Thank you for signing up for your custom budget!

Please fill out all fields below and leave anything that doesn't pertain to you blank.

Also, make sure to make a one-time payment of $49.99 by clicking here to pay via Paypal - https://www.paypal.me/middleclassdad/49.99

No Paypal account is necessary.

Or just plug my home email address into your Paypal account and pay that way - jtlc512@gmail.com

I will start on your budget upon receiving your form and payment. All budgets will be ready and emailed to you within 72 business hours along with a customized plan to help you succeed.

Household Info

First Name of Household Member #1 *

Receive paychecks? *

Appx Pay Date Each Month (1st check if more than 1) * +

Net amount per check *

First Name of Household Member #2

Receive paychecks?

Appx Pay Date Each Month (1st check if more than 1) +

Net amount per check

Email Address *

Comments

Rent or Mortgage

Monthly Payment *

If Mortgage, does payment include taxes & insurance?

If no, please list approximate tax & insurance bills and when you usually pay it

Utility Bills

Fill in the average amount you pay for each bill. If one doesn't apply, just leave blank. If you have additional bills use the comment box below.

Electric Bill

Appx Due Date Each Month +

Gas Bill

Appx Due Date Each Month +

Water Bill

Appx Due Date Each Month +

Sewer/Trash Bill

Appx Due Date Each Month +

Phone Bill

Appx Due Date Each Month +

Internet/Cable Bill

Appx Due Date Each Month +

Netflix, Amazon, Hulu, etc (combined)

Approx Due Date Each Month +

Comments

Credit Cards & Loans

Fill in the minimum amount you pay for each month. If one doesn't apply, just leave blank. If you have additional bills use the comment box below.

Car loan 1 Monthly Payment

Balance on that loan

Approx Due Date Each Month +

Car loan 2 Monthly Payment

Balance on that loan

Approx Due Date Each Month +

Credit Card 1 Monthly Payment

Balance on that card

Approx Due Date Each Month +

Credit Card 2 Monthly Payment

Balance on that card

Approx Due Date Each Month +

Credit Card 3 Monthly Payment

Balance on that card

Approx Due Date Each Month +

Credit Card 4 Monthly Payment

Balance on that card

Approx Due Date Each Month +

Credit Card 5 Monthly Payment

Balance on that card

Approx Due Date Each Month +

Student Loan Monthly Payment (combine if more than 1)

Approx Due Date Each Month +

Balance on student loans

Personal/Home Equity Loan Monthly Payment (combine if more than 1)

Approx Due Date Each Month +

Balance on those loans

Any additional debts?

Savings & Investments

Fill in the minimum amount you pay for each month. If one doesn't apply, just leave blank. If you have additional bills use the comment box below.

401k, IRA or other retirement plans (combine if more than 1)

Approx Due Date Each Month +

Christmas/Holiday Savings Account

Amount you want to have to spend by November 1

Amount currently saved for holiday spending

Educational Savings Accounts (combine if more than 1)

Age of you child/Kids

Amount currently saved for kid's college

General Savings Accounts (combine if more than 1)

Insurance

Fill in the minimum amount you pay for each month. If one doesn't apply, just leave blank. If you have additional bills use the comment box below.

Auto insurance (combine if more than 1)

Approx Due Date Each Month +

Homeowner's/Renter's Insurance (if not in payment amount above)

Approx Due Date Each Month +

Life Insurance Payment 1

Approx Due Date Each Month +

Life Insurance Payment 2

Approx Due Date Each Month +

Medical Insurance (combine if more than 1)

Approx Due Date Each Month +

Other insurance (use comment box)

Approx Due Date Each Month +

By checking this box I acknowledge that I am sharing personal information electronically and I understand the risks of doing so. I also acknowledge that the information will be deleted upon receiving the customized budget plan. I also understand and hold Jeff Campbell dba Middle Class Dad harmless from any breech of information on the part of Formsite & Paypal and the internet providers used in our transaction. Lastly I understand that I am not asking for or receiving professional financial advice. I am seeking assistance with my personal bill payment and understand that Jeff Campbell dba Middle Class Dad is offering his assistance based on his personal experience and research. No financial goals are stated or implied and I understand if I need professional financial advice I will seek a qualified professional in my area. *

YES - I UNDERSTAND AND AGREE