DETERMINATION OF PARENTAL FINANCIAL SECURITY AND RESOURCES
Parent:	Household
Current Employer Name:	Combined Monthly Income	$
Verified?	Yes No
Employer’s Address:	Monthly Expense
Length at Current Employment:	Housing: (Rent/Mortgage)	$
Hours:	Utilities: (Electricity / Water)	$
Gross Salary:	$	Transportation: (Bus/Taxi/Uber/Lyft/ Car Payment/Gas)	$
Take Home Pay:	$	Car Insurance:	$
Frequency:	Weekly Biweekly Monthly	Food/Supplies:	$
Medicaid Eligible?)	Yes No Unknown	Medical:	$
Additional Support or Income:	$	Child Care:	$
Social Security Benefits:	$	Other Bills (include personal care/luxuries)
WAGES: (Temporary Case)	$	cell phones	$
Disability Benefits:	$	clothes/kids	$
Other Income (please list)	car payment	$
$	road supplies/showers etc	$
$	$
$	$
$	$
$	$
Total Monthly Income=	$	Total Monthly Expenses =	$
Total the parent can contribute to each Case Plan task=	$
If the parent can not contribute, explanation required:
Parent Statement To the best of my knowledge, I have provided truthful information on all questions asked of me. The parent may waive the signature of the document if the information has been obtained via phone. This must be indicated in the signature line of the parent and documented in FSFN.
Parent Printed Name:	Signature:	Date:
Case Manager or designee Printed Name:	Signature:	Date: