ITEM
COST PER MONTH
a. Housing
$__________
b. Food
$__________
c. Utilities
$__________
d. Medical,
dental, eye care $__________
e. Day
care
$__________
f. Transportation
$__________
g. Clothing
$__________
h. Other
debt requirements
_____________________________________________
$__________
_____________________________________________
$__________
_____________________________________________
$__________
_____________________________________________
$__________
_____________________________________________
$__________
_____________________________________________
$__________
_____________________________________________ $__________
_____________________________________________
$__________
TOTAL OF ALL EXPENSES LISTED $__________
4. The
plaintiff is obligated to pay the full amount of the expenses
listed above.
5. The sum
total of all income from every source available to the
plaintiff including, but not limited to,
wages, salary, commissions,
bonuses, rent, royalties, trade or
business income, interest, dividends,
pensions, annuities, social security,
worker’s compensation, veteran’s