Name(s) ______________________________ Loan #_____________________ Address___________________________________________________________ A. Household Expenses: B. Your Monthly Income: Fixed Monthly Expenses: Payment: Gross Income: Net Income (after taxes Mortgage and deductions): 2nd Mortgage $ $ Condo / Homeowner Association Fees Gas & Electric Spouse or Income Heating Oil Partner’s Water & Sewer Gross Income: Net Income (after taxes Telephone and deductions): Car Payment 1 $ $ Car Payment 2 Auto Insurance Life Insurance Medical Insurance Other Household Income: Alimony / Child Support Gross Income: Net Income (after Alarm System taxes and deductions): Property Taxes/Insurance $ $ Other/Minimum Credit Card Describe: Payment from Section C Sub-Total FIXED Expenses: C. Credit Cards and Other Debt: Variable Monthly Payment Expenses Creditor Name: Payment: Balance: Groceries Eating Out Gas Bus/Taxi/Parking Car Repairs Toiletries/Hair Care Medical Prescriptions Total $ $ Day Care Cable TV/Internet D. Surplus/Deficit: Clothing/Laundry Total Net Monthly $ Lottery Household Income: Church/Charity Subtract Total Monthly $ Entertainment Expenses: Cell Phone = Monthly Surplus or Deficit $ Other Sub-Total, VARIABLE Expenses: Total Monthly Expenses: Signature:__________________________ Date: ___________________________
Name(s) ______________________________ Loan #_____________________ Address___________________________________________________________ A. Household Expenses: Fixed Monthly Expenses: Payment: Mortgage 2nd Mortgage Condo / Homeowner Association Fees Gas & Electric Heating Oil Water & Sewer Telephone Car Payment 1 Car Payment 2 Auto Insurance Life Insurance Medical Insurance Alimony / Child Support Alarm System Property Taxes/Insurance Other/Minimum Credit Card Payment from Section C Sub-Total FIXED Expenses: Variable Monthly Expenses Payment Groceries Eating Out Gas Bus/Taxi/Parking Car Repairs Toiletries/Hair Care Medical Prescriptions Day Care Cable TV/Internet Clothing/Laundry Lottery Church/Charity Entertainment Cell Phone Other Sub-Total, VARIABLE Expenses: Total Monthly Expenses: B. Your Monthly Income: Gross Income: Net Income (after taxes and deductions): $ $ Spouse or Partner’s Income Gross Income: Net Income (after taxes and deductions): $ $ Other Household Income: Gross Income: Net Income (after taxes and deductions): $ $ Describe: C. Credit Cards and Other Debt: Creditor Name: Payment: Balance: Total $ $ D. Surplus/Deficit: Total Net Monthly Household Income: $ Subtract Total Monthly Expenses: $ = Monthly Surplus or Deficit $ Signature:__________________________ Date: ___________________________
ForeclosurePreventionIntakePackage.Final_.2016.docx