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UNITED STATES BANKRUPTCY COURT
DISTRICT OF ARIZONA
TUCSON DIVISION James
A Walsh Courthouse
38 S. Scott Avenue
Tucson, AZ 85701
520- 202-7500
PHOENIX DIVISION Federal
Building & U.S. Courthouse
230 N. First Ave., Suite 101
Phoenix AZ 85003
602-682-4000
www.azb.uscourts.gov
CHAPTER 7
YUMA DIVISION U.S.
Bankruptcy Court
325 W. 19
th
St., Suite D
Yuma, AZ 85364
928-783-2288
A bankruptcy case starts with the filing of a petition identifying the chapter. All
documents must be filed on official forms which can be found on the court’s website,
www.azb.uscourts.gov or on www.uscourts.gov/bankruptcy. Other helpful information is
also available on these websites. Filing bankruptcy can be a complex legal process and you
are advised to seek competent bankruptcy counsel before filing a petition.
THE FOLLOWING DOCUMENTS ARE NEEDED FOR INITIAL FILING OF A CASE.
1. Voluntary Petition for Individuals Filing for Bankruptcy (Form 101, 101A, 101B)
2. Valid State Issued ID
3. Statement about Your Social Security Numbers (Form 121)
THE FOLLOWING DOCUMENTS, IF THEY WERE NOT FILED WITH THE
BANKRUPTCY PETITION, ARE REQUIRED TO BE FILED NO LATER THAN 7
DAYS FROM THE DATE THE PETITION WAS FILED. IF ANY OF THESE
DOCUMENTS ARE NOT FILED WITHIN THAT TIME, YOUR CASE COULD BE
DISMISSED.
1. Typed Mailing List of Creditors
2. Credit Counseling Certificate. You may check the following web site for
approved providers, www.usdoj.gov/ust or call 602-682-4000. The credit
counselor will provide you the certificate you need to file with the court.
THE FOLLOWING DOCUMENTS, IF THEY WERE NOT FILED WITH THE
BANKRUPTCY PETITION, ARE REQUIRED TO BE FILED NO LATER THAN 14
DAYS FROM THE DATE THE PETITION WAS FILED. IF ANY OF THESE
DOCUMENTS ARE NOT FILED WITHIN THAT TIME, YOUR CASE COULD BE
DISMISSED.
1. Schedules (Form 106A/B, 106C, 106D, 106E/F, 106G, 106H, 106I, 106J, 106J-2,
106 Sum, 106 Dec)
2. Statement of Financial Affairs for Individuals Filing for Bankruptcy (Form 107)
3. Statement of Intention for Individuals Filing for Bankruptcy (Form 108)
4. Chapter 7 Statement of Your Current Monthly Income (Form 122A-1, 122A-2,
122A-1Supp)
5. Declaration of Evidence of Employers’ Payments within 60 Days
6. Declaration Under Penalty of Perjury for Debtor(s) Without an Attorney
FILING FEE $338
Cashier Check or
Money Order
ONLY
PREVIOUS BANKRUPTCY FILINGS
If you had a previous case pending within the preceding year that was dismissed, you are advised
that pursuant to 11 USC Section 362(c)(3), the automatic stay provided by Section 362(a) when
the bankruptcy petition is filed will terminate 30 days after the filing of your petition. You may
file a motion with the court seeking a continuation of the automatic stay and you will need to
demonstrate that the second case was filed in good faith. If you file a motion, please caption it
as an Emergency Motion.
If you had two or more previous cases pending within the preceding year that were dismissed,
you are advised that pursuant to 11 USC Section 362(c)(4), no stay under Section 362(a) went
into effect when your petition was filed. To obtain a stay, you must file a motion, within 30 days
of the date of the filing of the petition, and demonstrate that the new case was filed in good faith.
If you file this motion, please caption it as an Emergency Motion.
COMPLETION OF INSTRUCTIONAL COURSE CONCERNING PERSONAL
FINANCIAL MANAGEMENT
Subject to limited exceptions, an individual debtor must complete an instructional course in
personal financial management before a discharge can be entered by the court. You must
complete and file a Debtor’s Certification of Completion of Instructional Course Concerning
Personal Financial Management on the official form. This form is required to be filed within 60
days after the first date set for the meeting of creditors. Failure to file the certification could
result in your case being closed without entry of your discharge. If your case is closed without
entry of a discharge, to reopen the case to obtain your discharge, you could be required to pay a
reopening fee of $260.00.
You may check the following web site for approved providers, www.usdoj.gov/ust or call 602-
682-4000.
Official Form 121 Statement About Your Social Security Numbers
United States Bankruptcy Court for the:
__________ District of __________
Case number
(If known): _________________________
Fill in this information to identify your case:
Official Form 121
Statement About Your Social Security Numbers 12/15
Use this form to tell the court about any Social Security or federal Individual Taxpayer Identification numbers you have used. Do not file this
form as part of the public case file. This form must be submitted separately and must not be included in the court’s public electronic records.
Please consult local court procedures for submission requirements.
To protect your privacy, the court will not make this form available to the public. You should not include a full Social Security Number or
Individual Taxpayer Number on any other document filed with the court. The court will make only the last four digits of your numbers known
to the public. However, the full numbers will be available to your creditors, the U.S. Trustee or bankruptcy administrator, and the trustee
assigned to your case.
Making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in
fines up to $250,000, or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
Part 1: Tell the Court About Yourself and Your spouse if Your Spouse is Filing With You
For Debtor 1: For Debtor 2 (Only If Spouse Is Filing):
1. Your name
_________________________________________________
First name
_________________________________________________
Middle name
_________________________________________________
Last name
_________________________________________________
First name
_________________________________________________
Middle name
_________________________________________________
Last name
Part 2: Tell the Court About all of Your Social Security or Federal Individual Taxpayer Identification Numbers
2. All Social Security
Numbers you have
used
__ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __
You do not have a Social Security number.
__ __ __ __ __
__ __ __ __
__ __ __ __ __
__ __ __ __
You do not have a Social Security number.
3. All federal Individual
Taxpayer
Identification
Numbers (ITIN) you
have used
9 __ __ __ __ __ __ __ __
9 __ __ __ __ __ __ __ __
You do not have an ITIN.
9 __ __ __ __ __ __ __ __
9 __ __ __ __ __ __ __ __
You do not have an ITIN.
Part 3: Sign Below
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
_______________________________________
Signature of Debtor 1
Date _________________
M
M / DD / YYYY
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
_______________________________________
Signature of Debtor 2
Date _________________
M
M / DD / YYYY
District of Arizona
Print
Save As...
Reset
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 1
Official Form 101
Voluntary Petition for Individuals Filing for Bankruptcy 04/20
The bankruptcy forms use you and Debtor 1 to refer to a debtor filing alone. A married couple may file a bankruptcy case together—called a
joint case—and in joint cases, these forms use you to ask for information from both debtors. For example, if a form asks, “Do you own a car,”
the answer would be yes if either debtor owns a car. When information is needed about the spouses separately, the form uses Debtor 1 and
Debtor 2 to distinguish between them. In joint cases, one of the spouses must report information as Debtor 1 and the other as Debtor 2. The
same person must be Debtor 1 in all of the forms.
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). Answer every question.
Part 1:
Identify Yourself
About Debtor 2 (Spouse Only in a Joint Case):
1. Your full name
Write the name that is on your
government-issued picture
identification (for example,
your driver’s license or
passport).
Bring your picture
identification to your meeting
with the trustee.
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
___________________________
Suffix (Sr., Jr., II, III)
2. All other names you
have used in the last 8
years
Include your married or
maiden names.
