Payment: Original APR:
Issuer Type:  Credit Card/Store Card  Bank Loan  Student Loan  Dr./Hospital
Coll. Agency  Debt Buyer   
Primary Acct Holder:  Primary  Co-Client
Original Acct Number: 
Original Issuer: