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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="../spanish.htm"><img src="../99images/banrspan.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"><i>Consumer
Credit Counseling Service of Central New Jersey</i><br>
<font color="#17551D"><a name="top"></a>Un servicio de Family Guidance Center
Coporation </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="middle" align="left" bgcolor="#330033" width="240">
<div align="center"><font size="2" face="Arial, Helvetica, sans-serif" color="#FFFFFF">
<b>Información/Datos Personales</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>Presupuesto
Mensual</b></font></div>
</td>
</tr>
<tr>
<td align="right" valign="top" bgcolor="#FFFFFF" width="72"> <font size="1" face="Arial, Helvetica, sans-serif"><b><font color="#FF0000">Instrucciones
para llenar la solicitud</font></b><br>
<br>
Por favor llene esta solicitud de la manera más completa posible.<br>
<br>
Si tiene alguna pregunta llámenos al<br>
(609) 586-2574. <br>
<br>
Usted puede mandar esta solicitud por el "fax" al<br>
(609) 586-4759 o puede traerla con usted el día de su cita. <br>
<br>
Usted puede enviar la solicitud por correo a: <br>
CCCS of<br>
Central <br>
New Jersey<br>
117 Estates Blvd.<br>
Trenton, NJ 08610</font><br>
<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"> Nombre<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"> Nombre de su Esposo/a
<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"> Dirección <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"> Dirección <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"> Ciudad<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"> Estado y Código
Postal <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"> Fecha de Nacimiento
</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"> Fecha de Nacimiento
de su Esposo/a<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"> Teléfono
de su Casa <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"> Teléfono
de su Trabajo <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"> Teléfono
de su Esposo/a<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"> Número
de Seguro Social <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 face="Arial, Helvetica, sans-serif" size="1">Número
de Seguro Social de su Esposo/a</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>Información Acerca de sus Acreedores</b></font></div>
</td>
</tr>
</table>
<p><font face="Arial, Helvetica, sans-serif" size="1" color="#000000"> (Utilize
otra hoja si necesita más espacio y añadala a esta solicitud)<br>
<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"><br>
Nombre del Acreedor<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"><br>
Número de Cuenta <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"><br>
</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"><br>
Nombre del Acreedor<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"><br>
Número de Cuenta<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"><br>
</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"><br>
Nombre del Acreedor<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"><br>
Número de Cuenta<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"><br>
</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"><br>
Nombre del Acreedor<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"><br>
Número de Cuenta<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"><br>
</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>
</font><font face="Arial, Helvetica, sans-serif" size="1" color="#000000">Nombre
del Acreedor</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"><br>
</font><font face="Arial, Helvetica, sans-serif" size="1" color="#000000">Número
de Cuenta</font><font size="1" face="Arial, Helvetica, sans-serif"><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>
</font><font face="Arial, Helvetica, sans-serif" size="1" color="#000000">Nombre
del Acreedor</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"><br>
</font><font face="Arial, Helvetica, sans-serif" size="1" color="#000000">Número
de Cuenta</font><font size="1" face="Arial, Helvetica, sans-serif"><br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"><br>
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>
Ingreso/Salario Neto del Solicitante <br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
Ingreso/Salario Neto del Esposo/a<br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
Otro Ingreso Mensual <br>
<br>
<img src="../99images/horzlin2.gif" width="237" height="3"> <br>
INGRESO TOTAL MENSUAL<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="#FF0000">Gastos</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><font color="#FF0033">Sub-total</font></b></font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Gastos
de Vivienda </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">Renta/Hipoteca
</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 size="1" face="Arial, Helvetica, sans-serif">Segunda
Hipoteca </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">Poliza
de Seguro </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">Servicios
Públicos (agua, gas, electricidad, etc.)</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">Teléfono
</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">Mantenimiento
de su Propiedad</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%" height="10"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Gastos
de Comida</b> <br>
</font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Compra
</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Comida
en el Trabajo/Escuela</font> </td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</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>Gastos
de Seguro</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 size="1" face="Arial, Helvetica, sans-serif">De
Vida </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 size="1" face="Arial, Helvetica, sans-serif">De
Salud</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Gastos
de Transportación </b></font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Pago
de Automóbil </font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" height="13"><font size="1" face="Arial, Helvetica, sans-serif">Seguro
de su Autómobil</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%" height="13"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" height="13"><font size="1" face="Arial, Helvetica, sans-serif">Gasolina/Aceite</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%" height="13"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Peaje/Estacionamiento</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Autobus/Transportación
Pública </font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Mantenimiento
del Auto</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</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>Gastos
de Cuidado de Niños </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 size="1" face="Arial, Helvetica, sans-serif">Guarderia/Niñera
</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 size="1" face="Arial, Helvetica, sans-serif">Dinero
para los niños</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 size="1" face="Arial, Helvetica, sans-serif">Pensión
Alimenticia</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Gastos
de Educación </b></font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Prestamos
Estudiantiles</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Materiales/Matrícula
</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Lecciones
(musica/piano/baile, etc.)</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</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>Gastos
Ropa</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 size="1" face="Arial, Helvetica, sans-serif">Para
la Familia</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 size="1" face="Arial, Helvetica, sans-serif">Lavado
de Ropa/Lavandería</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</font></td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"> </td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%" bgcolor="#FFFFCC"><font face="Arial, Helvetica, sans-serif" size="1"><b>Gastos
Médicos</b></font></td>
<td width="31%" bgcolor="#FFFFCC" height="14"> </td>
<td width="31%" bgcolor="#FFFFCC"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Doctor/Dentista</font>
</td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Prescripciones</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Consjeria
</font></td>
<td width="31%" height="14"><font size="1">____________</font></td>
<td width="31%"><font size="1">$____________</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>Gastos
de Entretenimiento</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
</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 size="1" face="Arial, Helvetica, sans-serif">Comer
a Fuera</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 size="1" face="Arial, Helvetica, sans-serif">Películas/Deportes</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>Otros
Gastos</b></font></td>
<td width="31%" height="14"> </td>
<td width="31%"> </td>
</tr>
<tr valign="bottom" align="left">
<td width="38%"><font size="1" face="Arial, Helvetica, sans-serif">Vacaciones
</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 size="1" face="Arial, Helvetica, sans-serif">Regalos
</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 size="1" face="Arial, Helvetica, sans-serif">Cuotas/Membresias
</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 size="1" face="Arial, Helvetica, sans-serif">Libros/Revistas</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 size="1" face="Arial, Helvetica, sans-serif">Productos
de Belleza/Salón de Belleza </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 size="1" face="Arial, Helvetica, sans-serif">
Iglesia/Templo</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 size="1" face="Arial, Helvetica, sans-serif">Cuido
de Mascotas</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 size="1" face="Arial, Helvetica, sans-serif">Cigarrillos/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 size="1" face="Arial, Helvetica, sans-serif">Otros
gastos </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
de Gastos </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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