Fillable Application to Have the Chapter 7 Filing Fee (US Courts)

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Application to Have the Chapter 7 Filing Fee (US Courts)

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Official Form 103B
Application to Have the Chapter 7 Filing Fee Waived page 1
Official Form 103B
Application to Have the Chapter 7 Filing Fee Waived 12/15
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number
(if known).
Part 1: Tell the Court About Your Family and Your Family’s Income
1. What is the size of your family?
Your family includes y
ou, your
spouse, and an
y
dependents listed
on Schedule J: Your Expenses
(Official Form 10
6J).
Check all that apply:
You
Your spouse
Your dependents ___________________
How many dependents?
_
_____
_
______________
Total number of people
2. Fill in your family’s average
monthly income
.
Include
your spou
se’s income if
your spo
use is living with you, even
if y
our spouse is not filing.
Do not include your spouse’s
income if y
ou are separated an
d
your spo
use is not filing with you.
That person’s average
monthly net income
(take-home pay)
Add your income and your spouse’s income. Include the
value (if known) of any non-cash governmental assistance
that you receive, such as food stamps (benefits under the
Supplemental Nutrition Assistance Program) or housing
subsidies.
If you have already filled out Schedule I: Your Income, see
line 10 of that schedule.
You .................. $_________________
Your spouse ....
+ $_________________
Subtotal ............. $_________________
Subtract any non-cash governmental assistance that you
included above.
– $_________________
Your family’s average monthly net income
Total ..................
$_________________
3. Do you receive non-cash
go
vernmental assistan
ce?
No
Yes. Describe. ...........
Type of assistance
4. Do you expect your family’s
a
verage monthly net income to
increase or decrease by more th
an
10
% during the next 6 mont
hs?
No
Yes. Explain. .............
5. Tell the court why you are unable to pay the filing fee in
install
ments within 120 days. If you have some a
dditional
circumstances th
at cause you to not be able to pay
your filing
fee in installment
s, explain them.
Debtor 1 ________________________________________________________________
First Name Middle Name Last Name
Debtor 2 ________________________________________________________________
(Spouse, if filing) First Name Middle Name Last Name
United States Bankruptcy Court for the: __________ District of ___________
Case number ___________________________________________
(If known)
Fill in this information to identify your case:
Check if this is an
amended filing
__________ District of __________
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form 103B
Application to Have the Chapter 7 Filing Fee Waived page 2
Part 2: Tell the Court About Your Monthly Expenses
6. Estimate your average monthly expenses.
Include amounts paid by any government assistance that yo
u
reporte
d on line
2.
If
you have already filled out Schedule J, Your Expenses,
copy
line 22 from that
form.
$___________________
7. Do these expenses cover anyone
w
ho is not included in your family
as reported in line 1?
No
Yes. Identify who ........
8. Does anyone other than you
regularl
y pay any of th
ese
expenses?
If
you have already
filled out
Schedule I: Your
Income, copy the
total from line 11.
No
Yes. How much do you regularly receive as contributions? $_________ monthly
9. Do you expect your average
mon
thly expenses to increase or
decrease by more than 10% dur
ing
the n
ext 6 months?
No
Yes. Explain ................
Part 3: Tell the Court About Your Property
If you have already filled out Schedule A/B: Property (Official Form 106A/B) attach copies to this application and go to Part 4.
10. How much cash do you have?
Examples: Money
you have in
your
wallet, in your home, an
d on
hand
when you file this application
Cash: $_________________
11. Bank accounts and other deposits
of m
oney?
Examples: Chec
king, savings,
mone
y market, or
other financial
accounts; certificates of deposit;
shares in banks, credit unions,
brokerage
houses
, and other
similar inst
itutions. If y
ou have
more than o
ne account wi
th the
same institution, list each. Do not
include 401(k) an
d IRA accounts.
Institution name:
Checking account: __________________________________________________
Savings account: __________________________________________________
Other financial accounts: __________________________________________________
Other financial accounts: __________________________________________________
Amount:
$__________________
$__________________
$__________________
$__________________
12. Your home? (if you own it outright or
are purchasing it
)
Examples: Hous
e, condominium,
manufactured h
ome, or mobile home
_______________________________________________________
Number Street
_______________________________________________________
City State ZIP Code
Current value:
Amount you owe
on mortgage and
liens:
$_________________
$_________________
13. Other real estate?
_______________________________________________________
Number Street
_______________________________________________________
City State ZIP Code
Current value:
Amount you owe
on mortgage and
liens:
$_________________
$_________________
14. The vehicles you own?
Exam
ples: Cars, vans, tr
ucks,
spor
ts utility vehicles, motorcyc
les,
tractors, boats
Make: _____________________
Model: _____________________
Year: ____________
Mileage _____________________
Current value:
Amount y
ou owe
on liens:
$_________________
$_________________
Make: _____________________
Model: _____________________
Year: ____________
Mileage _____________________
Current value:
Amount y
ou owe
on liens:
$_________________
$_________________
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form 103B
Application to Have the Chapter 7 Filing Fee Waived page 3
15. Other assets?
Do not include household items
and clothing.
Describe the other assets:
Current value:
Amount you owe
on liens:
$_________________
$_________________
16. Money or property due you?
Examples: Tax re
funds, past due
or lump sum alimon
y,
spousal
support, child support,
maintenance, divorce or p
roperty
settlements, Social Security
benefits, workers’
compensation,
personal injur
y recovery
Who owes you the money or property?
___________________________________________
___________________________________________
How much is owed?
$_________________
$_________________
Do you believe you will likely receive
payment in the next 180 days?
No
Yes. Explain:
Part 4: Answer These Additional Questions
17. Have you paid anyone for
services for this case, including
filling out this applicatio
n, the
bankr
uptcy filing package, or th
e
sched
ules?
No
Yes. Whom did you pay? Check all that apply:
An attorney
A bankruptcy petition preparer, paralegal, or typing service
Someone else ________________________________________
How much did you pay?
$______________________
18. Have you promised to pay or do
you expect to pay someone fo
r
ser
vices for your bankruptcy
case?
No
Yes. Whom do you expect to pay? Check all that apply:
An attorney
A bankruptcy petition preparer, paralegal, or typing service
Someone else _________________________________________
How much do you
expect to pay?
$_______________________
19. Has anyone paid someone on
your behalf for services for this
case?
No
Yes. Who was paid on your behalf?
Check all that apply:
An attorney
A bankruptcy petition preparer,
paralegal, or typing service
Someone else _________________
Who paid?
Check all that apply:
Parent
Brother or sister
Friend
Pastor or clergy
Someone else __________
How much did
someone else pay?
$______________________
20. Have you filed for bankruptcy
within the last 8 years?
No
Yes. District _____________________________ When _____________ Case number _____________________
MM/ DD/ YYYY
District _____________________________ When _____________ Case number _____________________
MM/ DD/ YYYY
District _____________________________ When _____________ Case number _____________________
MM/ DD/ YYYY
Part 5: Sign Below
By signing here under penalty of perjury, I declare that I cannot afford to pay the filing fee either in full or in installments. I also declare
that the information I provided in this application is true and correct.
_____________________________________________ _____________________________________________
Signature of Debtor 1 Signature of Debtor 2
Date __________________ Date __________________
MM / DD / YYYY MM / DD / YYYY
Order on the Application to Have the Chapter 7 Filing Fee Waived
After considering the debtor’s Application to Have the Chapter 7 Filing Fee Waived (Official Form 103B), the court
orders that the application is:
[ ] Granted. However, the court may order the debtor to pay the fee in the future if developments in
administering the bankruptcy case show that the waiver was unwarranted.
[ ] Denied
. The debtor must pay the filing fee according to the following terms:
You m
ust pay…
On or before this date…
$_____________
_____________
Month / day / year
$_____________
_____________
Month / day / year
$_____________
_____________
Month / day / year
+ $_____________
_____________
Month / day / year
Total
If the debtor would like to propose a different payment timetable, the debtor must file a
motion promptly with a payment proposal. The debtor may use Application for Individuals to
Pay the Filing Fee in Installments (Official Form 103A) for this purpose. The court will
consider it.
The debtor must pay the entire filing fee before making any more payments or transferring any
more property to an attorney, bankruptcy petition preparer, or anyone else in connection with the
bankruptcy case. The debtor must also pay the entire filing fee to receive a discharge. If the
debtor does not make any payment when it is due, the bankruptcy case may be dismissed and
the debtor’s rights in future bankruptcy cases may be affected.
[ ] Scheduled for hearing.
A hearing to consider the debtor’s application will be held
on _____________ at _________ AM / PM at _________________________________________.
Month / day / year Address of courthouse
If the debtor does not appear at this hearing, the court may deny the application.
_____________ By the court: _____________________________________
Month / day / year United States Bankruptcy Judge
Debtor 1 ________________________________________________________________
First Name Middle Name Last Name
Debtor 2 ________________________________________________________________
(Spouse, if filing) First Name Middle Name Last Name
United States Bankruptcy Court for the: __________ District of __________
Case number _____________________________________________
(If known)
Fill in this information to identify the case:
___________________________ District of ________
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Application to Have the Chapter 7 Filing Fee (US Courts)

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Completed 10 October 2020

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