BENEVOLENT FUND (BUDGET ASSESSMENT WORKSHEET)
MONTHLY INCOME & EXPENSES
GROSS INCOME PER
MONTH
Salary
Interest
Dividends
Other
Entertainment &
Recreation
Eating Out
Baby Sitters
Activities/Trips
Vacation
Other
LESS
Tithe
Clothing
Tax
Savings
NET SPENDABLE INCOME
Housing
Mortgage/Rent
Insurance
Taxes
Electricity
Gas
Water
Sanitation
Telephone
Maintenance
Other
Medical Expense
Doctor
Dentist
Drugs
Other
Food
Automobile (s)
Payments
Gas & Oil
Insurance
License/Taxes
Maint./Repair
Insurance
Life
Medical
Other
Miscellaneous
Toiletry, Cosmetics
Beauty, barber
Laundry, cleaning
Allowances, lunches
Subscriptions
Gifts (incl. Christmas)
Cash
Other
School/Childcare
Tuition
Materials
Transportation
Day Care
Investments
TOTAL EXPENSES
INCOME VS. EXPENSES
Debts
Credit Card
Loans & Notes
Other
Net Spendable Income
Less Expenses
Unallocated Surplus Income
I certify the above information to be accurate and complete
______________________________
Applicant Signature
Revised 05/19/2010
OCBF Staff Forms: Benevolent Application
_________________________
Date