
                         [YEARLY SOURCES OF INCOME]


  EARNED INCOME        HUSBAND   WIFE    OTHER    TOTAL    MONTHLY 
|                    |        |        |        |        |         |
| Salary and wages___|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Self-employment____|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Bonus______________|________|________|________|________|_________|
|                    |        |        |        |        |         |
| INVESTMENT INCOME__|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Interest on savings|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Interest from bonds|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Dividends__________|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Rental income______|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Trust income_______|________|________|________|________|_________|
|                    |        |        |        |        |         |
| PENSIONS/ANNUITIES_|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Social Security____|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Employers's pension|________|________|________|________|_________|
|                    |        |        |        |        |         |
| IRA________________|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Other______________|________|________|________|________|_________|
|                    |        |        |        |        |         |
| OTHER INCOME_______|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Gifts              |        |        |        |        |         |
| Unemployment,      |        |        |        |        |         |
| disability insur.__|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Alimony/child sppt.|________|________|________|________|_________|
|                    |        |        |        |        |         |
| Other______________|________|________|________|________|_________|
|                    |        |        |        |        |         |
| GROSS INCOME_______|________|________|________|________|_________|
====================================================================
                              DEDUCTIONS
====================================================================
   EARNED INCOME       HUSBAND   WIFE    OTHER    TOTAL    MONTHLY 
|                    |        |        |        |        |         |
|TAXES_______________|________|________|________|________|_________|
|                    |        |        |        |        |         |
|Federal_____________|________|________|________|________|_________|
|                    |        |        |        |        |         |
|State_______________|________|________|________|________|_________|
|                    |        |        |        |        |         |
|Local_______________|________|________|________|________|_________|
|                    |        |        |        |        |         |
|SOCIAL SECURITY_____|________|________|________|________|_________|
|                    |        |        |        |        |         |
|CONTRIBUTION TO     |        |        |        |        |         |
|BENEFITS____________|________|________|________|________|_________|
|                    |        |        |        |        |         |
|OTHER_______________|________|________|________|________|_________|
|                    |        |        |        |        |         |
|NET INCOME__________|________|________|________|________|_________|


