Benefit amount from current disability income policy $____________
Income from spouse $____________
Investment income $____________
Any other income $____________
Total Monthly Income Available $____________
Mortgage or Rent $____________
Car Payments $____________
Food and Clothing $____________
Child Care Expenses $____________
Loans & Credit Card Payments $____________
Medical Expenses $____________
Insurance Premiums (Home, Auto, Life, Health) $____________
Savings, Investments, Retirement Contributions $ ____________
Other Expenses (Education, Entertainment, etc.) $____________
Total Monthly Expenses $____________
Total Monthly Income Available: $_______________
Minus Total Monthly Expenses: $________________
Equals Need for Additional Monthly Income Due to Disability: $________________
Disability Income Insurance provides money to replace earned income while disabled from sickness or an accident.
*Source: Social Security Administration, Fact Sheet Jan. 2009.
**Source: Council for Disability Awareness, Long-Term Disability Claims Review, 2010.
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