Monthly Income

Source of income	Description	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)				
	Medicare				
	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)				
	Medicare				
	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)				
	Medicare				
	Union dues				
	Insurance payments				
	Child support withholding				
	Other deductions (specify):				
					
	Subtotal Job 3	$		$	
	Total Wages and Salary			$	
					
B. Self-Employment Income					
Job 1: 	Gross pay, including overtime	$			
	Subtract:				
	Federal taxes				
	State taxes				
	Self-employment taxes				
	Other deductions (specify):				

	Subtotal Job 1	$		$	
Job 2: 	Gross pay, including overtime	$			
	Subtract:				
	Federal taxes				
	State taxes				
	Self-employment taxes				
	Other deductions (specify):				

	Subtotal Job 2	$		$	
	Total Self-Employment Income			$	
					
C. Investment Income	Dividends	$		$	
	Interest	$		$	
	Leases	$		$	
	Licenses	$		$	
	Rent	$		$	
	Royalties	$		$	
	Other deductions (specify):				
		$		$	
	Total Investment Income			$	
					
D. Other Income	Bonuses	$		$	
	Note or trust income	$		$	
	Alimony or child support	$		$	
	Pension/retirement income	$		$	
	Social Security	$		$	
	Other public assistance	$		$	
	Other (specify)				
		$		$	
		$		$	
	Total Other Income			$	
	Grand Total Monthly Income			$