Coast u G ard Budget Form Mutual Assistance Page 1 of 3

Coast Guard Mutual Assistance

Budget Form

Page 1 of 3

Instructions: As you move though the form totals fields will update as you enter information. Complete each block that applies to your situation. Use actual figures when possible otherwise use your best estimates. Attach a LES or pay stub for each source of income. Include any anticipated changes in your income (longevity, step increase, advancement, bonus, etc.) Do not include allotment deductions from your pay. When finished, print the completed pages and return them, along with your application for assistance and supporting documents, to your local CGMA Representative.

Monthly Income

Applicant

Gross Income Less Deductions

Primary Income Current

Planned

Gross Income Less Deductions

Secondary Income Current

Taxes Garnishments Advances (Show End Date Below) Other Deductions (Explain Below) Total Deductions Net Income

Taxes Garnishments Advances (Show End Date Below) Other Deductions (Explain Below) Total Deductions Net Income

Spouse/Other Family Members

Gross Income Less Deductions

Primary Income Current

Planned

Gross Income Less Deductions

Secondary Income Current

Taxes Garnishments Advances (Show End Date Below) Other Deductions (Explain Below) Total Deductions

Taxes Garnishments Advances (Show End Date Below) Other Deductions (Explain Below) Total Deductions

Net Income

Net Income

Planned Planned

Other Income Current

Alimony (Received) Child Support (Received) Social Security Disability VA Public Assistance

Investment Income Rental Income Other Income (Explain Below) Total Other Income

Planned

Total Income

Total Gross Income Plus Other Income

Less Deductions

Current

Net Income

Planned

Comments:

CGMA Form 15 (Revised 02/08)



CGMA-HQ (800) 881-2462

Coast Guard Mutual Assistance

Budget Form

Page 2 of 3

Instructions: Complete each block that applies to your situation. Use actual figures when possible otherwise use your best estimates. Include any anticipated changes in your expenses. Do not include expenses in more than one category. Do not include expenses that are included as part of another payment.

Housing Expenses Current

Rent/Mortgage Electric Heating Oil/Natural Gas Water/Sewage/Garbage Homeowners/Renters Assn Fees Other (Explain Below) Total Housing Expenses

Transportation Expenses Current

Gasoline Repairs and Maintenance Tolls/Parking/Fees Inspections Other (Explain Below) Total Transportation Expenses

Monthly Expenses

Planned

Family Living Expenses Current

Food/Groceries/Household Items Clothing Child Care Barber/Beauty Shop Personal Care Items Telephone/Cell Phone/Pager Cable/Satellite TV

Internet Access Fees Laundry/Dry Cleaning

Planned Recreation/Entertainment

School Supplies and Expenses Newspapers/Magazines Work/School Lunches Medical/Dental Care Other (Explain Below) Total Family Living Expenses

Planned

Other Expenses Current

Alimony (Paid) Child Support (Paid) Charity Contributions Gifts/Holidays (Avg. Monthly Amt.) Pets/Vet/Kennel/Food/Misc. Organizations/Clubs Fees/Dues Property and Personal Taxes CDs/Tapes/Videos/DVDs Other (Explain Below) Total Other Expenses

Savings and Investments Current

Savings (Short Term) Savings (Long Term) Investments TSP/401k/403b etc. Other Investments Total Savings and Investments Comments:

Planned

Insurance (not included as part of other payments)

Current

Planned

Life

Heath Medical/Dental

Disability

Automobile

Homeowner/Renter

Other (Explain Below)

Total Insurance Expenses

Planned

Total Expenses and Expenditures Current Planned

Housing Family Living Transportation Insurance Other Expenses Savings and Investments Total Expenses

CGMA Form 15 (Revised 02/08)



CGMA-HQ (800) 881-2462

Coast Guard Mutual Assistance

Budget Form

Page 3 of 3

Instructions: Complete each block that applies to your situation. Use actual figures when possible otherwise use your best estimates. Installment Loans: Include credit card, automobile and other monthly loan payments. Do not include mortgage payments or other payments which have been included elsewhere. Assets/Savings: List all assets, indicate which assets are and are not readily available to use (due to fees, penalties, lost interest etc).

Installment Loans

Payee

Purpose of Loan

Date Incurred

Interest Rate

Original Amount

Balance Owed

Monthly Payment

Current

Planned

Total

Assets/Savings

Available Cash Checking Savings Emergency Funds Certificates of Deposit Christmas Clubs etc. Savings Bonds Stocks Bonds Mutual Funds Retirement(401k/IRA/TSP)

Education Accounts Real Estate/Property Other Assets

Not Available

Summary

Current

Net Income (Page 1)

Less: Expenses (Page 2) Installment Payments (Page 3)

Monthly Surplus or (Deficit)

Total Note: Indicate below why an asset is not available Comments:

Planed

CGMA Form 15 (Revised 02/08)



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