INCOME
ANNUAL AMOUNT
Put in the amount of your gross earnings from your paycheck(s), and other income, such as pension income, investment income, alimony & child support received, as well as gifts.
Salary and wages
Total from all sources
Bonuses, commissions, tips
Self-employment income
Interest and dividends
Include this only if the total is more than $200
Alimony/child support received
Total amount
Gifts received
Pension income
Social Security income
Public assistance, unemployment and/or disability benefits
Other income: _______________
All other income
TOTAL INCOME
Total the income amounts above.
OUTFLOW
Savings/investing
Whatever amount you are saving and investing. Include the amount you put into your 401(k), IRAs, and other retirement accounts.
Federal & state taxes
Enter the amount for federal and state taxes. Include Social Security, Medicare, and local tax. Use your pay stub, or use the amount from your last year's tax return if you're using Statement II and you don't expect many changes in your taxable income. Note: Due to your decrease in income, you may be able to subtract a little.
Mortgage or rent
What you pay, not including taxes and insurance. If your mortgage payment includes taxes and insurance, leave those lines blank below.
Home repair/maintenance
Any maintenance and repairs on your home or apartment, condo fees, etc.
Property taxes
Real estate (and in some states) personal property taxes
Disability Insurance
Include any insurance premiums deducted from your paycheck
Life insurance
Home/renter's insurance
Premium payments
Auto insurance
Credit card/loan payment
Loans other than your mortgage, including car loans and credit card payments
Utilities & telephone
Water, telephone, electricity, gas, garbage, sewer, etc.
Food (include dining out)
All food and restaurants
Clothing
All clothes
Grooming
Hair care, beauty supplies, etc.
Transportation
Gas for automobiles and other modes of transportation
Auto repair/maintenance
Major repairs, oil changes, new tires, etc.
Other transportation
Tolls, train fare, bus fare, etc.
Medical care
Medical and Dental expenses not covered by insurance, including health insurance premiums deducted from your paycheck and all other health insurance premiums.
Education
Tuition and fees, room and board, meal plans, etc.
Child care
All costs for babysitting and child care expenses
Alimony/child support
Amounts paid
Entertainment
Sporting events, hobbies, movies, etc.
Vacations
Including airplane fare
Gifts/charitable contributions
Gifts to charitable organizations, gifts to relatives and friends
Laundry/cleaning
Amount spent
Other: _____________________
All other items of outflow unique to your situation.
TOTAL OUTFLOW
Total the outflow amounts above.
NET CASH FLOW
Subtract outflow from income
Securities and advisory services are offered through LPL Financial (LPL), a registered investment advisor and broker-dealer (member FINRA/SIPC. Insurance products are offered through LPL or its licensed affiliates. Premier America Credit Union and Premier America Investment & Retirement Services are not registered as a broker-dealer or investment advisor. Registered representatives of LPL offer products and services using Premier America Investment & Retirement Services, and may also be employees of Premier America Credit Union. These products and services are being offered through LPL or its affiliates, which are separate entities from, and not affiliates of Premier America Credit Union or Premier America Investment & Retirement Services. CA Insurance License #0759204, TX Insurance License#1643255.
Securities and insurance offered through LPL or its affiliates are: