Fillable Financial Statement Template 2008 (Page 2 of 3) in pdf

Financial Statement Template 2008 Page 2

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EMPLOYMENT & INCOME INFORMATION

I am currently employed

I am currently unemployed

My employer is:______________________________________________ Since:_____________________________

My employer’s address is:________________________________________________________________________

My Occupation is:____________________________________

FULL-TIME /

PART-TIME

My gross pay is $__________________________

weekly /

bi-weekly /

monthly

I have earned the following overtime or bonus pay:

This year to date: $____________ /

Last year: $_____________ /

Previous year: $___________

I am on unemployment. I receive $________________________________

weekly /

bi-weekly

Note: You MUST attach a copy of your most recent pay stub or verification from the Department of

Job and Family Services Ohio Unemployment Benefits of the amount you receive in unemployment

benefits.

I am on public assistance. I receive $__________________ monthly (ADC, food stamps)

Note: You MUST attach verification from the Department of Job and Family Services of the amount

you receive in benefits.

I receive Worker’s Compensation Benefits in the amount of $______________________ per _________

Note:

You MUST attach verification from the Department of Job and Family Services Bureau of

Worker’s Compensation of the amount you receive in benefits.

I receive social security benefits for myself in the amount of $________________________ monthly

Retirement benefits /

Disability benefits /

Other ____________________________

I receive social security benefits for this child in the amount of $_____________________ monthly

Survivor benefits /

Disability benefits /

Other ____________________________

I receive social security benefits for _____________________ in the amount of $___________ monthly

Retirement benefits /

Disability benefits /

Other ____________________________________

Note:

You MUST attach verification from the Social Security Administration of the amount you

receive in benefits.

I earn additional income (source and amount) (include interest, stocks, bonds, rental property, etc.):

_______________________________________________________________________________________________________

Financial Statement Template 2008 Page 2

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