Client Budget

Client Information
Check box if someone in your household receives:
Medicaid: Medicare: WIC:

Please complete the following using your average monthly expenditures.
Disregard any items that are not a regular monthly expense for your household.

Housing Expense

Utility Expenses
Food Expenses
Transportation Expenses
Medical/Health Expenses
Doctor/Dental Bills:

Insurance Expenses (if not out of check)
If not out of check:
Personal Expenses
If monthly
If you pay
Debt Expenses
Number of Credit Cards
Credit Card Payments
Student Loans
Other Debt Payments

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