INTAKE BUDGET

AGORA INTAKE BUDGET Form

Housing Counseling Data - Complete "Budgeted Area" ONLY and enter 0 if line item is not applicable to your budget expenses.
How did you hear about this Housing Referral Service*
Name*

First Name Last Name
Date*

MonthDay Year
Date
Total Monthly Gross Household Income. {Include all income of all members of household, even if they are not on the Mortgage. NOTE: Complete "Budgeted" Column ONLY!*

Charity*

	Spent	Budgeted
Tithes
Charity & Offerings
Totals

Food*

	Spent	Budgeted
Groceries
Restaurants
Totals

Saving*

	Spent	Budgeted
Emergency Fund
Retirement Fund
College Fund
Totals

Clothing*

	Spent	Budgeted
Adults
Children
Cleaning/Laundry
Totals

Housing*

	Spent	Budgeted
Rent
1st Mortgage
2nd Mortgage
Real Estate Taxes
Home Owner Insur..
Association Dues
Totals

Utilities*

	Spent	Budgeted
Electricity
Gas
Water
Trash
Phone/Mobile
Internet
Cable
Totals

Transportation*

	Spent	Budgeted
Gas & Oil
Repairs & Tires
License & Taxes
Car Replacement
Other
Totals

Medical/Health*

	Spent	Budgeted
Medications
Doctor Bills
Dentist
Optometrist
Vitamins
Other
Totals

Personal*

	Spent	Budgeted
Child Care
Toiletries
Beauty
Education
Books
Child Care
Alimony
Subscriptions
Dues
Gifts
Furniture
His Fun
Her Fun
Baby Supplies
Pet Supplies
Savings.
Emergency Fund
Totals

Debts*

	Spent	Budgeted
Car Payment 1
Car Payment 2
Credit Card 1
Credit Card 2
Credit Card 3
Credit Card 4
Credit Card 5
Student Loan 1
Student Loan 2
Student Loan 3
Student Loan 4
Home Repairs paid monthy
Other 3
Other 4
Other 5
Totals

Insurance*

	Spent	Budgeted
Life
Health
Rent/Homeowner's
Auto
Disability
Identity Theft
Long Term Care
Totals

Recreation*

	Spent	Budgeted
Vacation
Totals

Total Income*
Total Amount Budgeted
Net Income (Should be 0!)
SIGNATURE {Your typed name}. Hit Submit if you are unable to type Name in Box.
Should be Empty: