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Monthly Income From All Sources

1 2 3 4
Amount of Period covered Amount
Source of Income each payment by each payment per month

A. Wages or Salary

Job 1:
______________
Gross pay, including overtime: $___________ _____________
Subtract: ___________
Federal taxes ___________
State taxes ___________
Social Security (FICA) ___________
Union dues ___________
Insurance payments ___________
Child support wage withholding ___________
Other mandatory deductions (specify):
___________________________ ____________
Subtotal $___________ _____________
____________

Job 2:
______________
Gross pay, including overtime: $___________ _____________
Subtract: ___________
Federal taxes ___________
State taxes ___________
Social Security (FICA) ___________
Union dues ___________
Insurance payments ___________
Child support wage withholding ___________
Other mandatory deductions (specify):
___________________________ ____________
Subtotal $___________ _____________
____________

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Monthly Income From All Sources (cont'd)
1 2 3 4
Amount of Period covered Amount
Source of Income each payment by each payment per month

Job 3:
______________
Gross pay, including overtime: $___________ _____________
Subtract: ___________
Federal taxes ___________
State taxes ___________
Social Security (FICA) ___________
Union dues ___________
Insurance payments ___________
Child support wage withholding ___________
Other mandatory deductions (specify):
___________________________ ____________
Subtotal $___________ _____________
____________

B. Self-Employment Income

Job 1:
______________
Gross pay, including overtime: $___________ _____________
Subtract: ___________
Federal taxes ___________
State taxes ___________
Self-employment taxes ___________
Other mandatory deductions (specify):__________
___________________________ ____________
Subtotal $___________ _____________
____________

Job 2:
______________
Gross pay, including overtime: $___________ _____________
Subtract: ___________
Federal taxes ___________
State taxes ___________
Self-employment taxes ___________
Other mandatory deductions (specify):__________
___________________________ ____________

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Subtotal $___________ _____________
____________

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Monthly Income From All Sources (cont'd)
1 2 3 4
Amount of Period covered Amount
Source of Income each payment by each payment per month

C. Other Sources
Bonuses ______________________________________ ___________ _____________ ____________
Dividends and interest ___________________________ ____________ _____________ ____________
Rent, lease, or license income _____________________ ____________ _____________ ____________
Royalties ______________________________________ ____________ _____________ ____________
Note or trust income _____________________________ ____________ _____________ ____________
Alimony or child support you receive ________________ ____________ _____________ ____________
Pension or retirement income _____________________ ____________ _____________ ____________
Social Security _________________________________ ____________ _____________ ____________
Other public assistance __________________________ ____________ _____________ ____________
Other (specify):_________________________________ ____________ _____________ ____________
_____________________________________________ ____________ _____________ ____________
_____________________________________________ ____________ _____________ ____________
_____________________________________________ ____________ _____________ ____________
_____________________________________________ ____________ _____________ ____________
Total monthly income $__________

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