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Budget & Financial Need Form
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Steps
1.
Customer Information
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2.
Monthly Revenue / Income
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3.
Monthly Expenses
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4.
Totals
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5.
Signature & Agreement
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Customer Information
Customer Name
Date
Date
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Monthly Revenue / Income
A. Family Income
1. Wages (Self)
2. Wages (Spouse)
3. Self-Employment
Total Income
B. Financial Assistance
1. Educational Assistance (Pell, etc.)
2. Veterans Affairs Benefits
3. Housing Assistance
4. Public Assistance
5. Unemployment
6. Food Stamps
7. Child Support
8. Other Assistance
Total Assistance
C. Other Income
1. Interest
2. Dividends
3. Rental Income
4. Retirement
5. Social Security
6. Other
Total Other Income
Total All Income
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Monthly Expenses
A. Residential Expenses
1. Rent
2. Mortgage
3. Electricity
4. Gas
5. Water / Garbage
6. Telephone
7. Cable / Subscriptions
8. Internet
9. Household Items
Total Residential Expenses
B. Other Expenses
1. Food
Vehicle Expenses
2. Car Payment
a) Gas / Oil
b) Insurance
3. Clothing
4. Child Care
5. Medical & Insurance
Debt Expenses
6. Debt Payments
a) Credit Cards
b) Other
Other
Please list all other expenses.
Total Other Expenses
Total All Expenses
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Totals
Total All Income
Total All Expenses
Net Monthly Financial Need
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Signature & Agreement
Truth of Information Provided
I, the undersigned, do hereby certify that the above information provided is true and correct. I further certify that should any of the information provided change, that it will be my sole responsibility to inform my Career Coach.
Acknowledgement of Termination Risk Upon False Information
I also understand and agree that should any of the information provided be determined to have been falsified, that I may be terminated from my respective program and that I may be liable to repay funds for services received.
Requirements for Financial Assistance
I understand that receipt of financial assistance from Workforce Solutions of West Central Texas is contingent upon my active and continued participation in the agreed upon program activities. I also understand that the amount of financial assistance that I receive may be reduced or increased due to my participation and/or changes in my financial need. I further understand that continued receipt of financial assistance is contingent upon Workforce Solutions of West Central Texas having adequate support service funds available to provide such services.
Electronic Signature Agreement
*
By checking the "I agree" box below, you agree and acknowledge that: your application will not be signed in the sense of a traditional paper document, by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, you may still be required to provide a traditional signature at a later date.
I agree
Customer Signature
*
Date
*
Date
Workforce Staff Signature
Date
*
Date
Change of Information
I attest that no information has changed in the last month.
Customer Signature
Date
Date
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice).
Funding
Public Information
This service is funded in whole or in part with federal funds. More detailed information is located on the Public Information page on the Board’s website.
En Español
Este documento contiene información importante sobre los requisitos, los derechos, las determinaciones y las responsabilidades del acceso a los servicios del sistema de la fuerza laboral. Hay disponibles servicios de idioma, incluida la interpretación y la traducción de documentos, sin ningún costo y a solicitud.
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