Please complete and send back to our office at least three busines days prior to your meeting. Fax: 312-706-9779 Email: siara.lump@nm.com
Client Income $3,186 PROJECTED MONTHLY "SURPLUS"
$591 ACTUAL MONTHLY INCOME (After Partner/Spouse Income $0 (Actual income minus expenses) Tax) Other Income $0 Total monthly income $3,186 ENTERTAINMENT Video/DVD rentals $0 HOUSING CDs $0 Primary residence mortgage/rent $700 Movies $0 Second mortgage/Home Eq. Loan $0 Concerts $0 Electricity $75 Sporting events $0 Gas $50 Live theater $0 Water and sewer $0 Travel (monthly) $0 Cable $0 Other $0 Internet $0 Subtotals $0 Waste removal $0 Maintenance or repairs $0 LOANS Home telephone $0 Student loans $0 Cell phones $0 Loans from others (personal) $0 Subtotals $825 Credit card $0 Credit card $0 TRANSPORTATION Other $0 Vehicle #1 payment $0 Subtotals $0 Vehicle #2 payment $0 Public Transportation $0 TAXES Car insurance $0 Federal $0 License and Taxes $0 State $0 Fuel $125 Real Estate $0 Maintenance $0 Other $0 Car Replacement Fund $0 Subtotals $0 Subtotals $125 SAVINGS OR INVESTMENTS PERSONAL INSURANCE Retirement account $0 Homeowners Insurance $0 Investment account $0 Health Insurance $18 Education/School $0 Dental Insurance $10 Short-term savings/emergency $500 Life Insurance $0 Subtotals $500 Disability Insurance $0 Long Term Care Insurance $5 PETS Subtotals $33 Food $0 Medical $0 FOOD Grooming $0 Groceries $200 Toys $0 Dining out $150 Other $0 Other $0 Subtotals $0 Subtotals $350 GIFTS AND DONATIONS PERSONAL CARE Charity 1 $550 Medical/Dental (co-pays, prescriptions) $0 Charity 2 $0 Hair/nails $0 Subtotals $550 Clothing $200 Dry cleaning $0 OTHER Health club $12 Alimony payments $0 Organization dues or fees $0 Child support payments $0 Other $0 Payments on lien or judgment $0 Domestic Help $0 School Tuition $0 Professional Dues (Attorney, CPA) $0 Adult Education $0 Dependent/Child Care $0 Payments to support family $0 Subtotals $212 Subtotals $0