Expense Breakdown Example, CWL-4611



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|EXPENSE BREAKDOWN EXAMPLE |

|(For Optional Use) |

|Michigan Department of Health and Human Services |

|Division of Child Welfare Licensing |

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|Please use monthly figures (optional form) |

|Mortgage/Rent |      |Dependent Care/ Child Care |      |Medical Insurance |      |

|Property Taxes |      |Donation/ Charity/ Tithing |      |Life Insurance |      |

|Homeowners/ Renters Insurance |      |Credit Cards |      |Prescriptions/ Medical Expenses |      |

|Heat/Utilities/Water/ Waste |      |Child Support |      |Health Club Memberships |      |

|Home Repairs (misc). |      |Allowance/Spending |      |Long Term Care |      |

|Household Supplies (hygiene, |      |Food/Groceries |      |Internet/TV |      |

|cleaning products etc.) | | | | | |

|Domestic Services (housekeeping/ |      |Gifts (birthdays/ holidays etc.) |      |Auto Maintenance/ Upkeep |      |

|lawn care etc.) | | | |(registration, license etc.) | |

|Auto Payment |      |Hobbies |      |Travel |      |

|Auto Insurance |      |Alimony |      |Subscriptions |      |

|Gas/Transportation Costs |      |Personal Care (haircut, nails etc.) |      |Savings/Investments |      |

|Second/Vacation Home Payment |      |Recreation Payments (RV, boat, ATV |      |Smoking |      |

| | |etc.) | | | |

|Home Equity Loans/ Personal Loans |      |Clothing |      |Phone/Cell Phones(s) |      |

|Other/Miscellaneous |      | | | | |

|Total: |      |Total: |      |Total: |      |

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|Grand Total: |      | |

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|The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, |

|color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. |

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