DEPARTMENT OF SOCIAL AND HEALTH SERVICES CHILDREN’S ADMINISTRATION Financial Worksheet
APPLICANT NAME(S)
Income
List all regular net income, including but not limited to wages, Social Security, pensions and child support. Add additional sheets if needed.
SOURCE	NET MONTHLY AMOUNT	VERIFICATION ATTACHED (SPECIFY TYPE, I.E., WAGE STUB)
Other Resources
List any other resources you depend upon to meet your expenses, including but not limited to tribal payments, family support and inheritance. Add additional sheets if needed.
SOURCE	NET MONTHLY AMOUNT	VERIFICATION ATTACHED (SPECIFY TYPE, I.E., BANK STATEMENT)
Average Expenses
MONTHLY EXPENSES	AMOUNT	MONTHLY EXPENSES	AMOUNT
Housing	Medical
Utilities / phone	Child Support
Food	Loans other than mortgage / rent
Car	Credit card payments
Insurance	Other (specify):
Have you ever filed for bankruptcy? Yes No; if yes, please explain:
Are you current on your child support payments? Yes No; if not, please explain:
APPLICANT SIGNATURE	DATE
APPLICANT SIGNATURE	DATE