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STATE OF WISCONSIN

DEPARTMENT OF CHILDREN AND FAMILIES

Division of Family and Economic Security

WBW

HOUSEHOLD BUDGET WORKSHEET FOR WISCONSIN WORKS (W-2)

|Name: ______________________________________ | | | |Household Size: ________ |

|RFA/Case Number: ____________________________ | | | |Date: ___/___/___ | |

|Resource Specialist: | | | | | |

|____________________________ | | | | | |

| | |$__________ | | |

|Self-Employment Income |+ $__________ | |Life Insurance Cash Value | |+ $__________ |

|Unemployment Insurance |+ $__________ | |Certificates of Deposit |+ $__________ |

|Child Support |+ $__________ |Stocks or Bonds | |+ $__________ |

|Alimony |+ $__________ | |Land/Buildings other than | | |

|Social Security (SSI/SSDI) |+ $__________ | |Homestead | |+ $__________ |

|Veterans |+ $__________ |Farm Equipment/Livestock | |+ $__________ |

|Railroad Retirement |+ $__________ | |Notes/Contracts of Value | |+ $__________ |

|Sick or Disability Payments |+ $__________ |Retirement Accounts | |+ $__________ |

|School Grants or Loans |+ $__________ | |Burial Accounts | |+ $__________ |

|Money received regularly | | | |Own Land Contract/Mortgage |+ $__________ |

|from relatives, friends, etc. |+ $__________ | |Trust Funds | |+ $__________ |

|Charitable Organizations |+ $__________ |Other | |+ $__________ |

|Dividends/Interest |+ $__________ | |Total Assets | |= $__________ |

|FoodShare |+| | | |

| |$| | | |

| |_| | | |

| |_| | | |

| |_| | | |

| |_| | | |

| |_| | | |

| |_| | | |

| |_| | | |

| |_| | | |

| |_| | | |

| |_| | | |

| | | | | | |

|Real Estate Taxes |+ $__________ |(Fair Mkt. - Loan Value) | | |

|Home Owner’s Insurance |+ $__________ |Vehicle #2 Equity | |+ $__________ |

|Utilities |+ $__________ |(Fair Mkt. - Loan Value) | | |

|Uniform Expense |+ $__________ | |Vehicle #3 Equity | |+ $__________ |

|Child Care Expenses |+ $__________ |(Fair Mkt. - Loan Value) | | |

|Vehicle Payment |+ $__________ | |Total Vehicle Equity | |= $__________ |

Vehicle Maintenance |+ $__________ | | | | | | | |Vehicle Insurance |+ $__________ | | | | | | | |Public Transportation |+ $__________ | | | | | | | |Child Support |+ $__________ | | | | | | | |Food |+ $__________ | | | | | | | |Clothing |+ $__________ | | | | | | | |Personal Care |+ $__________ | | | | | | | |Health Insurance |+ $__________ | | | | | | | |Medical Expenses |+ $__________ | | | | | | | |Personal Loans |+ $__________ | | | | | | | |Life Insurance |+ $__________ | | | | | | | |Education |+ $__________ | | | | | | | |Entertainment |+ $__________ | | | | | | | |Total Expenses |= $__________ | | | | | | | |

NET HOUSEHOLD BUDGET: $__________

(Income Minus Expenses)

DWSP-2443 (R. 02/2009)

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