Pre-Appointment Information Sheet Service …

1 NMCRS 223 (October 2016) Pre-Appointment Information Sheet Service Member s Name: Complete this form and bring it with you to your appointment . If married, it is helpful to involve your SPOUSE. All dollars should be entered on a MONTHLY basis (average if needed). Bring a copy of your LATEST monthly Leave and Earnings Statement (LES). INCOME, LIVING & TRANSPORTATION EXPENSES (MONTHLY) MONTHLY INCOME: DOLLARS: LIVING EXPENSES: DOLLARS: Military take-home pay Groceries Net pay from 2nd job Fast Food/Dining Out Net pay of spouse Beverages/Lunches Social Security Clothing/Shoes VA Disability Laundry/Dry Cleaning VA Education Benefits Hair Cuts/Salons Child Support Personal Care/Toiletries Food Stamps (Yes/No) Child Care WIC (Yes/No) Diapers HOME EXPENSES.

2 Child Support (non-allotted) Rent/Mortgage Household Supplies Electric SM s Deployed Expenses Natural Gas CONTRIBUTIONS: Water/Sewage/Garbage Family Homeowners/Renters Insurance Religious/Charity/Other HOA Fees/Taxes CHILDREN/SCHOOL EXPENSES: Security Systems Activities/Sports/Allowances Cell Phone Tuition Home Phone/Internet/Cable School Lunches/Supplies Home Repairs/Maintenance Uniform/Lessons Other Other TRANSPORTATION: ENTERTAINMENT/MISCELLANEOUS: Gasoline Nights Out/Movies Vehicle Maintenance Memberships Vehicle Insurance Books/E-books/Magazines Vehicle Registration Tobacco/Alcohol Parking/Tolls/Public Transportation Pets HEALTH EXPENSES: Storage Unit Fees Insurance (life, other) Leisure/Hobbies/Gambling/Gaming Medical (co-pays, dentist, orthodontics) Gifts/Holidays Other Bank Fees See reverse for reporting monthly debt payments NMCRS 223 (October 2016) VEHICLE Information VEHICLE PAYMENTS MONTHLY DEBTS (PERSONAL LOANS, CREDIT CARDS, FURNITURE, AUTO LOANS, ETC.)

3 YEAR MAKE MODEL Vehicle #1: Vehicle #2: Vehicle #3: Vehicle #4: To Whom Owed Interest Rate Type of Vehicle Date Incurred Original Amount Balance Owed Monthly Payment To Whom Owed Interest Rate Purpose Date Incurred Original Amount Balance Owed Monthly Payment

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