My monthly income from social security, company,
government, institutional, or other sources is:
1.
My monthly income from the interest of savings,
money market funds, and bonds is:
2.
My monthly income from dividends of stocks or mutual
funds is;
3.
My monthly income from rental property I own is:
4.
My monthly income from Christian Science practice/work
is:
5.
My monthly income from the support of family members
is:
6.
My monthly income from from other sources is/are
(identify):
7.
Sub Total
8.
Add line 1 through
7
Do you expect any of the above income to cease
within the near future? Yes
No
If "yes," deduct the monthly amount from the Sub Total. Explain
the reduction:
9.
Total Monthly
Income
10.
Subtract 9 from 8
H
My
Assets Are
My monthly rent or mortgage payment is:
1.
My monthly food expenses are:
2.
My monthly transportation expenses are:
3.
My monthly insurance expenses are:
4.
My other monthly miscellaneous expenses are:
5.
My total monthly expenses are:
6.
Add 1 through 5
I
My
Present Expenses Are
The estimated value of property I own is:
1.
The estimated value of mutual funds, stocks or
bonds I hold is:
2.
The amount I have in savings , checking, money
market funds or certificates of deposit is:
3.
The estimated value of my automobile(s) is/are:
4.
The value of all other assets I hold are estimated
to be:
5.
The total value of my assets is:
6.
Subtract 9 from
8
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