Please complete the following form with your name, address, phone, branch served in, criminal background, and information regarding household members/household income.  

Please then estimate (realistically) your average monthly expenses.  If you pay any of these expenses weekly, bi-weekly, quarterly, semi-annually, or annually, you will need to adjust the amount to show it as a monthly amount (for example, if you pay the expense weekly, you can show that as a monthly expense by multiplying the weekly amount by 4.3).  If you are not sure how to do this, let us know of any expenses you do not pay monthly.  

When completing the form, remember to think about any and all debts possible.  This includes, but is not limited to:

  • Medical bills
  • Mail Order bills
  • Schools
  • Credit Card bills
  • Judgments
  • Student Loans
  • Store charges
  • Loan companies
  • Welfare Debts
  • Cable TV bills
  • Debts you cosigned
  • Back Rent
  • Payday loans
  • Bills owed to old landlords
  • Traffic/parking Tickets
  • Utility/telephone bills
  • Condominium Assessments
  • Loans from relatives
  • Provided to your dependents
  • Criminal restitution debts
  • Loans on pensions
  • Bills for goods/services
  • Money owed to creditors who repossessed your property

 Leaving this page and/or refreshing the form will result in your answers being lost; please be cautious so as not to lose your work.


Questions regarding this form can be directed to

Contact Information

Estimated Monthly Income

Estimated Monthly Expenses