Supplementary Expenses Worksheet

Total expenses that are incurred each month by, or for, the person with the disability.

Government Benefits $____________
(Total income from all government resources excluding family assistance. Do not include basic medical/dental care that is paid by Medicaid, Medicare, MediCal, or private medical/dental insurance.)


$______ Housing (Description: _________________)
      ________ Rent/Month
      ________ Utilities
      ________ Maintenance
      ________ Cleaning Home
      ________ Laundry Costs
      ________ Other

$______ Care Assistance
      ________ Live-In
      ________ Respite
      ________ Custodial
      ________ Other

$______ Personal Needs
      ________ Haircuts, Beauty Shop
      ________ Telephone (Basic, TDD, etc.)
      ________ Books, Magazines, etc.
      ________ Allowances
      ________ Other

$______ Employment
      ________ Transportation
      ________ Workshop Fees
      ________ Attendant
      ________ Training
      ________ Other

$______ Education
      ________ Transporation
      ________ Fees
      ________ Books
      ________ Other

$______ Special Equipment
      ________ Environmental Control
      ________ Elevator
      ________ Repair of Equipment
      ________ Computer
      ________ Audiobooks
      ________ Ramp
      ________ Guide/Hearing Dog
      ________ Technical Instruction
      ________ Hearing Aids
      ________ Wheelchair
      ________ Other

$______ Medical/Dental Care
      ________ General Medical/Dental Visits
      ________ Therapy
      ________ Nursing Services
      ________ Meals of Attendants
      ________ Evaluations
      ________ Transportation
      ________ Other

$______ Social/Recreational
      ________ Sports
      ________ Special Olympics
      ________ Spectator Sports
      ________ Vacations - Friends/Relatives
      ________ TV/Rental
      ________ Camps
      ________ Transportation Costs
      ________ Other

$______ Clothing - Extra

$______ Food
      ________ Meals, Snacks - Home
      ________ Outside of Home
      ________ Special Foods/Gastric Tube
      ________ Other

$______ Automobile/Van
      ________ Payments
      ________ Gas/Oil/Maintenance
      ________ Other

$______ Insurance
      ________ Medical/Dental
      ________ Burial
      ________ Van/Automobile
      ________ Housing/Rental
      ________ Other

$______ Miscellaneous
      ________ Other
      ________ Other
      ________ Other

Total Expenses $______
Less Government Benefits $______


Supplementary Expenses $______

services icon Looking for Help?

book icon Featured Book

JVIB Special Issue on Critical Issues in Visual Impairment & BlindnessJVIB Special Issue on Critical Issues in Visual Impairment & Blindness

JVIB Special Issue on Critical Issues in Visual Impairment & Blindness

Join Our Mission

Help us expand our resources for people with vision loss.