MEANS TEST

NEW MEAN'S TEST ANALYSIS (bring with you to the first meeting with Ms. Drain)

NOTES:

Review the example below for directions on filling out the form.
All income must be separated by employers and individual receiving the income.
All income must be gross (before taxes and other deductions).
- Make sure to include tips and bonuses.
- If your income is commissions, then list the exact amount earned each month.
- include business income
- include retirement income but DO NOT INCLUDE SOCIAL SECURITY OR DISABILITY
- includes all monies received from any source must be listed, including money from cashing in retirement accounts, sales of large items, gifts or loans from friends or relatives.
- include money from rents
- include income for anyone who lives in your home
The income must be for a full month; therefore use the last full 6 months, do not include the current month.

Name	Employer/Other

Example: John and Mary are filling out this form on the 23^rd of the June. They have a renter and their mother has been giving them

$200.00 a month for the last 5 months.

Name	Employer/Other	May	April	March	February	January	December
John	ABC Plumbing	891.12	218.17	809.62	951.00	514.52	733.54
	Joe's Bar & Grill	230.00	415.00	213.75	450.00	120.31	1,213.52
	Renter	300.00	300.00	300.00	300.00	300.00	300.00

Mary	$ From Mother	200.00	200.00	200.00	200.00	200.00
	Social Security	899.00	899.00	899.00	899.00	899.00	845.00
	Pension	1,012.00	1,012.00	1,012.00	1,012.00	1,012.00	1,012.00
	Yard Sales	300.00	150.00	1200.00	130.00	240.00	130.00

If your average gross income exceeds the following you will need to answer the rest of the questions set out below. Average gross income is

determined by adding together all income for the last full 6 months and dividing it by 6. Include everyone who lives in your home.

If more than 4 people live in your home add $575 per month.

One person	Two People	3 people	Four people
$3,412.08/month	$4,429.42/month	$4,981.83/month	$5,575.25/month

Additional questions - answer only if you income exceeds the amount set forth above. Each of these amounts are to be the average monthly amount you actually spend.

1) Average monthly taxes taken out of paychecks - add together as one number $__________
2) Mandatory payroll deductions (employer forces you to pay) $_____________
3) Life insurance - monthly premium: $__________
4) Court ordered payments (such as child support/alimony that you must pay) $___________
5) Education expenses for employment or physically/mentally challenged child $__________
6) Childcare costs $__________
7) Health care such as co-pays, eye-glasses, dental, etc (do not insurance payments) $__________
8) Phone/cable $__________
9) Health insurance (include dental and all other insurance) $__________
10) Disability Insurance $__________
11) Health Savings account (flex accounts) $__________
12) Expenses for the care of elderly, chronically ill or disabled member of your household who cannot pay their own expenses: $__________
13) Protection against family violence $__________
14) Education expenses for children under 18 $__________
15) Charitable contributions $__________
16) Additional business expenses that are not reimbursed by your employer(s) $__________
17) Amount withheld to repay loans from retirement accounts $__________

Additional issues:

1) Amount of back taxes that you owe $__________