Income Worksheet

Income Worksheet
Date: ________________
Gross Earned Income per Pay Period
Taxes





In
Out
$ ____________
Federal
State
Local/City
Social Security – FICA
Medicare
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
Total Taxes Withheld
$ ____________
Other Deductions
 Medical insurance
 Life insurance
 Disability insurance
 Dental insurance
 Other insurance: ___________________
 Flexible spending account FSA (sec 125)
 Health savings account HSA
 Retirement plan: 401(k), 403(b), 457 or other
 Retirement plan loan repayment
 Dues: ______________________
 Other: ______________________
 Other: ______________________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
Total of Other Payroll Deductions
$ ____________
Net Income per Pay Period
$ ____________
Gross Earned Income - Taxes and Deductions
Number of Pay Periods per Month
Monthly Net Earned Income
_____
$ ____________
Net income per Pay Period x Pay Periods per Month
Other Income
 Social Security
 Pension benefits
 Annuity payments
 Interest income from investments
 Dividend income from investments
 Child / Spousal support
 Other: ______________________
 Other: ______________________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
$ ____________
Total Other Income
$ ____________
Total Monthly Income
$ ____________
Monthly Net Earned Income + Total Other Income