DBHDS Financial Need for Housing Housing Initiatives for ...

DBHDS Financial Need Form for Housing

Housing Initiatives for Individuals in Settlement Agreement Population

NET MONTHLY INCOME SSI SSDI Employment Other income 1 ___________ Other income 2 ___________ TOTAL INCOME (A)

Individual's Name: __________________________________

If you refer an individual who currently leases his/her own unit for a housing resource, attach this form to the Housing Assessment and Referral Form. List current monthly income and expenses. Complete separate forms for each adult household member. If household members split rent and/or utilities, list the individual's share of these expenses. If family helps cover certain expenses each month, list the family's contribution as "other income."

FIXED MONTHLY EXPENSES Rent Electric Gas/Oil Water/Sewer Home Phone Cell Phone Internet Services Trash pickup Cable Medical Insurance Auto Insurance Life Insurance Renter's Insurance Child Support/Alimony Child Care Other TOTAL FIXED (B)

DEBT PAYMENTS Installment Loans Automobile loans Credit Card Credit Card Credit Card TOTAL DEBIT (C)

Alternative Resource* used to pay expense

(Please list below)

Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____

Yes _____ Yes _____ Yes _____ Yes _____ Yes _____

FLEXIBLE MONTHLY EXPENSES Savings Groceries Lunch (work/school) Eating Out Entertainment/Hobbies Laundry/Drycleaning Housecleaning Supplies Clothes/Personal Care Supplies Gasoline/Bus/Taxi Newspaper/Magazines Alcohol/Cigarettes Church/Charity Tuition/Books Barber/Beauty shop Auto Maintenance House Maintenance Doctor/ Dentist Pets Tolls/Parking Lottery/Bingo Lawn Care Maintenance/Repairs Other(funishings,copays,gifts) TOTAL FLEXIBLE (D)

Alternative Resource* used to pay expense

(Please list below)

Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ Yes _____

EXPENSES FIXED (B) DEBT (C ) FLEXIBLE(D) TOTAL EXPENSES (E)

Subtract Expenses from income (A-E): TOTAL INCOME (A) TOTAL EXPENSES (E ) DIFFERENCE +or-

List and quantify all alternative resources used to cover expenses above (e.g., food stamps, utility assistance, gifts/donations, transportation

subsidy, student aide etc.): Resource

Amount

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Form Date (7/2019)

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