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<html>
<head>
<title>CCCS of Central New Jersey</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
<meta name="author" content="Pat Schrader, www.patschrader.com">
</head>
<body bgcolor="#FFFFFF">
<table border="0" cellspacing="0" cellpadding="0" width="600">
<tr>
<td colspan="5" align="left" valign="top"><a href="../index.htm"><img src="../99images/mainbanr.gif" width="600" height="72" alt="Consumer Credit Counseling Service" border="0"></a></td>
</tr>
<tr valign="bottom">
<td align="right"><font face="Arial, Helvetica, sans-serif" size="3"><b><br>
<font color="#17551D">CCCS</font></b></font></td>
<td><img src="../99images/pxspace.gif" width="17" height="1"></td>
<td colspan="3" align="left"><font face="Arial, Helvetica, sans-serif" size="2"><br>
<font color="#17551D"><a name="top"></a>A Service of Family Guidance Center
Corporation</font></font></td>
</tr>
<tr height="17">
<td align="left" valign="bottom" colspan="2" height="17"><br>
<img src="../99images/horzrule.gif" width="80" height="2"></td>
<td valign="top" align="left" width="240"><img src="../99images/pxspace.gif" width="240" height="1"></td>
<td height="17"> </td>
<td height="17" width="240"><img src="../99images/pxspace.gif" width="240" height="1"></td>
</tr>
<tr height="17">
<td align="right" valign="top" bgcolor="#FFFFFF" height="17" width="72"><font face="Arial, Helvetica, sans-serif" size="1"><b><img src="../99images/pxspace.gif" width="72" height="1">
</b></font></td>
<td rowspan="3" align="center" valign="top" height="17"><img src="../99images/vertrule.gif" width="2" height="800"></td>
<td valign="top" align="left" bgcolor="#330033" width="240">
<div align="center"><font size="2" face="Arial, Helvetica, sans-serif" color="#FFFFFF"><b>Personal
Information</b></font></div>
</td>
<td height="17"><img src="../99images/pxspace.gif" width="17" height="1"></td>
<td bgcolor="#330033" height="17" width="240">
<div align="center"><font face="Arial, Helvetica, sans-serif" size="2" color="#FFFFFF"><b>Monthly
Budget Information</b></font></div>
</td>
</tr>
<tr>
<td align="right" valign="top" bgcolor="#FFFFFF" width="72"> <p><font size="1" face="Arial, Helvetica, sans-serif"><font color="#FF0000"><b>Application
Instructions</b></font><br>
<br>
Please print out this form and fill in the information as completely as
possible. <br>
<br>
Call our office at 609-586-2574</font></p>
<p><font size="1" face="Arial, Helvetica, sans-serif"> if you have any questions.
<br>
<br>
You may fax the application to 609-586-4759</font></p>
<p><font size="1" face="Arial, Helvetica, sans-serif"> or bring it with
you for your appointment.<br>
<br>
You can mail the application to:<br>
CCCS of<br>
Central <br>
New Jersey<br>
1931 Nottingham Way.<br>
Hamilton , NJ<br>
08619</font><br>
</p>
<td valign="top" align="left" width="240"><font face="Arial, Helvetica, sans-serif" size="1"> <br>
<br>
</font> <img src="../99images/horzlin2.gif" width="237" height="3"><br>
<font face="Arial, Helvetica, sans-serif" size="1"> Name<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font> <img src="../99images/horzlin2.gif" width="237" height="3"><br>
<font face="Arial, Helvetica, sans-serif" size="1"> Spouse's Name <br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font> <img src="../99images/horzlin2.gif" width="237" height="3"><br>
<font face="Arial, Helvetica, sans-serif" size="1"> Address<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font> <img src="../99images/horzlin2.gif" width="237" height="3"><br>
<font face="Arial, Helvetica, sans-serif" size="1"> Address<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font> <img src="../99images/horzlin2.gif" width="237" height="3"><br>
<font face="Arial, Helvetica, sans-serif" size="1"> City<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font> <img src="../99images/horzlin2.gif" width="237" height="3"><br>
<font face="Arial, Helvetica, sans-serif" size="1"> State and Zip Code<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font> <img src="../99images/horzlin2.gif" width="237" height="3"><br>
<font face="Arial, Helvetica, sans-serif" size="1"> Date of Birth</font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font><font face="Arial, Helvetica, sans-serif" size="3"> </font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3"><br>
</font> <font size="1" face="Arial, Helvetica, sans-serif"> Spouse's Date
of Birth<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3"><br>
</font> <font size="1" face="Arial, Helvetica, sans-serif">Home Telephone<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3"><br>
</font> <font size="1" face="Arial, Helvetica, sans-serif"> Work Telephone<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3"><br>
</font> <font size="1" face="Arial, Helvetica, sans-serif"> Spouse's Telephone<br>
</font> <font face="Arial, Helvetica, sans-serif" size="3"> </font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3"><br>
</font> <font size="1" face="Arial, Helvetica, sans-serif"> Social Security
Number <br>
<font size="3"> </font></font><font face="Arial, Helvetica, sans-serif" size="3"> </font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3"><br>
</font> <font size="1" face="Arial, Helvetica, sans-serif">Spouse's Social
Security Number</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000"><br>
<br>
<br>
</font>
<table width="100%" border="0" cellspacing="0" cellpadding="0" bgcolor="#000000" height="17">
<tr bgcolor="#330033">
<td>
<div align="center"><font face="Arial, Helvetica, sans-serif" size="2" color="#FFFFFF"><b>Creditor
Information</b></font></div>
</td>
</tr>
</table>
<p><font face="Arial, Helvetica, sans-serif" size="1" color="#000000">(Use
separate sheet if more space is needed and add to this application.)<br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">Creditor
Name<br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">
Account #<br>
</font> <font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">
Balance</font><font face="Arial, Helvetica, sans-serif" size="1" color="#000000"><br>
</font> <font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">Creditor
Name<br>
</font> <font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">
Account #<br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">
Balance</font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">Creditor
Name<br>
</font> <font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">
Account #<br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">
Balance</font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">Creditor
Name<br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">
Account #<br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
</font> <font face="Arial, Helvetica, sans-serif" size="1"><img src="../99images/horzlin2.gif" width="237" height="3">
</font> <font face="Arial, Helvetica, sans-serif" size="1" color="#000000">
Balance</font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
Creditor Name<br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
Account #<br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
Balance<br>
<br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"><br>
Creditor Name<br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
Account #<br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> Balance<br>
<br>
</font><font face="Arial, Helvetica, sans-serif" size="1"><br>
</font> </p>
</td>
<td> </td>
<td align="left" valign="top" width="240"> <font face="Arial, Helvetica, sans-serif" size="1"> <br>
</font><font face="Arial, Helvetica, sans-serif" size="1"><br>
<img src="../99images/horzlin2.gif" width="237" height="3"><br>
Net Income Applicant <br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
Net Income Spouse<br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
Other Income<br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
TOTAL INCOME<br></font>
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="middle" align="left">
<td width="38%" bgcolor="#C9D3AE"><font face="Arial, Helvetica, sans-serif" size="1"><b><font color="#FF0033">Expenses</font></b><br>
</font></td>
<td width="31%" bgcolor="#C9D3AE" height="14"> </td>
<td width="31%" bgcolor="#C9D3AE"><font face="Arial, Helvetica, sans-serif" size="1" color="#CC0033"><b>Sub-total</b></font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Housing
</b> </font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Rent/Mortgage</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Second
Mortgage</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Insurance</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Utilities</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Telephone</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" height="10"><font face="Arial, Helvetica, sans-serif" size="1">Maintenance</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%" height="10"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Food</b><br>
</font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Groceries</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">At
Work/School</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" height="9" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Insurance</b><br>
</font></td>
<td width="31%" height="14" bgcolor="#FFFFCC"> </td>
<td width="31%" height="9" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Life</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Health</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Transportation</b></font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Auto
Payment</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" height="13"><font face="Arial, Helvetica, sans-serif" size="1">Auto
Insurance</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%" height="13"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" height="13"><font face="Arial, Helvetica, sans-serif" size="1">Gas/Oil/Lube</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%" height="13"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Tolls/Parking</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Bus/Ride
Fare</font> </td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Maintenance</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Child
Care</b></font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Day
Care/Babysitter</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Child
Allowance</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Support/Alimony</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Education</b></font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Student
Loans</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Tuition/Supplies</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Lessons
(Music)</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" height="14" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Clothing</b></font></td>
<td width="31%" height="14" bgcolor="#FFFFCC"> </td>
<td width="31%" height="14" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Family</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Laundry/Cleaners</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Medical</b></font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Doctor/Dentist</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Prescriptions</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Counseling</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Entertainment</b></font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Cable
TV</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Dining
Out</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Movies/Sports</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left" bgcolor="#FFFFCC">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1"><b>Other</b></font></td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Vacations</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Gifts</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Dues/Membership
Fees</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Books/Magazine</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Hair
Care/Beauty Supplies</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Church/Temple</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" height="12"><font face="Arial, Helvetica, sans-serif" size="1">Pet
Care</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%" height="12"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Tobacco/Alcohol</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1">Other/Miscellaneous</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font face="Arial, Helvetica, sans-serif" size="1"><b>Total
Expenses</b></font></td>
<td width="62%" colspan="2" height="14"><font size="1"><b>$___________________________</b></font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
</table>
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