CDL class A, welder, forklift operator, Microsoft, Excel, and SAP

PERSONAL BUDGET FORM

PERSONAL BUDGET NAME: Dalion Banks PID:

INCOME

Source 1

none

Income Total none

Source 2 none Expense Total none

Other Sources none Difference none

HOME EXPENSES LOANS/CREDIT CARDS/MISC.

Rent/Mortgage none Student Loans none

Electric none Personal Loans none

Gas none Home Equity Loan none

Water none Credit Cards none

Phone 35.00 Personal Care none

TV/Cable/Wi-Fi none Child Care none

Insurance none Personal Care none

Taxes none Clothing none

Repairs none Tax Penalty Payment none

Home Owner Assoc Fees none Supplies none

Food none Other none

AUTO/TRANSPORTATION EXPENSES MEDICAL EXPENSES

Auto Payment none Insurance none

Insurance none Medication none

Gas none Co-pay none

Repair/Maintenance none Other none

Participant Signature Dalion Banks Date

10-29-21

Case Manager Date

Instructions: Fill in participant name and ID# in the appropriate box. Identify income sources and fill in the appropriate box. Fill in dollar amount of all expenses in the box next to the appropriate listed expense. Expenses not listed should be filled in as other. Total all income sources and list the dollar amount next to the Income Total box. Total all expenses and list the dollar amount next to the Expense Total box. Subtract Income Total for Expense Total to calculate the Difference and enter the dollar amount in the appropriate box. Equal opportunity employment/program. Auxiliary aids and services are available upon request to individuals with disabilities. SUPPORTIVE SERVICE NEEDS CHECKLIST

Check any issues for which you have a need at this time. Yes No

1. Assistance with transportation -yes

2. Assistance with child care or dependent care - no 3. Assistance with housing -no

4. Referral to medical assistance -no

5. Assistance with uniforms or other work attire -yes 6. Assistance with tools, equipment, or supplies -yes 7. Assistance with eye glasses and/or protective eye glasses -yes 8. Need special adaptation for work or training because of disability -no 9. Assistance with family or personal issues -no

Indicate any concerns not addressed in the above list: Dalion Banks 10-29-21 Signature Date

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..OS IM$trriefl •rt !)It l,l#IOl\ftql,lffl 110 .-!ti\__ Applicant Name: Dalion Banks

CONTACT INFORMATION

Workforce Oklahoma WIOA must occasionally contact you, both during and after participation on our programs, to provide you with follow-up information and assistance critical to your employment and training needs. Please list three individuals who may help us locate you in the event that we are unable to contact you at your current phone number or address. Contact information should be different from your personal information. Please list 3

individuals who will probably always know how to contact you. Contact 1:

Name: _Vickie Cook Relationship: Friend

Address: 901 N. Ash st. Owasso Ok.

74055 Phone #:

__918-408-3324 Alternate# Email: ************@*****.***

Contact 2:

Name: Thomas Banks

Relationship: Brother

_422732 E. B st._Checotah__Ok. 74426

Address: 918-***-**** Phone #: Alternate Email: Contact 3:

Name: Nawakis

Banks Relationship:

_niece Address: Phone #:

_918-490-0027 Alternate

#: Email:

Contact this candidate