Family Financial Report




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Child Welfare



Family Financial Report




Date:

     

Applicant 1: 1:

     




     




     




(Last)




(First)




(Middle)




Applicant 2:

     




     




     




(Last)




(First)




(Middle)




Total number of people in household:

   







A. Monthly income:

Monthly average:

Applicant #1 – from employment (net/take home) ………………………




     

Applicant #2 – from employment (net/take home) ………………………




     

Property income ......……………………………………………………..




     

Investment income ...…....………………………………………..……...




     

Business income ..…………………………………………..…………....




     

Subtotal A− Monthly income:




$0.00







B. Other monies received: Check each below that you receive and enter the total
monthly average (enter total in “subtotal B”).


 Child support  Alimony  Retirement  SSI  Food stamps

 Unemployment  Trust  Inheritance  TANF



 Other (specify type):

     




Subtotal B Monthly net average:




     







C. Monthly amount of the following (if any):

Foster care payment ..…………...……………………………………….




     

Adoption assistance benefits ..…………..……………………………….




     

Non-needy relative grant ………………………………………………..




     

Subtotal C − Monthly amount:




$0.00

Add subtotals from boxes A, B and C for:

Total − Average monthly income amount:




$0.00







D. Yearly net income total







Multiply “total in box C” by 12 for:

Total D − Yearly net income:




$0.00







Has either applicant declared personal or business bankruptcy within the last ten years?

 Yes  No



If yes, when?

     

Please explain (attach additional sheets if needed):

     

     

     



Outstanding loans, credit cards,

or installment payments

Monthly expenses

Balance

due

1.

Mortgage − Are insurance and tax included in the payment:  Yes  No …….……………………...




     




     

2.

Rental …………………………………………..…….




     







3.

Child support …………………………………………




     




     

4.

Garnishments .……………………………………..….




     




     

5.

Home owners insurance ………………………...…....




     




     

6.

Health insurance premiums .…………………..……..




     







7.

Credit card (name):

     




     




     

8.

Credit card (name):

     




     




     

9.

Car insurance …………………………………………




     




     

10.

Car payment ……………………………..….….…….




     




     

11.

Food ...…………………….……………………….....




     







12.

Student loans …………………………………………




     




     

13.

Utilities (heat, light, water, telephone, garbage) …….




     







*Other expenses:













14.

     




     




     

15.

     




     




     

Total:




$0.00




$0.00




*Other estimated monthly expenses should include the following: transportation, medications, clothing, other miscellaneous living expenses and insurance payments.

E.

Total yearly expenses: …...…………………………




$0.00

x 12 =

$0.00

Yearly discretionary income Total in box D minus total in box E:

$0.00







Assets:

Amount:

Savings account (average balance)




     

Checking account (average balance)




     

Property value minus mortgage owed equals home equity




     

Value, other property (real estate, boat, RV, jewelry, collectables, etc.)




     

Investments (stocks/bonds, IRA, retirement and/or deferred comp. accounts) ..




     

Total assets: 




$0.00










If you anticipate any future financial changes, please specify:

     




     




     




     




     




     

Employment history over the past five years (attach additional pages as needed):

Applicant 1

Applicant 2

Occupation:

     

Occupation:

     

Employer:

     

Employer:

     

Employer’s

address:


     

Employer’s

address:


     

     

     

Reason for leaving:

     

Reason for leaving:

     

Supervisor:

     

Supervisor:

     

From:

     

To:

     

From:

     

To:

     







Applicant 1

Applicant 2

Occupation:

     

Occupation:

     

Employer:

     

Employer:

     

Employer’s

address:


     

Employer’s

address:


     

     

     

Reason for leaving:

     

Reason for leaving:

     

Supervisor:

     

Supervisor:

     

From:

     

To:

     

From:

     

To:

     







Applicant 1

Applicant 2

Occupation:

     

Occupation:

     

Employer:

     

Employer:

     

Employer’s

address:


     

Employer’s

address:


     

     

     

Reason for leaving:

     

Reason for leaving:

     

Supervisor:

     

Supervisor:

     

From:

     

To:

     

From:

     

To:

     







Applicant 1

Applicant 2

Occupation:

     

Occupation:

     

Employer:

     

Employer:

     

Employer’s

address:


     

Employer’s

address:


     

     

     

Reason for leaving:

     

Reason for leaving:

     

Supervisor:

     

Supervisor:

     

From:

     

To:

     

From:

     

To:

     



















     










     

Applicant 1 signature

Date




Applicant 2 signature

Date







CF 1291 (07/12)

File in: Section 2 Assessment information Page of




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