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Name:
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MONTHLY INCOMEBorrowerCo-Borrower or SpouseASSETSAmount ($)Where HeldAmount ($)Where Held
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Salary/Commission: Monthly income you receive from your main employerCash: How much money you have in all checking accounts
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Social Security: Monthly benefits you receive for SSI or SSDIInvestments: Savings accounts, stocks/bonds
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Other Public Cash Benefits: Ohio Works First benefits with the Department of Job and Family ServicesCash or Investments Held Outside the U.S.
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Additional Employment: Any income you are receiving by working a second job, for instance Real Estate (estimated value)
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Other Income: anything not listed aboveOther Assets (boats, RV, etc)
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TOTAL HOUSEHOLD INCOME$0.00$0.00TOTAL
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MONTHLY EXPENSES
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Recurring BillsDEBT/LIABILITIESAmount ($)Debt Holder/ServicerAmount ($)Debt Holder/Servicer
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Rent/MortgageVehicle Loan
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2nd Mortgage/Home Equity LoanCredit Card Balances
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Property Taxes (if not included in mortgage)Mortgage Balance
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Homeowner's or Renter's Insurance (if not included in mortgage)Payday Loans
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Utilities (electric, gas, water, sewer)Other Personal Loans
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Cell Phone/Home PhoneTOTAL$0.00$0.00
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Internet/Cable
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Subscription Services (Netflix, Hulu, etc)
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Car Payment
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Auto Insurance
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Public Transportation
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Gasoline
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Healthcare Premium (if paid out of pocket and not deducted from paycheck)
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Medical/Dental Bill Payment Plan: any payment plan you are on with your medical or dental providers
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Daycare/Babysitter
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Before/Aftercare at Child's School
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Life Insurance (if paid out of pocket and not deducted from paycheck)
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Other:
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Necessities
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Food (groceries)
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Food (restaurants, takeout, food delivery)
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General Shopping (clothing, household items, toiletries)
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Personal Care (grooming, hair salon, etc.)
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Pet Care
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Prescriptions
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Other:
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Debt Payments
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Total minimum monthly credit card payments
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Total minimum monthly student loan payments
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Total minimum monthly personal loan payments
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Taxes
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Income Taxes: If you have a balance due with the IRS, how much do you pay monthly?
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Business Taxes/Additional Real Estate Taxes (ex: rental property)
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Other
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Extra curricular lessons (swim, dance, sports…)
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School Supplies
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Tuition: private schools, colleges/universities
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Recurring donations/tithes
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Entertainment/Recreation
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Other: gifts
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Long-term savings goals
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Total Expenses$0.00$0.00
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For Office Use Only:BorrowerCo-Borrower or Spouse
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Monthly Household Income$0.00$0.00
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Monthly Household Expenses$0.00$0.00
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Proposed HFLA Payment
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Remainder$0.00$0.00
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