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
3. Only the last 4 digits of
your Social Security
number or federal
Individual Taxpayer
Identification number
(ITIN)
xxx – xx – ____ ____ ____ ____
OR
9 xx – xx – ____ ____ ____ ____
United States Bankruptcy Court for the:
________________ District of ________
Case number (If known): _________________________ Chapter you are filing under:
Chapter 7
Chapter 11
Chapter 12
Chapter 13
Fill in this information to identify your case:
Check if this is an
amended filing
District of Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 2
About Debtor 2 (Spouse Only in a Joint Case):
4. Any business names
and Employer
Identification Numbers
(EIN) you have used in
the last 8 years
Include trade names and
doing business as names
I have not used any business names or EINs.
_________________________________________________
Business name
_________________________________________________
Business name
___ ___ – ___ ___ ___ ___ ___ ___ ___
EIN
___ ___ – ___ ___ ___ ___ ___ ___ ___
EIN
5. Where you live
If Debtor 2 lives at a different address:
_________________________________________________
Number Street
_________________________________________________
_________________________________________________
City State ZIP Code
_________________________________________________
County
If Debtor 2’s mailing address is different from
yours, fill it in here. Note that the court will send
any notices to this mailing address.
_________________________________________________
Number Street
_________________________________________________
P.O. Box
_________________________________________________
City State ZIP Code
6. Why you are choosing
this district to file for
bankruptcy
Check one:
Over the last 180 days before filing this petition,
I have lived in this district longer than in any
other district.
I have another reason. Explain.
(See 28 U.S.C. § 1408.)
________________________________________
________________________________________
________________________________________
________________________________________
Check one:
Over the last 180 days before filing this petition,
I have lived in this district longer than in any
other district.
I have another reason. Explain.
(See 28 U.S.C. § 1408.)
________________________________________
________________________________________
________________________________________
________________________________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 3
Part 2:
Tell the Court About Your Bankruptcy Case
7. The chapter of the
Bankruptcy Code you
are choosing to file
under
Check one. (For a brief description of each, see Notice Required by 11 U.S.C. § 342(b) for Individuals Filing
for Bankruptcy (Form 2010)). Also, go to the top of page 1 and check the appropriate box.
Chapter 7
Chapter 11
Chapter 12
Chapter 13
8. How you will pay the fee
I will pay the entire fee when I file my petition. Please check with the clerk’s office in your
local court for more details about how you may pay. Typically, if you are paying the fee
yourself, you may pay with cash, cashier’s check, or money order. If your attorney is
submitting your payment on your behalf, your attorney may pay with a credit card or check
with a pre-printed address.
I need to pay the fee in installments. If you choose this option, sign and attach the
Application for Individuals to Pay The Filing Fee in Installments (Official Form 103A).
I request that my fee be waived (You may request this option only if you are filing for Chapter 7.
By law, a judge may, but is not required to, waive your fee, and may do so only if your income is
less than 150% of the official poverty line that applies to your family size and you are unable to
pay the fee in installments). If you choose this option, you must fill out the Application to Have the
Chapter 7 Filing Fee Waived (Official Form 103B) and file it with your petition.
9. 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
10. Are any bankruptcy
cases pending or being
filed by a spouse who is
not filing this case with
you, or by a business
partner, or by an
affiliate?
No
Yes. Debtor _________________________________________________ Relationship to you _____________________
District __________________________ When _______________ Case number, if known____________________
MM / DD / YYYY
Debtor _________________________________________________ Relationship to you _____________________
District __________________________ When _______________ Case number, if known____________________
MM / DD / YYYY
11. Do you rent your
residence?
No. Go to line 12.
Yes. Has your landlord obtained an eviction judgment against you?
No. Go to line 12.
Yes. Fill out Initial Statement About an Eviction Judgment Against You (Form 101A) and file it as
part of this bankruptcy petition.
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 4
Part 3:
Report About Any Businesses You Own as a Sole Proprietor
12. Are you a sole proprietor
of any full- or part-time
business?
A sole proprietorship is a
business you operate as an
individual, and is not a
separate legal entity such as
a corporation, partnership, or
LLC.
If you have more than one
sole proprietorship, use a
separate sheet and attach it
to this petition.
No. Go to Part 4.
