(To determine what you can afford to pay, it is helpful to look at your monthly income and expenses. Fill in the following worksheet with your best estimates. You can use this information to explain to the utility company what you can afford to pay.)
Monthly Income*:
| Source of income: (list below) | Amount |
| $ | |
| + $ | |
| + $ | |
| TOTAL MONTHLY INCOME | = $ |
*If you are paid by the week, multiply your weekly income by 4.3 to get monthly income. If income is from employment, use net pay (amount left after taxes & deductions). If income is from TFA (Temporary Family Assistance), think about when TFA benefits end so the payment agreement does not assume this income is available when it has actually ended.
Expenses:
| $ | Rent or Mortgage, Insurance & Taxes |
| $ | Food and Household Supplies |
| $ | Medical Expenses (bills, insurance, medicine) |
| $ | Clothing |
| $ | Personal Needs (work uniforms, haircuts, etc.) |
| $ | Transportation (car, insurance, gas, maintenance, bus, other transportation etc.) |
| $ | Child Care |
| $ | Telephone |
| $ | Laundry |
| $ | Other Utility or Energy Expense: ___________________ |
| $ | Other Utility or Energy Expense: ___________________ |
| $ | Debts:_______________________________ |
| $ | Other Expenses: _______________________________ |
| $ | TOTAL MONTHLY EXPENSES |
$ _________ TOTAL MONTHLY INCOME
- $ _________ (minus) TOTAL MONTHLY EXPENSES
= $ _________ (equals) REMAINING INCOME *
* Part of your remaining income can be
applied toward your utility bill each month. BUT avoid paying all your remaining
income toward this bill; you may have other unexpected expenses.
Legal Assistance Resource Center of
Connecticut. www.larcc.org May 2008