Mediation Budget Form 3
Name*
First Name Middle Name Last Name
Date
Number of people in the entire family
Present expenses, entire family Post-Separation expenses for:
Two clumns may be used for expenses in each person's expenses of two houses.
(All expenses should be listed on a monthly basis. If any items are paid on a weekly basis multiply by 4.33 to obtain monthly cost. Annual expenses should be devided by 12 etc.)
(a) Housing

	$	$
1. Mortgage payment (firs mortgage)
2. Home equity loan (second mortgage)
3. Condominium/Cooperative charges
4. Assesment
5. Homeowner insurance, if paid separately
6. Rent
7. Parking (where you live)
8. Taxes if paid separately from mortgage
Total (a)

Additional questions for housing
4.1 Assesment (till)
6.1 Rent stabilized?
Type a question
Yes No
(b) Utillity Services

	$	$
1. Gas/Electric
2. Regular home telephone
3. Cell phone
4. Cell phone replacement
5. Cable / Dish / Triple Play / Internet
6. Netflix / Hulu / Spotify / I-Tunes etc.
7. Security / Alarm
8. Pest control (if monthly)
9. Healting / Oil / Propane
10. Water / Sewer
11. Garbage
12. Gardening / Lawn mower / Sprinkler / Pool
13. Snow plowing / Firewood
14. Other (describe below 14.1)
Total (b)

Additional questions for utilities
1.1 Is gas / electric in budget planing?
Yes No
3.1 How many people?
14.1 Other utility services?
Type a question
Type here
FIXED HOUSING EXPENSES
$ $
Total a plus total b
(c) Household Maintenance
Calculate monthly amount

	$	$
Total a plus total b

	$	$
1. Ongoing repairs (capetners, electricians, plumbers, etc.)
2. Replacement of furniture, linens, etc. (not new purchases)
3. Maintenance of appliances (service contract?)
4. Replacement of major appliances(Heating, AC, TV, etc.)
5. Painting (outsice & inside)
6. Pest control (if not already included in monthly cost)
7. Housekeeping or cleaning person
8. Heavy duty periodic cleaning including window washing
9.Carpet and furniture cleaning
10. Maintenance of furnace / chimney and septic
Subtotal (c)

$
Total (c) both columns
(d) Food

	$
Total (c) both columns

	$	$
1. Usual supermarket expenses (food and non-food)
2. Food brought in ( eating out under entertainment)
3. Wine & liquor
4. Extra cost for holiday meals (dvide annualy by 12)
5. Pet food if purchased separately
6. Miscellaneous (describe below 6.1)
Subtotal (d)

$
Total (d) both columns
Additional questions for food
6.1 Describe miscellaeneous.
Type a question
Type here
(e) Clothing etc.
$ $
1. Self
2. Children
3. Outside laundry, dry cleaning and shoe repair
4. Jewelery, watches and accessories
Subtotal (e)
$
Total (e) both columns
(f) Automobiles
List data for each automobile separately

	$
Total (d) both columns

	$
Total (e) both columns

	Car#1	Car #2	Car #3
1.Year
2.Make
3. Lease or purchase
4. Till when?
5. Monthly payments
6. Gas
7. Maintenance & repairs
8. Insurance
9. Registration fees, taxes, road service (AAA) etc.
10. Garage parking (non resident)
11. Tolls, EZ-Pass, tickets, car wash
Subtotal (f) lines 5-11

$
Total (f) all columns
(g) Health / Medical

	$
Total (f) all columns

	$	$
1. Insurance (ma be different moving forward)
2. Co-Insurance cost (# of monthly visits x co-payments)
3. Unreimbursed or uncovered medical
4.Unreimbursed or uncovered dental
5. Unreimbursed orthodontics (provide balance below 5.1)
6. Optical ( exam plus cost for glasses or contacts)
7. Medicine drugs (# of prescriptions x co-payment)
8. Non-prescription medicines etc. (if not already included)
9.Psychotherapy (after reimbursment 46 weeks per year)
10. Other (describe below 10.1)
Subtotal (g)

$
Total (g) all columns
Additional questions for health / medical
5.1 Provide balance for unreimbursed othodomics.
$
Balance for unreimbursed othodomics
10.1 Describe miscellaeneous.
Type a question
Type here
(h) Insurance (non-health) and Professional Services

	$
Total (g) all columns

	$
Balance for unreimbursed othodomics

	$	$
1. Life insurance throuh emplyment (indicate monthly costs)
2. Life insurance (monthly costs, provide face amount below 2.1)
3. Disability (monthly costs, provide benefit amount below 3.1)
4.Umbrella policy (separate and in addition to homeowners)
5. Accountant, Financial Planner, Attorney etc.
6. Office supplies, stationery, compuer supplies, postage etc.
7. Replacement of computer
8. Insurance for device, Apple Care
9. Other (describe below 9.1)
Subtotal (h)

$
Total (h) all columns
Additional questions for insurance and professional services
2.1 Provide face amount for life insurance.
$
Face amount for life insurance
3.1 Provide disability benefit amount.
$
Disabilty benefit amount
9.1 Describe other.
Type a question
Type here
(i) Loans and Credit Card Payments

	$
Total (h) all columns

	$
Face amount for life insurance

	$
Disabilty benefit amount

	Total Owed	Monthly Payment	Interest Rate
1. Student loans
2.Credit cards (provide last four digits below 2.1)
MasterCard (1)
MasterCard (2)
Visa (1)
Visa (2)
American Express
Department Stores
3. Overdraft checking
4. Credit Union personal checking (describe below 4.1)
5 Other (describe below 5.1)
Subtotal (i)

$
Total (i) all columns
Additional questions for loans and credit card payments
2.1 Provide last four digits for credit cards.
Last four digits
MasterCard (1)
MasterCard (2)
Visa (1)
Visa (2)
American Express
Department Stores
4.1 Describe Credit Union personal checking.
Type a question
Type here
5.1 Describe other.
Type a question
Type here
(j) Education and Private School
Child 1 Child 2 Child 3
1. Tuition
2.Additional contribution
3. Transportation
4. Books & School Supplies
5. Uniforms
6. Lunch (if paid annualy)
7 Other (describe below 7.1)
Subtotal (j)
$
Total (j) all columns
Additional questions for education and private schools
7.1 Describe other.
Type a question
Type here
(k) College
Net after scholarship
for child for self
Child 1 Child 2 Child 3
1. Tuition
2.Room & Board
3. Books & supplies
4. Fees
5. Transportation
6. Allowance
7 Other (describe below 7.1)
Subtotal (k)
$
Total (k) all columns
Additional questions for college
7.1 Describe other.
Type a question
Type here
(l) Direct Child Expenses
List for each child seperately

	$
Total (i) all columns

	Last four digits
MasterCard (1)
MasterCard (2)
Visa (1)
Visa (2)
American Express
Department Stores

	$
Total (j) all columns

	$
Total (k) all columns

	Child 1	Child 2	Child 3
1.Child care person (salart, taxes, MetroCard etc.)
2.Baby-Sitter in addition to above (while not working)
3. Day Care / Nursery School
4. Diapers and othe baby supplies (if not listed already)
5. After school costs (include holiday periods)
6. Summer camp and related expenses
7. Music and other lessons
8. Tutoring and remediation
9. Religious instruction
10 Sports team and equipment
11. Toys, games etc.
12. Computer hardware and software
13. School lunches and snacks
14. School extras (supplies, photos, trips etc.)
15. Trips & vacations taken without a parent
16. Gifts for children's friends (birthdays etc.)
17. Allowance
18. Other (describe below 18.1)
Subtotall (l)

$
Total (l) all columns
Additional questions for direct child expenses
18.1 Describe other.
Type a question
Type here
(m) Recreation / Entertainment
Separate amount for self and children

	$
Total (l) all columns

	Self	Child
1. Eating out
2.Movies, theater and concerts
3. Amusement parks, sightseeing , etc.
4. Spectator sports
5. Annual vacations (summer, spring , winter)
6. Hobbies (golf, crafts, etc.)
7. Weekend vacations, family events, etc.
8. Purchase of books, CDs, DVDs, etc.
9. Country club, gym membership, tennis club etc.
10 Personal trainer
11. Other (describe below 11.1)
Subtotall (m)

$
Total (m) all columns
Additional questions for recreation / entertainment
11.1 Describe other.
Type a question
Type here
(n) Personal Care
Separate amount for self and children

	$
Total (m) all columns

	Self	Child
1. Beauty parlor / barber
2. Manicure , pedicure, facial etc.
3. Cosmetics & Toiletries (if not already included)
4. Cosmetic maintenance
5. Other (describe below 5.1)
Subtotall (n)

$
Total (n) all columns
Additional questions for pesonal care
11.1 Describe other.
Type a question
Type here
(o) Miscellaneous
Separate amount for self and children

	$
Total (n) all columns

	Self	Child
1. Magazines, newspaper, etc, ( subscriptions +daily)
2.Museum membership, Costco, Amazon Prime etc.
3. Union and organization dues
4. Holiday expenses ( Christmass tree, gift for mailman etc.)
5. Gifts (holidays, birthdays, etc.)
6. Pet expenses, vet bills (if not already included)
7. Flowers and plants
8. Church and Synagoge dues
9. Charitable contributions
10 Car services, taxi, cab
11. Commutation and transportation costs (MetroCard)
12. Spending money (cigarettes, lunch, snacks etc.)
13. Child support, alimony, maintenance (prior marriage)
14. Savings including college, 401k contributions, etc.
15. Other (describe below 15.1)
Subtotal (o)

$
Total (0) all columns
Additional questions for miscellaneous
11.1 Describe other.
Type a question
Type here
Should be Empty:

	$	$
1. Self
2. Children
3. Outside laundry, dry cleaning and shoe repair
4. Jewelery, watches and accessories
Subtotal (e)

	Child 1	Child 2	Child 3
1. Tuition
2.Additional contribution
3. Transportation
4. Books & School Supplies
5. Uniforms
6. Lunch (if paid annualy)
7 Other (describe below 7.1)
Subtotal (j)

	Child 1	Child 2	Child 3
1. Tuition
2.Room & Board
3. Books & supplies
4. Fees
5. Transportation
6. Allowance
7 Other (describe below 7.1)
Subtotal (k)

Mediation Budget Form 3

Two clumns may be used for expenses in each person's expenses of two houses.

(a) Housing

(b) Utillity Services

(c) Household Maintenance

(d) Food

(e) Clothing etc.

(f) Automobiles

(g) Health / Medical

(h) Insurance (non-health) and Professional Services

(i) Loans and Credit Card Payments

(j) Education and Private School

(k) College

(l) Direct Child Expenses

(m) Recreation / Entertainment

(n) Personal Care

(o) Miscellaneous