PORTLAND REFUGEE SUPPORT GROUP
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PRSG
Monthly/Biweekly Expense Report
*
Indicates required field
Client's Name
*
First
Last
Cell Phone Number
*
Type of Report
*
Monthly Report
Biweekly Report
Please fill out this form to the best of your ability. If an amount is $0 please place a 0 in the space provided.
EXPENSE
*
Expense Amount
Housing Rent/Mortgage
*
Natural Gas (for home)
*
Electric
*
Trash
*
Water
*
Car Payment
*
Car Insurance
*
Transportation (gas or public transit)
*
Health Insurance
*
Medical (medications, treatments, etc.)
*
Food
*
Consumable Household Goods (cleaning supplies, etc.)
*
Pets
*
Other Expenses - Please explain in detail.
*
Total Expense
*
INCOME
*
Income Amount
Earned Income (work)
*
TANF (Cash Assistance)
*
Food Stamps (SNAP)
*
Housing Assistance
*
SSI (disability)
*
Child Support
*
Gift Money
*
Scholarship from school
*
Social Security (Retirement)
*
Other Income - Please explain in detail.
*
Total Income
*
Expense - Income = (Please subtract)
*
By signing this form, I hereby agree that all information provided is true and accurate to the best of my knowledge. I also acknowledge that the information provided on this form can be used to determine eligibility for assistance.
PRSG Core Volunteer's Name
*
First
Last
Date (month/day/year)
*
Email
*
Cell Phone Number
*
Submit
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" or you see the message "
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