DETAILS OF INCOME AND EXPENSES

For the month of _________________, 20 _____

MONTHLY INCOME Debtor Spouse

Net employment income . . . . . . . . . . . . . . . . ____________ ____________ Name_____ ____________ ___

Net pension/Annuities . . . . . . . . . . . . . . . . . . ____________ ____________
Net child support . . . . . . . . . . . . . . . . . . . . . . ____________ ___________ Address_________ _ ______________
Net spousal support . . . . . . . . . . . . . . . . . . . ____________ ____________
Net employment insurance benefits . . . . . . . ________ ___ ____ __ _____
Net social assistance . . . . . . . . . . . . . . . . . . ____________ ____________
Self-employment income . . . . . . . . . . . . . . . . Phone Number______________ _____
Gross ____________Net . . . . . . . . . . . . . . . ____________ ____________
Other net income . . . . . . . . . . . . . . . . . . . . . . ____________ ____________ # of persons in household Family Unit __ _____
(Provide details )

TOTAL MONTHLY INCOME . . . . . . . . . . . . $_____ ____(1) $______ __(2) ( 1 + 2) $ (3)

MONTHLY NON-DISCRETIONARY EXPENSES

Child support payments . . . . . . . . . . . . . . . . . ____________
Spousal support payments . . . . . . . . . . . . . . ____________
Child care . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________
Medical condition expenses . . . . . . . . . . . . . ____________
Fines/Penalties imposed by the court . . . . . . ____________
Expenses as a condition of employment . . . . ____________
Debts where stay has been lifted . . . . . . . . . ____________
Other expenses . . . . . . . . . . . . . . . . . . . . . . ____________ (Provide details _____________ )

TOTAL MONTHLY NON-DISCRETIONARY EXPENSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - $ _______ (4)

MONTHLY DISCRETIONARY EXPENSES: (Family unit)
Housing expenses Living expenses
Rent/Mortgage . . . . . . . . . . . . . . . . . . . . . . . . . __ ___ Food/Grocery . . . . . . . . . . . . . . . . . . . ____ ___
Property taxes/Condo fees . . . . . . . . . . . . . . . ___ ____ Laundry/Dry cleaning . . . . . . . . . . . . . . ___ ____
Heating/Gas/Oil . . . . . . . . . . . . . . . . . . . . . . . . ___ ____ Grooming/Toiletries . . . . . . . . . . . . . . . _____ __
Telephone . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ___ Clothing . . . . . . . . . . . . . . . . . . . . . . . . ___ ____
Cable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ___ Other . . . . . . . . . . . . . . . . . . . . . . . . . . ___ ____
Hydro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ ____ Transportation expenses
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ ____ Car lease/Payments . . . . . . . . . . . . . . ____ ___
Furniture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ___ Repair/ Maintenance/Gas . . . . . . . . . . ___ ____
Personal expenses Public transportation . . . . . . . . . . . . . . ___ ____
Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ ____ Insurance expenses
Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ ____ Vehicle . . . . . . . . . . . . . . . . . . . . . . . . ___ ____
Dining/Lunches/Restaurants . . . . . . . . . . . . . . __ _____ House . . . . . . . . . . . . . . . . . . . . . . . . . ____ ___
Entertainment/Sports . . . . . . . . . . . . . . . . . . . . ____ ___ Furniture/Contents . . . . . . . . . . . . . . . . ____ ___
Gifts/Charitable donations . . . . . . . . . . . . . . . . ____ ___ Life insurance . . . . . . . . . . . . . . . . . . . ___ ____
Allowances . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ___ Other . . . . . . . . . . . . . . . . . . . . . . . . . . ___ ____
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ ____ Payments
Non-recoverable medical expenses To the estate (Trustee) . . . . . . . . . . . . ____ ___
Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ___ To secured creditor . . . . . . . . . . . . . . . ___ ____
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ___ (Other than mortgage and vehicle) . . . _____ __
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _____ __ Irregular & Annual expenses (specify) . ____ ___

TOTAL MONTHLY DISCRETIONARY EXPENSES (FAMILY UNIT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - $ ______ (5)

MONTHLY SURPLUS OR (DEFICIT) FAMILY UNIT ((3) - (4) - (5)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = $ ______ (6)

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Bankrupt’s (Debtor’s) Signature Date