Yes. Name and location of business
_______________________________________________________________________________________
Name of business, if any
_______________________________________________________________________________________
Number Street
_______________________________________________________________________________________
_______________________________________________ _______ __________________________
City State ZIP Code
Check the appropriate box to describe your business:
Health Care Business (as defined in 11 U.S.C. § 101(27A))
Single Asset Real Estate (as defined in 11 U.S.C. § 101(51B))
Stockbroker (as defined in 11 U.S.C. § 101(53A))
Commodity Broker (as defined in 11 U.S.C. § 101(6))
None of the above
13. Are you filing under
Chapter 11 of the
Bankruptcy Code, and
are you a small business
debtor or a debtor as
defined by 11 U.S. C. §
1182(1)?
For a definition of small
business debtor, see
11 U.S.C. § 101(51D).
If you are filing under Chapter 11, the court must know whether you are a small business debtor or a debtor
choosing to proceed under Subchapter V so that it can set appropriate deadlines. If you indicate that you
are a small business debtor or you are choosing to proceed under Subchapter V, you must attach your
most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or
if any of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B).
No. I am not filing under Chapter 11.
No. I am filing under Chapter 11, but I am NOT a small business debtor according to the definition in
the Bankruptcy Code.
Yes. I am filing under Chapter 11, I am a small business debtor according to the definition in the Bankruptcy
Code, and I do not choose to proceed under Subchapter V of Chapter 11.
Yes. I am filing under Chapter 11, I am a debtor according to the definition in § 1182(1) of the
Bankruptcy Code, and I choose to proceed under Subchapter V of Chapter 11.
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 5
Part 4: Report if You Own or Have Any Hazardous Property or Any Property That Needs Immediate Attention
14. Do you own or have any
property that poses or is
alleged to pose a threat
of imminent and
identifiable hazard to
public health or safety?
Or do you own any
property that needs
immediate attention?
For example, do you own
perishable goods, or livestock
that must be fed, or a buildi
ng
t
hat needs urgent repairs?
No
Yes. What is the hazard? ________________________________________________________________________
___
_____________________________________________________________________
If immediate attention is needed, why is it needed? _______________________________________________
________________________________________________________________________
Where is the property? ________________________________________________________________________
Number Street
________________________________________________________________________
________________________________________ _______ ____________________
City State ZIP Code
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 6
Part 5:
Explain Your Efforts to Receive a Briefing About Credit Counseling
15. Tell the court whether
you have received a
briefing about credit
counseling.
The law requires that you
receive a briefing about credit
counseling before you file for
bankruptcy. You must
truthfully check one of the
following choices. If you
cannot do so, you are not
eligible to file.
If you file anyway, the court
can dismiss your case, you
will lose whatever filing fee
you paid, and your creditors
can begin collection activities
again.
About Debtor 1:
About Debtor 2 (Spouse Only in a Joint Case):
You must check one:
I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, and I received a
certificate of completion.
Attach a copy of the certificate and the payment
plan, if any, that you developed with the agency.
I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, but I do not have a
certificate of completion.
Within 14 days after you file this bankruptcy petition,
you MUST file a copy of the certificate and payment
plan, if any.
I certify that I asked for credit counseling
services from an approved agency, but was
unable to obtain those services during the 7
days after I made my request, and exigent
circumstances merit a 30-day temporary waiver
of the requirement.
To ask for a 30-day temporary waiver of the
requirement, attach a separate sheet explaining
what efforts you made to obtain the briefing, why
you were unable to obtain it before you filed for
bankruptcy, and what exigent circumstances
required you to file this case.
Your case may be dismissed if the court is
dissatisfied with your reasons for not receiving a
briefing before you filed for bankruptcy.
If the court is satisfied with your reasons, you must
still receive a briefing within 30 days after you file.
You must file a certificate from the approved
agency, along with a copy of the payment plan you
developed, if any. If you do not do so, your case
may be dismissed.
Any extension of the 30-day deadline is granted
only for cause and is limited to a maximum of 15
days.
