Resource Parent Portal

Forms

Family Financial Statement

My Caseworker:

Applicant's Name:
Email:

Income

Monthly Earnings

Applicant 1

Applicant 2

Gross:
Net:
Child Support:
Alimony:
Benefits/Pensions:
Other (Specify):
Other (Specify):

Assets

Checking:
Savings:
Other (Specify):

Expenses (Combined, If Married Couple)

Monthly Expenses

Housing

First Mortgage:
Second Mortgage:
Rent:
Maintenance:

Utilities

Gas & Electric:
Heat:
Telephone:
Water:
Auto Loans:
Auto Insurance:
Added Transportation Costs:
Food:
Clothing:
Child Care:
Medical:
Entertainment:
Contributions:
Savings:
Retirement Plan/IRA:
Child Support:
Educational Expenses:

Credit Cards

Credit Card A:
Credit Card B:
Credit Card C:

Other Revolving Loans

Other Revolving Loans A:
Other Revolving Loans B:
Other Revolving Loans Other:
Other Revolving Loans Other:

Insurance

Name of Company		Monthly Cost	Coverage
Life:
Health:
Other:

Will your Current plan cover adopted children a time of placement and before final decree is obtained?:

Yes
No

Will it cover preexisiting medical conditions of adopted children?:

Yes
No

I hereby acknowledge that I have read, understand and agree to the terms of this document:

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