FORM # 6 Personal Budget Part A

RETURN TO FORMS
FORM # 5 BUDGET

PART A - PERSONAL

PERSONAL BUDGET FOR TAX EVALUATION - CONFIDENTIAL
a. DATE

Month Day Year Hour Minutes AM/PM Option
1. PERSONAL PROFILE
YOUR STATUS:

Taxpayer Taxpayer seeking innocent spouse Taxpayer's attorney, enrolled agent, CPA or other Taxpayer's relative Other status
Other status - explain:
THIS INFORMATION IS FOR SPOUSE SEEKING INNOCENT SPOUSE STATUS

Yes - innocent spouse Not innocent spouse
b. YOUR NAME (person filling out this form)
c. OTHER NAMES YOU HAVE USED IN THE LAST 10 YEARS:
Answer the questions below, then proceed down to the budget. Enter your average monthly expenses for each item listed below. Your average should be for a period of the last three months. An estimate is ok if you think it is reasonably accurate.
d. Number of people in your household living under the same roof, including children.

1 person 2 people 3 people 4 people 5 people 6 people More than 6
e. Of those - how many are related to you by blood or marriage?

1 person 2 persons 3 persons 4 persons 5 persons 6 persons More than 6
f. Your marital status

Married living together Married separated or living apart Married but divorce pending Presently unmarried "Civil union" and living together "Civil union" and living apart Other status
g. State you live in
How many months have you resided in the state?
h. County you live in
i. Present age of head of household

Under 66 66 or older
2. PERSONAL INCOME
MONTHLY INCOME: Check all sources of current regular income:

None Wages from employment Sole proprietorship income Income from your corporation, LLC, trust, or other owned business entity Domestic support (alimony or child support) Disability Unemployment Annuity from structured settlement (injury lawsuit) Other annuity Reverse mortgage Contributions from others Victim of terrorism or war crime Stock dividends Rental income Private pension plan: Social Security Interest income Bonuses from employment Commissions or royalties Other income
If "contributions from others" please identify the person making the contributions
If social security, how much do you receive each month?
MONTHLY INCOME due to your status as a victim of terrorism or war crime:
If receiving regular monthy contribution from other(s) please state how much?
If "other income" please explain:
HAVE YOU received any out-of-the-ordinary financial "windfalls" in the last 6 months? If so check applicable box:

None Inheritance Insurance payoff Won the Lottery Other gambling winnings Gift Grant or scholarship Sale of personal property Sale of real property Tax refund Lawsuit settlement or verdict Other
TOTAL GROSS AVERAGE MONTHLY INCOME $$ from all sources :
TOTAL NET AVERAGE MONTHLY INCOME from all sources, after taxes, social security, and other tax deductions:
Are you expecting an increase in monthly income in the next 12 months?

Yes No Maybe Not applicable
If yes, please explain the projected increase in income and estimate how much the increase may be per months::
3. EXPENSES

NATIONAL STANDARDS

FOOD - HOUSEKEEPING - PERSONAL

MONTHLY AVERAGE $ EXPENDITURES:
9. Food, including meals away
10. Housekeeping, cleaning supplies
11. Kitchen supplies, paper towels, napkins, etc. (not food)
12. Apparel & personal services, including clothing, dry cleaning, laundry, clothing repair
13. Personal care products, shaving needs, oral hygiene, feminine hygiene, cosmetics, bath preparations, haircuts & beautician services
14. Medical & health-care out-of-pocket expenses, prescriptions, eye care & eye glasses, co-pay, etc. (does not include health insurance premiums)
15. Miscellaneous
16. List and explain miscellaneous expenses:
4. EXPENSES

LOCAL STANDARDS - HOUSING & UTILITIES
17. Mortgage & other payments for notes against the house; or rent or lease payments
18. Property insurance
19. Homeowners' insurance
20. Maintenance & repair
21. Parking fees
22. HOA fees or dues
23. Property taxes
24. Gas & electric
25. Water
26. Trash & garbage
5. EXPENSES

LOCAL STANDARDS - TRANSPORTATION
27. Car payments (installments) for each vehicle
28. Car rent or lease payments for each vehicle
29. Insurance on all vehicles
30. Gas & oil
31. Repairs, tires, maintenance, smog for all vehicles
32. Vehicle registration fees
33. Parking & tolls
34. Public transportation expenses
35. ANY QUESTIONS? Describe here -
NOW PRINT THIS FOR YOUR RECORDS. THEN PRESS "SUBMIT."

UPON SUBMITTING THIS FORM YOU WILL BE TAKEN TO FORM # 5 PERSONAL BUDGET PART B
Type figures at right into box below - then hit *
Should be Empty: