INCOME INFORMATION. Yes No MONTHLY GROSS INCOME I am self employed. (List nature of self employment) (use net income from business) $ I have a job and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or other compensation: List the businesses and/or companies that pay you: Name of Employer 1) 2) 3) $ $ $ I receive cash contributions of gifts including rent or utility payments, on an ongoing basis from persons not living with me. $ I receive unemployment benefits. $ I receive Veteran’s benefits/income. Administration, GI Xxxx, or National Guard/Military $ I receive periodic social security payments. $ The household receives unearned income from family members age 17 or under (example: Social Security, Trust Fund disbursements, etc.). $ I receive Supplemental Security Income (SSI). $ I receive disability or death benefits other than Social Security. $ I receive Public Assistance Income (examples: TANF, AFDC) $ I am entitled to receive child support payments. I am currently receiving child support payments. If yes, from how many persons do you receive support? I am currently making efforts to collect child support owed to me. List efforts being made to collect child support: $ $ I receive alimony/spousal support payments $ I receive periodic payments from trusts, annuities, inheritance, retirement funds or pensions, insurance policies, or lottery winnings. If yes, list sources: 1) 2) $ $ I receive income from real or personal property. (use net earned income) $ Student financial aid (public or private, not including student loans) Subtract cost of tuition from Aid received $ Asset information YES NO INTEREST RATE CASH VALUE I have a checking account(s). If yes, list bank(s) 1) 2) % % $ $ I have a savings account(s) If yes, list bank(s) 1) 2) % % $ $ I have a revocable trust(s) If yes, list bank(s) 1) % $ I own real estate. If yes, provide description: $ I own stocks, bonds, or Treasury Bills If yes, list sources/bank names 1) 2) 3) % % % $ $ $ I have Certificates of Deposit (CD) or Money Market Account(s). If yes, list sources/bank names 1) 2) 3) % % % $ $ $ I have an XXX/Lump Sum Pension/Xxxxx Account/401K. If yes, list bank(s) 1) 2) % % $ $ I have a whole life insurance policy. If yes, how many policies $ I have cash on hand. $ I have disposed of assets (i.e. gave away money/assets) for less than the fair market value in the past 2 years. If yes, list items and date disposed: 1) 2) $ $ STUDENT STATUS YES NO Does the household consist of all persons wh...
INCOME INFORMATION. 8. Enter the total family size from your current federal tax return This includes you, your spouse if filing jointly, and all dependents listed on your Federal 1040, including qualifying relatives.
INCOME INFORMATION. Yes No MONTHLY GROSS INCOME I am self employed. (List nature of self employment) (use net income from business) $ I have a job and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or other compensation: List the businesses and/or companies that pay you: Name of Employer 1) $
INCOME INFORMATION. Monthly Income Sources Applicant Co-Applicant Combined Monthly Income Employment $ $ $ Social Security $ $ $ Disability $ $ $ Unemployment $ $ $ Spousal/Child Support $ $ $ Rental Property $ $ $ Investment Income $ $ $ Other: $ $ $ $ $ $ $ $ $ Total Combined Monthly Income $ UNEMPLOYMENT: If you do not have monthly income, please explain how you take care of your monthly expenses.
INCOME INFORMATION. Do you receive any of the following? Indicate if received money from: Amount • Supplemental Security Income (SSI) Benefits Yes No • Social Security Disability Benefits Yes No • Social Security Dependent Benefits Yes No • Social Security Survivor’s Benefits Yes No • Social Security Retirement Benefits Yes No • NYS Disability Yes No How do you see the trust money being spent? Referral Source: Name email:
INCOME INFORMATION. 8. Enter the total number of claimed exemptions from your current federal tax return (Line 6d of the 1040 or 1040A, or line 5 of the 1040EZ) .........................................................
INCOME INFORMATION. Everyone must answer all questions in this section. □ □ Did you receive any unemployment benefits during the year? □ □ Did you receive any disability income during the year? □ □ Did you receive any Social Security benefits during the year? □ □ Did you receive any income in 2017 not reported on a tax form and not written in the organizer you are providing to me? If so, how much? $ and from what source? □ □ Did any of your life insurance policies mature, or did you surrender any policies? □ □ Did you receive any awards, prizes, hobby income, gambling or lottery winnings? □ □ Do you own any savings bonds that matured in 2017? (Issued in 1987) □ □ Did you engage in any bartering transactions in 2017? □ □ Do you know why the Secret Service was originally established to do? □ □ Did you have any foreign income and/or pay any foreign taxes during the year, directly or indirectly, such as from investment accounts, partnerships or a foreign employer? □ □ Did you receive any income in 2017 from property sold prior to 2017? (ie: installment sale proceeds) □ □ Did you receive any property tax refunds or credits in 2017? If so, what was the amount? $
INCOME INFORMATION. Marital Status: Yourself Spouse Job title/occupation: Employer: How long there: Payroll address: City, ST Zip Payroll office phone #: Date next paycheck expected CHILDREN & STEP-CHILDREN Name Age Relationship Does child live with you? Child support $ paid/received EXPECTED CHANGES IN INCOME: Describe when & why: INCOME & EXPENSES Please note that under current bankruptcy laws, a debtor must provide the previous seven (7) months of household income in order to evaluate a case for means testing purposes. Therefore, please provide copies of your paystubs for the past seven (7) months. If you are self employed, please provide documentation of your income from the past seven (7) months. Additionally, if you have other sources of income, please provide documentation of that income as well.
INCOME INFORMATION. Homebuyer has submitted an Applicant Affidavit and additional information verifying income eligibility to City and Participant prior to execution of this Agreement. Homebuyer represents, warrants, and declares under penalty of perjury to City that all information Homebuyer has provided and will provide in the future to City is and will be true, correct and complete, and that there are no material omissions or misrepresentations in such information. Homebuyer acknowledges that City is relying upon Homebuyer’s representations that Homebuyer is an Eligible Household as set forth in the Guidelines, and that City would not have entered into this Agreement if Homebuyer did not so qualify.
INCOME INFORMATION. Title 23 of the PA Consolidated statutes requires a guideline amount of support to be established. Please provide the following income information for both parties: Plaintiff: $ (weekly, biweekly, monthly) gross income. (circle one) Defendant: $ (weekly, biweekly, monthly) gross income. (circle one) NOTE: BY SIGNING THE ABOVE IT’S UNDERSTOOD THAT YOU AGREE TO THE CURRENT SUPPORT OBLIGATION AND THAT THIS SUPPORT OBLIGATION MAY NOT BE MODIFIED OR REVIEWED UNLESS THERE IS WRITTEN CONSENT FROM BOTH PARTIES, A SIGNIFICANT CHANGE IN CIRCUMSTANCE, OR IT HAS BEEN AT LEAST 3 YEARS. YOU ALSO AGREE TO THE AMOUNT WITHOUT A CONFERENCE. DRS WILL COMPLETE A GUIDELINE CALCULATION OF THIS CASE BASED ON THE INCOMES PROVIDED ABOVE. YOU ARE ABLE TO VERIFY AN ESTIMATED GUIDELINE SUPPORT AMOUNT BY USING THE SUPPORT ESTIMATOR ON THE CHILD SUPPORT WEBSITE (xxx.xxxxxxxxxxxx.xxxxx.xx.xx). DATE PLAINTIFF SIGNATURE PHONE # DATE DEFENDANT SIGNATURE PHONE # DRS Personnel accepting agreement:
