| Source of Income |
Amount |
| After-tax wages (yours) |
$ |
| After-tax wages (others in your household) |
$ |
| Tips or bonuses |
$ |
| Child support |
$ |
| Unemployment |
$ |
| Interest from savings or other accounts |
$ |
| Investment income |
$ |
| Public assistance |
$ |
| Sources of income related to your child's disability |
Amount |
| State programs |
$ |
| Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) |
$ |
| Assistance from community organizations |
$ |
| Assistance from family and friends |
$ |
| TOTAL INCOME |
$ |
