Gross wages, salaries, tips, etc:
Self:       
Spouse:       
Other:       
Total:       

Income from business, self-employment, and dependents:
Self:       
Spouse:       
Other:       
Total:       

Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income:
Self:       
Spouse:       
Other:       
Total:       

Interest, dividends, rents, royalties, income from estates, trusts, educational assistance,
alimony, child support, assistance from outside the household, and other miscellaneous sources:
Self:       
Spouse:       
Other:       
Total: