x-Expense Report-x

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 *

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 *

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

∙ Make sure you click the SUBMIT button well, until you see the confirmation message "Thank you. Your information has been submitted" or you see the message "Please correct the highlighted fields".