ReCapture™ Household Intake Worksheet

Complete the worksheet below so your household spending can be reviewed for ReCapture™ participation and structured spending eligibility.

Household Information

Program

Household Income Structure

Enter the household take-home income by pay schedule.

Monthly Expenses

Monthly Bill

Monthly Amount

How It’s Paid

Mortgage/Rent

HELOC

Car Note #1

Car Note #2

Car Insurance

Life Insurance

Health Insurance

Electricity/Hydro

Natural Gas

Water

Garbage/Sewer

Streaming

Internet

Emergency

Miscellaneous

Creditor 1

Creditor 2

Creditor 3

Creditor 4

Creditor 5

Creditor 6

Creditor 7

Creditor 8

Creditor 9

Creditor 10

Student Loans

Groceries

Clothes Shopping

Entertainment

Car Gas

Child Support

Religious

Cable

Storage

Gym

Trips

Dry Cleaning

Cosmetic

Investments

Cell Phone

Legal

Renters/Property Tax

Additional Creditor 1

Additional Creditor 2

Additional Creditor 3

Additional Expense 1

Additional Expense 2

Additional Expense 3

Additional Expense 4

Additional Expense 5

Total Monthly Expenses

Standard Weekly Deposit