Financial Fitness Analysis

Member Information

Your Name:
Member Account Number:
Social Security Number:	- -
Date of Birth:	/ /
Joint Member Name:
Joint Member Social Security Number:	- -
Joint Member Date of Birth:	/ /
Number of People in Household:
Street Address:
City:
State:
Zip:
Home Phone:	( )
Work/Daytime Phone:	( ) Ext:

Average Monthly Expenses

Housing:	Amount	Comments
Rent/Mortgage	$
Heat*	$
Electric	$
Water	$
Phone/Cell	$
Cable	$
Internet Access	$
Repairs/Improvements*	$
Household Expenses	$
Homeowners Insurance	$
* Take year's estimate & divide by 12

Food:	Amount	Comments
Groceries	$
Non-Food/Toiletries	$
Mid-week Shopping	$
Meals Out	$

Transportation:	Amount	Comments
Gas/Vehicle	$
Maintenance	$
Parking	$
Car Insurance	$

Other Expenses:	Amount	Comments
Clothing*	$
Medical/Dental*	$
Education*	$
Self Paid Life Insurance	$
Gifts*	$
Donations*	$
Entertainment**	$
Child Care	$
Vacations*	$
Beauty/Barber	$
Laundry/Dry Cleaning	$
Pets*	$
Alcohol/Tobacco	$
Other	$
Other	$
* Take year's estimate & divide by 12
** Entertainment includes: reading, videos, movies, hobbies, etc.

Subtotal:	$
+ Savings:	$
= Monthly Expenses:	$

Average Monthly Income

Net Pay:	Amount	Employer Name
Your Monthly Income	$
Joint Member's Monthly Income	$

Other Income:	Amount	Comments
Child Support	$
Alimony	$
Rental Property	$
Other	$
Other	$
Total Income	$

Total Income:	$
- Expenses:	$
= Total Available for Debt:	$


	Total Debt: $	Total Mo. Payment: $

One Credit Union Plaza | PO Box 1450 | Corning, NY 14830 | 800-677-8506 | 607-962-3144
Routing & Transit # - 222380359