Monthly Income

Source of Income	Amount of each payment	Time period covered by each payment	Monthly Income	
A. Wages or Salary	
Job 1: ___________________________________	
Gross pay, including overtime	$__________________	_____________	
Subtract:	
Federal taxes	$__________________	
State taxes	$__________________	
Social Security (FICA)	$__________________	
Union dues	$__________________	
Insurance payments	$__________________	
Child support withholding	$__________________	
Other deductions (specify):  ______________________	$__________________	
Subtotal Job 1:	$__________________	_____________	$__________________	
Job 2: ___________________________________	
Gross pay, including overtime	$__________________	_____________	
Subtract:	
Federal taxes	$__________________	
State taxes	$__________________	
Social Security (FICA)	$__________________	
Union dues	$__________________	
Insurance payments	$__________________	
Child support withholding	$__________________	
Other deductions (specify):  ______________________	$__________________	
Subtotal Job 2:	$__________________	_____________	$__________________	
Job 3: ___________________________________	
Gross pay, including overtime	$__________________	_____________	
Subtract:	
Federal taxes	$__________________	
State taxes	$__________________	
Social Security (FICA)	$__________________	
Union dues	$__________________	
Insurance payments	$__________________	
Child support withholding	$__________________	
Other deductions (specify):  ______________________	$__________________	
Subtotal Job 3:	$__________________	_____________	$__________________	
Total wages or salary	$_______________	___________	$_______________	

B. Self-Employment Income	
Job 1: ______________________________	
Gross pay, including overtime:	$__________________	_____________	$__________________	
Subtract:	
Federal taxes	$__________________	
State taxes	$__________________	
Self-Employment	$__________________	
Other deductions (specify): ________________________	$__________________	
Subtotal Job 1:	$__________________	_____________	$__________________	
Job 2: ______________________________	
Gross pay, including overtime:	$__________________	_____________	$__________________	
Subtract:	
Federal taxes	$__________________	
State taxes	$__________________	
Self-Employment	$__________________	
Other deductions (specify): ________________________	$__________________	
Subtotal Job 2:	$__________________	_____________	$__________________	
Total Self-Employment Income	$_______________	___________	$_______________	

C. Investment Income	
Dividends	$__________________	_____________	$__________________	
Interest	$__________________	_____________	$__________________	
Leases	$__________________	_____________	$__________________	
Licenses	$__________________	_____________	$__________________	
Rent	$__________________	_____________	$__________________	
Royalties	$__________________	_____________	$__________________	
Other (specify): ____________	$__________________	_____________	$__________________	
Total Investment Income	$_______________	

D. Other Income	
Bonuses	$__________________	_____________	$__________________	
Note/ trust income	$__________________	_____________	$__________________	
Alimony or child support	$__________________	_____________	$__________________	
Pension/retirement income	$__________________	_____________	$__________________	
Social Security	$__________________	_____________	$__________________	
Other public assistance	$__________________	_____________	$__________________	
Other (specify): ____________	$__________________	_____________	$__________________	
Total Other Income	$_______________	

Grand Total Monthly Income	$_______________