Request for Information Household Expense Listing

Household Expense Listing
Cost per
Month

Food, Clothing and Other Expenses

Out of Pocket Health Care Expenses

Cost per
Month

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Cost per
Month

Housing and Utilites

Transportation

Cost per
Month

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# Persons in Household _______
Disaster No.
FEMA Application No:_____________

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NAME:____________________________________________
ADDRESS: _________________________________________
CITY:______________________________________________
STATE and ZIP: _____________________________________
COUNTY:_____________________________
PHONE #:____________________________________

Best Time to Call
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EMAIL ADDRESS: ____________________________________________

Instructions:
Fill in the number of persons in your household. Enter
FEMA Application No. Enter Disaster No. Enter the
Debtor's full name. Enter Debtor's current address and
include the street address, city, state, zip code and
county. Enter your phone number(s). Note the best time
to call. Enter your Email Address (optional). Monthly
expenses vary -- to find the Cost per Month, total up the
amount you spend for each type of expense for the whole
year; then, divide by 12 to calculate the average monthly
cost of each household expense. In the spaces provided
above write in the type or description and Cost of your
Monthly household expenses under each category. Call 1800-816-1122 if you have questions.