| Husband
|
Referred by
|
| Wife
|
Marital Status
|
| |
# of Dependants
|
| Social Security
Number(s) and/or Federal ID number (if any) |
| Husband |
Wife |
| Address for the
past two years: |
|
|
|
|
| All phone numbers
(home, work, pager, etc.) |
|
|
|
|
| Places of
Employment |
|
|
|
|
|
|
|
|
|
|
|
|
| Wages
received
|
| Child
Support/Alimony Received |
|
|
| Amount and type of
taxes due (if any) |
|
| If buying a home,
when did you buy it? |
|
| How long have you
lived in the state of Florida? |
|
|
Vehicle: Year, Model, amount of lien, mileage.
|
List
assets and estimated market value (based on amount for which
item could be sold at a garage sale,
for example: sofa and love
seat,
$150.00
|
| Have you received
any income other than wages in the past one year? If yes,
please state source and total amount: |
|
| Monthly
Income |
| Husband
|
Husband
|
| Wife
|
Wife
|
| Usual
monthly expenses: |
| Rent/Mortgage |
|
| Real Estate Taxes |
|
| Property Insurance |
|
| Electricity and heating fuel |
|
| Water & sewer |
|
| Telephone |
|
| Cell Phone |
|
| Cable |
|
| Home maintenance |
|
| Food |
|
| Clothing |
|
| Laundry and dry cleaning |
|
| Medical and dental expenses |
|
| Transportation (gas, repairs, etc.) |
|
| Recreation, entertainment |
|
| Charitable contributions |
|
| Insurance (Homeowners) |
|
| Insurance (Life) |
|
| Insurance (Health) |
|
| Insurance (Auto) |
|
| Insurance (Other) |
|
| Taxes |
|
| Alimony paid |
|
| Child Support Paid |
|
| Installment payments |
|
| Vehicle #1 |
|
| Vehicle #2 |
|
| Other |
|