Independent Living Stipend Budget Worksheet

CP&P Form 10-11

(rev. 3/2017) Independent Living Stipend Budget Worksheet

Youth’s Name ______Case ID# ______

Submission Date ______Budget Period ______to ______(may not exceed six months) Transitional Plan for YOUth Success Independent Living Stipend Responsibility Agreement Voluntary Services Agreement

______

Monthly Income / Support Monthly Expenses Table 1. Net Monthly Income Use mutually agreed upon verification to determine expenses Wages $ Table 6. Monthly Independent Living Stipend Expenses Rent Expenses Table 2. Other Net Monthly 16 to 21 Year Old Support Rent/Mortgage $ SSI/SSD $ Utilities $ SNAP $ Total Rent Expenses $ Food Expenses $ TANF/GA $ Total Food Expenses $ Other $ Incidentals Expenses Total Support $ Cell Phone $ Personal Toiletries $ Table 3. Other Net Monthly Support Household Items $ Child Support $ Entertainment $ SSI/SSD for Child $ Transportation (not bus $ WIC $ card) Other $ Table 4. Savings* Other $ Wages $ Total Incidentals Expenses $ Savings* (10%) $ TOTAL IL STIPEND $ Adjusted Income $ EXPENSES (Rent, Food & Incidentals) Table 5. Total Income/Support Adjusted Income or Wages $ Table 7. Other Monthly Expenses Total Support (Table 2) $ Renter’s Insurance $ FINAL INCOME/SUPPORT $ Laundry/Dry Cleaning $ Car Payment $ *Savings – 16 to 21 year olds can only use his or her wages towards savings Car Insurance $ and cannot exceed 10% of his or her net income from wages. Gas $ Cable $ Note: Clothing is provided in the amount of either $98 or $103 each month Credit Card(s) $ and is not part of the budget. Loans $ Medical Expenses $ Use mutually agreed upon verification to determine income and expenses. Child Related Expenses $ Other $ Total Monthly Expenses $ Note: Changes in income/monthly expenses must be shared with my Worker to do a revised budget.

______IL Stipend Distribution

1 Table 8. Incidentals Total Incidental Expenses $ Total Income towards Incidentals $ Difference $ Amount of IL Incidental Stipend $

Table 9. Food Total Food Expenses $ Total Income towards Food $ Difference $ Amount of IL Food Stipend $

Table 10. Rent Total Rent Expenses $ Total Income Towards Rent $ Difference $ Amount of IL Rent Stipend $

______Adolescent / Young Adult’s Signature Date ______Worker’s Signature Date

For Office Use Only

Supervisor’s Signature ______Date signed ______