Single or Husb Income per Pay period:
Social Sec. $_______ Pension inc.$_______ Gross pay
$_______ Less Fica $_____
Fed tax $_____ Medicare $_____ Insurance $_____
Union Dues $_____ Pension $_____
NET PAY $_____
Spouse Income: per Pay period Gross pay $_______ Less
Fica $_____ Fed tax $_____
Medicare $_____ Insurance $_____ Union Dues $_____
Pension $_____
NET PAY $_____
Rent_____$_____ Mortgage__$_____ 2nd Mtge__$_____
Assessmt__$_____ R.E.Tax___$_____ Insurance_$_____
Electric__$_____ Heating___$_____ Phone_____$_____
Cellphone_$_____ Water bill$_____ Gasoline__$_____ Car
Insur_$_____ Car repair$_____ Tolls_____$_____
Haircuts__$_____ Clothes___$_____ School fee$_____
Tuition___$_____ Childcare_$_____ Drugstore_$_____
Church____$_____ Cable TV__$_____ Web_______$_____
Other __________$_____ __________$_____
__________$_____