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CLAIM FOR UNDUE HARDSHIP EXEMPTION - INCOME AND EXPENSE WORKSHEET

Name:_______________________________ Date:_______________

Creditor Name:__________________________________

UNDUE HARDSHIP CLAIM Amount of Garnishment: _____________________

Total Family Members: _____________ # of Children _____ Ages: ___________________

Bank account balances: Checking: ________________ Savings: _____________________

Weekly income after taxes: _________________ x 4.3 = ________________________

Biweekly income after taxes:_________________ x 2.15 = ______________________

Semi-monthly income after taxes: __________________ x 2 = ___________________

Monthly income after taxes: _______________________

Other Sources of Income: _______________________

Child Support Income: _______________________

Total Monthly Income: _______________________

Housing Expenses:

Housing/rent/mortgage: ___________________

Electricity ___________________

Natural gas ___________________

Water and Trash ___________________

Telephone ___________________

Other ___________________

Food:

Food: ___________________

School Lunches: ___________________

Baby Milk: ___________________

Clothing:

Clothing: ___________________

Laundry: ___________________

Transportation:

Car Payment: ___________________

Car Insurance: ___________________

Gas: ___________________

Bus: ___________________

Other: ___________________

TOTAL EXPENSES: ___________________

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