Form Name:Household Members Average Monthly BudgetInvestigator Name:Jana OyerbidesClick here to view a sample form. Household Members Average Monthly BudgetThis budget should include expenses and income for all household members for the last 30 days.Contact InfoYour Full Name*Email* Phone*Preferred form of contact Email PhoneHousingType of payment* Rent Payment Mortgage PaymentRent / Mortgage Payment*Electric Bill*Gas / Heating (Propane)*Water Bill*Cellular Phone*Landline Telephone*Internet Service*Cable / Satellite TV / Radio*Furniture Rentals*Security Alarm Payment*TOTAL*Food & IncidentalsGroceries*Toiletries*Laundry Expenses*Cleaning Supplies*TOTAL*(Food & Incidentals)Automobile / Transportation1st Car Payment*2nd Car Payment*Gasoline Expenses*Car Maintenance*Car Insurance*Bus Fare*TOTAL*(Automobile / Transportation)Health ExpensesHealth Insurance Premiums*Medical / Dental Bills*Medication Expenses*TOTAL*(Health Expenses)Children's ExpensesDaycare*School Tuition / Education*School Lunches*Child Support Payments*Diapers / Formula*Clothing / Shoes*Sports Expenses*TOTAL*(Children's Expenses)Payday / Cash Loans(All active accounts in last 30 days)1st Loan*2nd Loan*TOTAL*(Payday / Cash Loans)Recreation ExpensesEating Out / Ordering In*Theatre / Video Rentals*Lottery / Bingo / Other*Cigarettes / Tobacco*Health Fitness Memberships*Newspaper / Magazines*TOTAL*(Recreation Expenses)Miscellaneous ExpensesHaircuts / Nails*Life Insurance Premiums*Adult Education Expenses*Church / Charities*Adult Clothing / Work Clothes*TOTAL*(Miscellaneous Expenses)Credit Cards1st Card*2nd Card*3rd Card*TOTAL*(Credit Cards)Monthly IncomeWages / Earnings*Unemployment*Workmans Comp*Child Support*Spousal Support*VA Income*Social Security*School Income*Retirement*Cash From JFS*TOTAL*(Monthly Income)AccountsBank Account #1*Bank Account #2*Bank Account #3*Debit Account #1*TOTAL*(All Accounts)Digital SignatureTotal Household Members*Initial*Please enter your initials to verify total household members. (2 character max)Certify / Authorize*Under Penalty of perjury, I certify that the information presented in the certification is true and accurate to the best of my knowledge for all household members. The undersigned further understands that providing false representation herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of financial assistance from this office and/or prosecution. I AgreeSignature*Please type your name to digitally sign this form.Date* MM slash DD slash YYYY