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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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