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JD-FM-6-LONG Rev. 2-16
Hours worked per week
Gross yearly income from prior tax year. Provide amount of income, not copies of forms ............................... $
List here and explain any other income including but not limited to: non-reported income; and support provided by relatives,
friends, and others:
2) Mandatory Deductions
(If consistent deductions don't occur every pay check provide average amounts.)
(1) Federal income tax deductions
Job 1
$
$
$
$
$
$
$
$
Job 2
$
$
$
$
$
$
$
$
Job 3
$
$
$
$
$
$
$
$
$
Totals
(claiming exemptions)
$
$
$
$
(2) Social Security or Mandatory Retirement
(3) State income tax deductions
$
(claiming
exemptions)
(4) Medicare
(5) Health insurance
(6) Union dues
(7) Prior court order — child support or alimony
(8) Total Mandatory Deductions
(add items 1 through 7)
$
$
3) Net Weekly Income..............................................................................................................................
$
Subtract the Total Mandatory Deductions [see item I., 2), (8)] from the Total Gross Weekly Income/Monies and Benefits
From All Sources [see item I., 1), z) ]
4) Other Deductions
(1) Credit Union Loan ..................................
$
(2) Savings .................................................
$
(3) Retirement.............................................
$
(4) Subsequent Other Order of Court............
$
(i.e., child support, alimony)
(5) Health Savings Account(s) or Plan(s)......
$
(6) Deferred Compensation or 401K ............
$
(7) Other Pre-Tax Deductions......................
$
(8) Other Wage Executions .........................
$
(9) Total Other Deductions (add items 1 through 8) ...............................................................................
$
II. Weekly Expenses Not Deducted From Pay
If expenses are not paid weekly, adjust the rate of payment to weekly as follows:
Bi-weekly → divide by 2 Semi-monthly → multiply by 2, multiply by 12, divide by 52
Monthly → multiply by 12, divide by 52
Annually → divide by 52
Insert an ("x") in the box if you are not currently paying the expense, or if someone else is paying the expense.
Home:
Rent or Mortgage (Principal, Interest —
Real Estate Taxes and Insurance if
escrowed)
$
2nd Mortgage/Home Equity Line of Credit
or Other Lien
$
Property taxes and assessments ..........
$
Household Improvements
Condominium Fees................................
$
(Specify)
$
Utilities:
Oil ........................................................
$
Electricity ..............................................
$
Gas ......................................................
$
Water and Sewer...................................
$
Telephone/Cell/Internet............................
$
Trash Collection ......................................
$
T.V./Internet ............................................
$
Groceries (after food stamps): Including household supplies, formula, diapers .........................................
(Not including take out meals)
$
Restaurants
(Including take out meals) ..................................................................................................
$
Transportation:
Gas/Oil .................................................
$
Repairs/Maintenance .............................
$
Automobile Insurance/Tax/Registration ...
$
Auto Loan or Lease .................................
$
Public Transportation...............................
$
Insurance Premiums:
Medical/Dental (Out-of-pocket expense
after Health Savings Account/Plan) ......
$
Life .........................................................
$
Uninsured Medical/Dental not paid by insurance ...................................................................................
$