Qualifying Questionnaire

Client(s) Name:

Address:

City:

State:

Zip Code:

Phone:

Electricity:

Trash:

Doctors Co-Pay:

Work/School: Lunch

Sewer/Water:

Gas/Oil - Hm:

Food/Groceries:

Life Insurance:

Child Care:

Cable:

Dining Out:

Medications:

Car Insurance:

Tuition/School Fees:

Medical Equipment:

Gasoline:

Business Expenses/Union Dues:

TOTAL:

Gross/Month:

Total Expenses/Rent/Secured Payments:

Net Income/Month:

Income Left:

Deductions for Loans and Retirement:

Home Rent:

Auto Rent:

Other Rent:

TOTAL:

Mortgage 1:

Mortgage 2:

Auto 1:

Auto 2:

Stud. Loans:

Taxes:

Other:

Phone:

Cell:

Internet:

Entertainment:

Clothing:

Health Insurance:

Dental Insurance:

Dental Co-Pay:

Veterinary:

Clubs, Sports & Hobbies

Auto Expenses:

Taxi/Parking/Public Transportation:

Contribution

Child Support:

Beauty/Barber/Nails/Dry Cleaning:

Other (Holidays, Birthday, Cigarettes, etc.: