AVERAGE PER CHECK	DEBTOR	SPOUSE
Select your pay-period interval:	Interval Weekly Bi-Weekly Twice per month Monthly	Interval Weekly Bi-Weekly Twice per month Monthly
Average minimun gross pay before deductions per paycheck (not per month):
Average estimated overtime pay per pay period:
AVERAGE PAYROLL DEDUCTION PER CHECK	DEBTOR	SPOUSE
Payroll taxes and social security:
Insurance (life/health/dental):
Union dues:
Manditory retirement:
Other deductions required by law:
GOVERNMENT PAYMENTS PER CHECK	DEBTOR	SPOUSE
Select pay-check interval:	Interval Weekly Bi-Weekly Twice per month Monthly	Interval Weekly Bi-Weekly Twice per month Monthly
Disability per check:
Worker's compensation per check:
Unemployment per check:
ALL OTHER NON-PAYCHECK INCOME PER MONTH	DEBTOR	SPOUSE
Self-employment:
Pension:
Retirement:
Alimony or spousal support received:
Child support:
Social security:
Public assistance:
Food stamps value:
Rents received:
Annuities:
Supplemental security income (SSI):
Trust payments:
Inheritance payments:
Other monthly income:
Total net after-tax income per month for each person:
Total net after-tax household income per month:
Name to include on printed report:
Date to include on printed report: