Financial Worksheet

Expectant Mother’s Name*
Completed for month/year*
Income Sources:
Wages (please also include name of workplace)
Amount/Month
Cash Assistance
Amount/Month
Food Stamps
Amount/Month
WIC
Amount/Month
Disability Payments
Amount/Month
Child Support /Alimony
Amount/Month
Subsidized Housing
Amount/Month
Other (please specify)
Amount/Month
Total Monthly Income:
Monthly Expenses
Rent/mortgage
Estimated Amount
Food
Estimated Amount
Household Needs
Estimated Amount
Toiletries
Estimated Amount
Phone
Estimated Amount
Internet
Estimated Amount
Other utilities
Estimated Amount
Estimated Amount
Estimated Amount
Bus/Train/Uber
Estimated Amount
Medical Costs (not covered by insurance)
Estimated Amount
Clothing (Maternity)
Estimated Amount
Clothing (Non-Maternity)
Other (please specify)
Estimated Amount
Other (please specify)
Estimated Amount
Total Monthly Expenses
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