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Monthly Statement of Income and Expenses

  1. Monthly Expenses and Income Form
    If the question does not apply please indicate N/A
  2. By completing the form below, I certify the information I supply is correct
  3. Please list in the box the month that you are reporting on.
  4. Include cash payments, odd jobs, plasma donation, temporary work, collection of cans for cash, cash gifts from friends or relatives or anything else that is provided for you.
  5. How do you earn or receive cash or pocket change – you must list the cash value.
  6. Current Monthly Expenses:
  7. Do you currently live with the person paying the rent/utilities?
  8. Do you receive Food Stamps?*
  9. Toothpaste, Shampoo, Etc.
  10. Do you smoke?*
  11. Do you use liquor/beer/wine products?*
  12. Do you own a car?*
  13. I am currently registered with Iowa Workforce Development Center?*
  14. WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any Department or Agency of the U.S. as to any other matter within its jurisdiction.
  15. Leave This Blank:

  16. This field is not part of the form submission.