Date:
Carpenter Place
Financial Evaluation
Carpenter Place office use only
Resident Name: ______________________________________________________
Total Account Balance: ___________________
Approved account adjustment: ______________________________________________
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Instructions: Please complete the following information and return within 10 days of receipt.
Responsible Party: _________________________ Spouses Name: _________________
Employer: ________________________________ Spouse’s Employer: _____________
Length of Employment: _____________________ Length of Employment: _________
Income from most recent Federal Income Tax (total of all W-2 forms): $_____________
Number of dependents claimed on Federal Income tax Form: ______________________
Assets: Estimated Value: Unpaid Balance:
Residence $_______________________ $______________________
Vehicles $_______________________ $______________________
Farm $_______________________ $______________________
Business $_______________________ $______________________
Rental Prop. $_______________________ $______________________
Other $_______________________ $______________________
Other $_______________________ $______________________
Other Assets:
Financial Institution: ________________________________________________
Address: _________________________________________________________
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Checking Account Balance: ___________________
Savings Account Balance: ___________________
Other investments: ___________________
Monthly Income: Please indicate ALL sources of income.
Responsible Party’s Income: ________________________
Spouse’s Income: _________________________
Unemployment Income: ________________________
Child Support: _________________________
Disability Income: _________________________
Other Income: _________________________
Total GROSS Monthly Income: _________________________
Total NET Monthly Income: *1______________
Monthly Expenses: Please indicate average expenses for the following.
Groceries: _________________________
Utilities: _________________________
Gasoline: _________________________
Child Care: _________________________
Telephone: _________________________
Cable: _________________________
Clothing: _________________________
Other: _________________________
Monthly Expenses (subtotal) *2_______________
Creditors: Please list Creditor’s name and ALL monthly payments>
Whom: Unpaid Balances: Monthly payments:
Mortgage/Rent: _________________ _________________ _______________
Medical- Hospital: _________________ _________________ _______________
Doctor: _________________ _________________ _______________
Doctor: _________________ _________________ _______________
Automobile Loan: _________________ _________________ _______________
Insurance- _________________ _________________ _______________
Auto: _________________ _________________ _______________
Health: _________________ _________________ _______________
Life: _________________ _________________ _______________
Other: _________________ _________________ _______________
School Loans: _________________ _________________ _______________
Other Loans: _________________ _________________ _______________
Credit Cards: Amount Owed: Monthly Payment:
Visa ________________________ _______________
MasterCard ________________________ _______________
Discover ________________________ _______________
Depart.Store ________________________ _______________
Other ________________________ _______________
Other ________________________ _______________
Other ________________________ _______________
Monthly Payments (subtotal): *3___________________
Total Monthly Expenses (*2 +*3) *4______________
Income less Expenses (*1-*4) ________________
Please provide: A written explanation of your current financial situation.
Copies of the past 3 check stubs and a copy of all W2’s.
This information will be used to reach a reasonable determination regarding your account.
If you need additional space, please use the back of this form or additional pages provided.
Comments: ______________________________________________________________
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I certify all information is true and correct to the best of my knowledge. I understand the information is to be used to ascertain my ability to pay for services provided by Maude Carpenter Children’s Home. I hereby grant permission to Carpenter Place, to investigate the information contained herein.
Signature: _______________________ Date ___________
2/15/06
