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Exhibit Page 3 of 4 EXPENSES AFFIDAVIT ATTACHMENT TO INITIAL QUESTIONNAIRE MCLEAN COUNTY RESIDENTIAL FORECLOSURE MEDIATION PROGRAM 1. State the total number of people living your household: Excluding yourself, list names of people living in your household: Name Age Relationship 2. Housing Expenses A. Home equity loan B. Condominium fees C. Gas/Electric D. Water E. Sewer F. Garbage collection G. Telephone (land line) H. Cell phone I. Internet J. Cable/Satellite television K. Home repairs/maintenance L. Groceries M. Miscellaneous household N. Lawn care/snow removal O. Other TOTAL HOUSING EXPENSES 3. Medical Expenses (not paid by insurance) For you, spouse, child/children. A. Doctors B. Dentist/Orthodontist C. Prescriptions/medications D. Other TOTAL MEDICAL EXPENSES 4. car expenses (Total number of cars: A. Total amount of car loan payments B. Gasoline C. Maintenance and Repairs D. Insurance ---PAGE BREAK--- Exhibit Page 4 of 4 TOTAL CAR EXPENSES 5. TOTAL CHILD CARE EXPENSES 6. Other expenses A. Credit cards B. Consumer loans C. Student loans D. Court-ordered child support E. F. TOTAL OTHER EXPENSES I, the undersigned, certify under penalty of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, that I have read the foregoing Expenses Affidavit, that I know the contents thereof, and that the statements contained therein are true to the best of my knowledge, information and belief. Dated this day of (Signature) (printed name) (case number)