PROB 48B(Rev. 03/15)Last NameFirst NameMiddle NameSocial SecurityNumber Instructions for Completing Monthly Cash Flow StatementHaving been convicted in the United States District Court, you are required to prepare and file with theprobation officer a statement fully describing your financial resources, including a complete listing of allmonthly cash inflows and outflows.If you are placed on probation or supervised release (or other types of supervision), you may be periodicallyrequired to provide updated information fully describing your financial resources and those of your spouse,significant others, or dependents, as described above, to keep a probation officer informed concerningcompliance with any condition of supervision, including the payment of any criminal monetary penaltiesimposed by the court (see 18 U.S.C. 247 3603).Amendments were made to 18 U.S.C. 247247 3663 (a)(1)(B)(I), 3664(d)(3), and 3664(f)(2), and Rule 32(b)(4)(F)to clarify that the assets owned, jointly owned, or controlled by an offender; liabilities; and the financial needsand earning ability of an offender and an offender222s dependents are all relevant to the court222s decision regardingan offender222s ability to pay. Your Cash Flow Statement should include assets or debts that are yours alone (I-Individual), assets or debts that are jointly (J-Joint) held by you and a spouse or significant other, assets or debtsthat are held by a spouse or significant other (S-Spouse or Significant Other) that you enjoy the benefits of ormake occasional contributions toward, and assets or debts that are held by a dependent (D-Dependent) livingin your home that you enjoy the benefits of or make occasional contributions toward.Please complete the Monthly Cash Flow Statement in its entirety. You must answer 223None224 to any item thatis not applicable to your financial condition. Attach additional pages if you need more space for any item. Allentries must be accompanied by supporting documentation (see Request for Cash Flow Statement FinancialRecords (Prob. 48C)). Initial and date each page (including any attached pages), and sign and date the last pageof the Cash Flow Statement. American LegalNet, Inc. www.FormsWorkFlow.com PROB 48B(Rev. 03/15)Page 2 ofLast Name -MONTHLY CASH FLOW STATEMENTMonthly Cash InflowsDefendantGrossNetYour Salary/Wages (List both monthly gross earnings and take-home pay after payroll deductions.)Your Cash Advances (List all payroll advances or other advances from work.)Your Cash Bonuses (List all payments from work in addition to your salary that are not an advance.)Commissions (List all non-employee earnings as an independent contractor.)Business Income (List both monthly gross income and net income after deducting expenses.)Interest (List all interest earned each month.)Dividends (List all dividends earned each month.)Rental Income (List all monthly income received from real estate properties owned.)Trust Income (List all trust income earned each month.)Alimony/Child Support (List all alimony or child support payments received each month.)Social Security (List all payments received from Social Security.)Other Government Benefits (List all amounts received from the government not yet reported [e.g., food stamps and unemployment compensation].)Pensions/Annuities (List all funds received from pensions and annuities each month.)Allowances-Housing/Auto/Travel (List all funds received from housing allowances, auto allowances,travel allowances, and any other kind of allowance.)Gratuities/Tips (List all gratuities and tips received each month from any and all sources.)Spouse/Significant Other Salary/Wages (List all gross and net monthly salary and wages received byyour spouse or significant other.)Other Joint Spousal Income (List any monthly income jointly earned with your spouse or significantother [e.g., any income from spouse or income from a business owned or operated by the spouse that you have a joint ownership interest in or control]).Income of Other In-House (List all monthly income of others living in the household or themonthly amount actually paid for household bills by these persons.)Gifts from Family (List all amounts received as gifts from family members each month.)Gifts From Others (List all gifts received from any sources not yet reported.)Loans From Your Business (List all loan amounts received each month from all businesses ownedor controlled by you.)Mortgage Loans (List all amounts received each month from mortgage loans owed to you.)Other Loans (List all other loan amounts received each month not yet reported.)Other (specify) (List all other amounts received each month not yet reported.)TOTALS American LegalNet, Inc. www.FormsWorkFlow.com PROB 48B(Rev. 03/15)Page 3 ofLast Name -Necessary Monthly Cash OutflowsAmountRent or Mortgage (List monthly rental payment or mortgage payment.)Groceries (List the total monthly amount paid for groceries and the number of people in your household.)#Utilities (List the monthly amount paid for electric, heating oil/gas, water/sewer, telephone, and basic cable.)ElectricHeating Oil/GasWater/SewerTelephoneBasic Cable (no premium channels)Public Transportation (List the monthly amount paid for public transportation.)Car Payments (List all payments made to purchase or lease vehicles.)Commuting Expenses (List the monthly amount paid for gasoline, tolls, etc.)Auto Insurance (List the monthly amount paid for auto insurance.)Health Insurance (List the monthly amount paid for health insurance.)Homeowner/Rental Insurance (List the monthly amount paid for homeowner/rental insurance.)Clothing (List the monthly amount actually paid for clothing.)Loan Payments (List all monthly amounts paid toward verified loans, other than loans to family members, which arenon-allowable expenses.)Credit Card Payments (List all minimum monthly credit card or charge card payments.)Medical (List all expenses not covered by insurance.)Alimony/Child Support (List all alimony or child support payments made each month.)Criminal Monetary Penalty (List all monthly payments for court-ordered criminal monetary penalties.)Court-Ordered Costs (List the total monthly payments made for location monitoring and drug and mental health treatment.)Other (specify) (List all other necessary monthly amounts paid each month not yet reported.)Other Factors That May Affect Monthly Cash Flow (Describe)TOTALNET MONTHLY CASH FLOW: $(CASH INFLOWS LESS NECESSARY CASH OUTFLOWS)MONTHLY CRIMINAL MONETARY PENALTY PAYMENT: $PROSPECT OF INCREASE IN CASH INFLOWS (Give a general statement of the prospective increase of the value of any cash inflows reported.)SignatureDate American LegalNet, Inc. www.FormsWorkFlow.com