
                         [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__________|________|________|________|________|_________|     



