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8(Rev. 6/07/06) CCDR 0604 C
Case No. _________________________
STATEMENT OF MONTHLY LIVING EXPENSES
As of ____________________________
1.
Household
a. Mortgage or rent
$ ____________________________
(specify)
b. Home equity payment
____________________________
c. Real estate taxes, assessments
____________________________
d. Homeowners or renters insurance
____________________________
e. Heat/fuel
____________________________
f. Electricity
____________________________
g. Telephone (include long distance/cellular/fax or modem lines)
____________________________
h. Water and Sewer
____________________________
i. Refuse removal
____________________________
j. Laundry/dry cleaning
____________________________
k. Maid/cleaning service
____________________________
l. Furniture and appliance repair/replacement
____________________________
m. Repairs and maintenance to dwelling
____________________________
n. Lawn and garden/snow removal
____________________________
o. Food (groceries, household supplies, etc.)
____________________________
p. Liquor, beer, wine, etc.
____________________________
q. Cable/Satellite TV
____________________________
r. Internet Service Provider
____________________________
s. Other (specify): __________________________________________________________
____________________________
_______________________
SUBTOTAL HOUSEHOLD EXPENSES:
$
2.
Transportation
a. Gasoline
$ ____________________________
b. Repairs and Maintenance
____________________________
c. Insurance/license/city stickers
____________________________
d. Payments/replacement
____________________________
e. Alternative transportation
____________________________
f. Parking
____________________________
g. Other (specify): ___________________________________________________________
____________________________
_______________________
SUBTOTAL TRANSPORTATION EXPENSES:
$
3.
Personal
$ ____________________________
a. Clothing
____________________________
b. Grooming
____________________________
c. Medical
__________________________
(after insurance proceeds/reimbursement)
(1) Doctor
____________________________
(2) Dentist
____________________________
(3) Optical
____________________________
(4) Medication
____________________________
d. Insurance
(1) Life (term)
__________________________
(2) Life (whole or annuity)
__________________________
(3) Medical/Hospitalization
__________________________
(4) Dental/Optical
__________________________
e. Other (specify): ____________________________________________________
__________________________
________________________
SUBTOTAL PERSONAL EXPENSES:
$
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