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2. Monthly Statement of Income and Expenses
4. First & Last Name: *
6. Reporting for the Month of:*

   Please list in the box the month that you are reporting on.

8. Who are you submitting this to?*
   -- Select One --Crystal KilgoreTracy DoyleDawn BlatzHollie OhnesorgeTonya England Lauren Gonzales

   Please indicate the name of the staff member who is requesting this information.

10. All Household Income Received for This Month
    Please answer for all that apply.

12. Family Support
14. Amount Received
15. Household Member Name Who Receives the Income:
16. How Often Paid (weekly, bi-weekly, monthly)
18. Friend Support
20. Amount Received
21. Household Member Name Who Receives the Income:
22. How Often Paid (weekly, bi-weekly, monthly)
24. Odd Jobs
26. Amount Received
27. Household Member Name Who Receives the Income:
28. How Often Paid (weekly, bi-weekly, monthly)
30. Temporary Work
32. Amount Received
33. Household Member Name Who Receives the Income:
34. How Often Paid (weekly, bi-weekly, monthly)
36. Child Support
38. Amount Received
39. Household Member Name Who Receives the Income:
40. How Often Paid (weekly, bi-weekly, monthly)
42. Food Stamps
44. Amount Received
45. Household Member Name Who Receives the Income:
46. How Often Paid (weekly, bi-weekly, monthly)
48. Collection of Cans for Cash
50. Amount Received
51. Household Member Name Who Receives the Income:
52. How Often Paid (weekly, bi-weekly, monthly)
54. Plasma Donations
56. Amount Received
57. Household Member Name Who Receives the Income:
58. How Often Paid (weekly, bi-weekly, monthly)
60. Other

    Please specify type.

61. Amount Received
62. Household Member Name Who Receives the Income:
63. How Often Paid (weekly, bi-weekly, monthly)
65. Monthly Expenses

    List who pays each item and how much each items is monthly. 

67. Rent (how much is your rent?)*
68. Rent (who pays your rent?):*
70. Electric (amount each month):*
71. Included in Your Rent?*

    1. Yes
    2. No
72. Paid by Whom?*
74. Gas (amount each month):*
75. Included in Your Rent?*

    1. Yes
    2. No
76. Paid by Whom?*
78. Water/Sewer/Trash (amount each month):*
79. Included in Your Rent?*

    1. Yes
    2. No
80. Paid by Whom?*
82. Food (who pays for your food?): *
83. Food (how much is your food?)*
85. Family Clothing (who pays for the clothing?):*
86. Family Clothing (how much is the clothing?)*
88. School Supplies (who pays for the school supplies?): *
89. School Supplies (how much are school supplies?)*
91. Cell Phone Bill or phone bill (who pays your phone bill?)*
92. Cell Phone Bill or phone bill (how much is your phone bill?)*
94. TV and/or Internet (who pays for your TV and/or internet?)*
95. TV and/or Internet (how much is your TV and/or Internet bill?)*
97. Medical/Dental Care (who pays this health care?):*
98. Medical/Dental Care (how much is your health care?)*
100. Medication & Prescriptions (who pays for your medication?):*
101. Medication & Prescriptions (how much are your medications?)*
103. Personal Care Items (who pays for your personal care items?):*

     (shampoo, toothpaste, etc.)

104. Personal Care Items (how much are your personal care items?)*
106. Transportation Expenses (who pays for your transportation?:*

     (bus pass, taxi, car payment, fuel, insurance)

107. Transportation (how much is your transportation?)*
109. Payment on other expenses not listed above (who pays & how much): *

     or Additional comments

110. Other Expenses (how much are your other expenses?)*
112. I live with the person who pay my expenses? *

     1. Yes
     2. No
114. Interested in finding work? IowaWORKS is located at 680 Main St 2nd Floor and specializes in helping you become work ready and finding a job that fits for you. You can also call them at 563-556-5800.
116. If you are interested in finding work, now is the time to enroll in the Family Self-Sufficiency (FSS) Program if you are not already a participant. You may qualify to earn money through our Next Level Savings Program! *

     I would like more information about FSS:

     1. Yes
     2. No
118. Other information I need to report to Housing:
120. 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. By completing the form below, I certify the information I supply is correct

     Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my
     knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete
     information may result in the termination of my lease agreement. I understand that I may be required to periodically update
     this information as requested by owner/agent.
     
     

122. Type Name as E-signature*
123. Date*
     Date
Leave This Blank:


125. Submit

* indicates a required field