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
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The Apartment Lady Newsletter/ Website
Facebook
Flyer
AGORA Housing Services
Name
*
First Name
Last Name
Date
*
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Month
-
Day
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!
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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.
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