Worksheet of Monthly Income and Expenses

    Name

    Email Address

    Note: The first 4 pages of this form are the most important. If you can complete them before our discussion of support, that will save you time and money. If you prefer to complete them during a mediation session, or with our Dispute Resolution Associate, that's fine, too.

    BUDGET INFORMATION

    Please base these figures on a monthly average. Please translate all items (e.g., weekly allowances, semi-annual insurance, etc.) into average monthly amounts.

    1) Rental/mortgage and household:

    a)Rental/mortgage payment-total

    $

    i) average principal

    $

    ii) average interest

    $

    b) Property Taxes:

    $

    c) Property Insurance:

    $

    d)Maintenance and Repairs Gardener & Mowing

    $

    Housekeeper

    $

    Repairs

    $

    Replacement costs budgeted For furnace, water heater, roof, Etc.

    $

    Plumbers, electricians

    $

    d) Maintenance and Repairs subtotal

    $

    e) Homeowner's Insurance

    $

    2) Medical (not covered by insurance)

    a)Doctor

    $

    b) Dentist

    $

    c) Optometrist

    $

    d) Contacts/glasses

    $

    e) Orthodontist

    $

    f) Prescriptions

    $

    g) Medical Insurance

    $

    h) Dental Insurance Premium

    $

    i) Vitamins and supplements

    $

    j) Other:

    $

    Total

    $

    3) Childcare: daycare, nanny, work-related

    sitters

    $

    Childcare: occasional sitters

    $

    4) Food and supplies:

    a)Groceries

    $

    b) Shampoo, toothbrushes, cleaning supplies (misc. grocery store

    $

    Total Grocery

    $

    c) Eating Out (alone or w/friends

    $

    d) Lunches out while at work

    $

    e) Eating out w/children

    $

    Total eating out:

    $

    5) Utilities

    a)Gas

    $

    b) Electric

    $

    c) Water

    $

    d) Garbage collection

    $

    e) Cable television

    $

    f) Satellite Radio

    $

    g) Other

    $

    Total:

    $

    6) Telephone

    a) Telephone

    $

    b) Cellular phone

    $

    c) Children's cell phones

    $

    d) Internet access

    $

    e) E-mail accounts

    $

    f) Other telephone

    $

    Total:

    $

    7) Laundry

    a) Laundry at Dry Cleaners

    $

    b) Dry Cleaning

    $

    c) Household supplies for Laundry

    $

    d) Laundromat

    $

    Total:

    $

    8) Clothing

    a) Your clothing

    $

    b) Children

    $

    c) Shoes

    $

    d) Shoe Repair

    $

    e) Alterations

    $

    f) Other

    $

    Total

    $

    9) Education

    a) Your tuition & school fees

    $

    b) Continuing Education fees for your profession

    $

    c) Private School Tuition

    $

    d) Tutors, books, videos

    $

    e) Outside classes (self orchildren)

    $

    10) Other

    a)Travel (you and children) ....Annual vacation, trip to see Grandparents, unreimbursed work Travel, weekend trips, school trips, etc.

    $

    b) Entertainment...Videos, children's parties, movies, Concerts, CD's, I-Pod downloads, Theater, etc.

    $

    c) Haircuts, manicures, personalcare

    $

    d) Gym membership, YMCA, other Dues and club memberships

    $

    Total

    $

    11) Transportation

    a)Car payments

    $

    Name of creditor

    b) Gas and Oil

    $

    c) Repairs

    $

    d) Oil changes

    $

    e) License

    $

    f) Car Wash

    $

    g) Auto club

    $

    h) Parking

    $

    i) Public transportation

    $

    j) Other

    $

    Total:

    $

    12) Insurance

    a)Auto

    $

    b) Medical and Dental

    $

    c) Life

    $

    d) Disability

    $

    e) Other

    $

    Total:

    $

    13)Savings and Investments:

    $

    14)Charitable Contributions:

    $

    15) Children

    a)Allowance

    $

    b) School lunches

    $

    c) Summer camp

    $

    d) Private School

    $

    e) Nursery school

    $

    f) Lessons

    $

    g) Activities

    $

    h) Participatory sports

    $

    i) Tutors

    $

    j) School activities

    $

    k) School pictures

    $

    l) Yearbooks

    $

    m) Other

    $

    Total:

    $

    16) Debts

    a) List of installment debts (car payments, credit cards, etc.):

    Payment to Payment for Monthly Payment Balance Date Last Payment Made

    Total Monthly Payments:

    $

    Personal Education and employment Information:

    Are you currently employed?

    YesNo

    If YES: Name, address, and telephone number of employer:

    Name:

    Address:

    Telephone No:

    When did you start work there?

    Approximate number of hours worked per week:

    What was your gross monthly income?

    If you do NOT work, date job ended:

    What is your occupation:

    Completed high school or equivalent?

    If no, please indicate highest year of education completed:

    Number of years of college completed:

    Degree (circle one)

    BABSOther

     

    Number of years of graduate school completed:

    Degree (circle one)

    MAMBAMFAJDMDPhDOther

     

    Professional/occupational license(s) (specify):

    Vocational training

    Income Information:

    Most of this information is easily extracted from your current pay stubs and looking at your most recent tax returns. Attach copies of your three most recent pay stubs and return them to the office with this worksheet.

    Most recent tax filing (year)

    Filing status: Single head of household married, filing separately married, filing jointly with:

    Did you file California state tax (circle one)

    YesNo

    If you answered no, in which state did you file

    If you file taxes in any additional states, please list below:

    Estimate of other party's income:

    $

    Total gross (before taxes) earnings for the past 12 months (do NOT include welfare, AFDC, SSI, spousal support from this marriage, or ANY child support):

    $

    Total gross earnings last month:

    $

    Of the following deductions, only some may apply to you. If the deductions aren't shown on your pay stub, then just write none, or leave the line blank. All of these deductions are based on monthly figures. If you're having problems with these figures, please call us after you've provided us with a pay stub.

    Type of Deduction Monthly amount last month Average monthly amount over the past 12 months
    State Income Tax
    Federal Income Tax
    Social Security Hospital tax (FICA and MEDI), self employment tax, or the amount used to secure retirement or disability
    Health Insurance for you and children
    State Disability Insurance
    Mandatory Union Dues
    Mandatory Retirement and Pension(Monthly amount last month)
    Child/Spousal support actually being paid from PREVIOUS relationship (Monthly amount last month)
    Necessary job-related expenses (Monthly amount last month)
    Hardship deductions(Monthly amount last month)
    Dividends/Interest Monthly amount last month Average monthly amount over the past 12 months
    Rental Property Income(Monthly amount last month)
    Trust Income(Monthly amount last month)
    Other: (specify)(Monthly amount last month)

    Are you self-employed? If so, please provide a list of business expenses for the past year, or year-to-date, and attach your Federal Tax Schedule C for the last two years.

    Income from self-employment, after business expenses for all businesses:

    I am the: sole proprietor business partner other (specify):

    Number of years in business:

    Name of business:

    Type of business:

    Have you received one time money (lottery winnings or inheritance, etc.) in the last 12 months?:

    YesNo

    If you answered yes, please specify source and amount:

    Source :

    Amount :

    Has your financial situation changed significantly over the last 12 months?:

    YesNo

    If you answered yes, please specify:

    Enter below the average monthly amount for the following:

    AFDC, welfare, spousal support from this marriage, and child support from previous relationships received each month:

    $

    Cash and checking accounts:

    $

    Savings, Credit Union, certificates of deposit, and money market accounts:

    $

    Stocks, bonds, and other liquid assets:

    $

    All other significant property, real or personal:

    $

    Expense Information:

    List all persons living in your home whose expenses are included in your figures and their age, relationship to you, and gross monthly income (child support received from previous relationship, etc.):

    List all other persons living in your home, whose expenses are not covered by you, their age, relationship to you and gross monthly income: