Resource Family Financial Assessment
Form 04AF010E v.2 08/23/2012 Page 1 of 4
Applicant
Employment
Income
Gross monthly income Take-home monthly income
Other Income or Benefits
Source of income Gross monthly income Take-home income
List other income or benefits such as Social Security benefits, adoption assistance payments, foster
care payments, child support, Supplemental Nutrition Assistance Program (SNAP), or Temporary
Assistance for Needy Families (TANF).
Present employer's name Working days and hours
First name M.I. Last name
Applicant
Employment
Income
Gross monthly income Take-home monthly income
Present employer's name Working days and hours
First name M.I. Last name
Other Income or Benefits
List other income or benefits such as Social Security benefits, adoption assistance payments, foster
care payments, child support, Supplemental Nutrition Assistance Program (SNAP), or Temporary
Assistance for Needy Families (TANF).
Source of income Gross monthly income Take-home income
Form 04AF010E v.2 08/23/2012 Page 2 of 4
Source of income Gross monthly income Take-home income
Household Income
Household total monthly take-home income:
Number of persons supported, including foster children, when applicable:
Monthly Expenses
Mortgage, rent payment, or other housing expenses:
Child support total:
List each child for whom child support is owed and the amount owed for each:
Groceries:
Child care:
Medical expenses not covered by insurance:
Vehicle payments:
Vehicle 1
Vehicle 2
Vehicle 3
Utilities:
Auto maintenance:
Gasoline:
Gas or propane:
Water, sewage, or trash:
Electric:
Cable or satellite:
Phone:
Cell phone(s):
Internet:
Home:
Medical:
Insurance total:
Form 04AF010E v.2 08/23/2012 Page 3 of 4
Auto:
Life:
Clothing:
Charitable donations to church or other organizations:
Entertainment or recreation:
Student loans:
Credit cards:
List each card and average monthly payment for each:
Other recurring monthly expenses:
Itemize each expense and average monthly payment for each:
Total monthly expenses:
Have you filed for bankruptcy in the last ten years? Yes No
If yes, bankruptcy court case number:
Where was bankruptcy action filed?
Do you have pending tax liens? Yes No
If yes, where?
Yes No
Are you subject to any type of settlement agreement(s) that obligates you to make a
payment now or in the future?
Total monthly income:
Total monthly expenses:
Form 04AF010E v.2 08/23/2012 Page 4 of 4
Applicant signature Date
Applicant signature Date
Unsworn Declaration Under Penalty of Perjury
I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct to
the best of my information and belief.
(city)
Subscribed on this day of , 20 at
, (state) .