I am not required to receive a briefing about
credit counseling because of:
Incapacity. I have a mental illness or a mental
deficiency that makes me
incapable of realizing or making
rational decisions about finances.
Disability. My physical disability causes me
to be unable to participate in a
briefing in person, by phone, or
through the internet, even after I
reasonably tried to do so.
Active duty. I am currently on active military
duty in a military combat zone.
If you believe you are not required to receive a
briefing about credit counseling, you must file a
motion for waiver of credit counseling with the court.
You must check one:
I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, and I received a
certificate of completion.
Attach a copy of the certificate and the payment
plan, if any, that you developed with the agency.
I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, but I do not have a
certificate of completion.
Within 14 days after you file this bankruptcy petition,
you MUST file a copy of the certificate and payment
plan, if any.
I certify that I asked for credit counseling
services from an approved agency, but was
unable to obtain those services during the 7
days after I made my request, and exigent
circumstances merit a 30-day temporary waiver
of the requirement.
To ask for a 30-day temporary waiver of the
requirement, attach a separate sheet explaining
what efforts you made to obtain the briefing, why
you were unable to obtain it before you filed for
bankruptcy, and what exigent circumstances
required you to file this case.
Your case may be dismissed if the court is
dissatisfied with your reasons for not receiving a
briefing before you filed for bankruptcy.
If the court is satisfied with your reasons, you must
still receive a briefing within 30 days after you file.
You must file a certificate from the approved
agency, along with a copy of the payment plan you
developed, if any. If you do not do so, your case
may be dismissed.
Any extension of the 30-day deadline is granted
only for cause and is limited to a maximum of 15
days.
I am not required to receive a briefing about
credit counseling because of:
Incapacity. I have a mental illness or a mental
deficiency that makes me
incapable of realizing or making
rational decisions about finances.
Disability. My physical disability causes me
to be unable to participate in a
briefing in person, by phone, or
through the internet, even after I
reasonably tried to do so.
Active duty. I am currently on active military
duty in a military combat zone.
If you believe you are not required to receive a
briefing about credit counseling, you must file a
motion for waiver of credit counseling with the court.
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 7
Part 6:
Answer These Questions for Reporting Purposes
16. What kind of debts do
you have?
16a. Are your debts primarily consumer debts? Consumer debts are defined in 11 U.S.C. § 101(8)
as “incurred by an individual primarily for a personal, family, or household purpose.”
No. Go to line 16b.
Yes. Go to line 17.
16b. Are your debts primarily business debts? Business debts are debts that you incurred to obtain
money for a business or investment or through the operation of the business or investment.
No. Go to line 16c.
Yes. Go to line 17.
16c. State the type of debts you owe that are not consumer debts or business debts.
_______________________________________________________________
17. Are you filing under
Chapter 7?
Do you estimate that after
any exempt property is
excluded and
administrative expenses
are paid that funds will be
available for distribution
to unsecured creditors?
No. I am not filing under Chapter 7. Go to line 18.
Yes. I am filing under Chapter 7. Do you estimate that after any exempt property is excluded and
administrative expenses are paid that funds will be available to distribute to unsecured creditors?
No
Yes
18. How many creditors do
you estimate that you
owe?
1-49
50-99
100-199
200-999
1,000-5,000
5,001-10,000
10,001-25,000
25,001-50,000
50,001-100,000
More than 100,000
19. How much do you
estimate your assets to
be worth?
$0-$50,000
$50,001-$100,000
$100,001-$500,000
$500,001-$1 million
$1,000,001-$10 million
$10,000,001-$50 million
$50,000,001-$100 million
$100,000,001-$500 million
$500,000,001-$1 billion
$1,000,000,001-$10 billion
$10,000,000,001-$50 billion
More than $50 billion
20. How much do you
estimate your liabilities
to be?
$0-$50,000
$50,001-$100,000
$100,001-$500,000
$500,001-$1 million
$1,000,001-$10 million
$10,000,001-$50 million
$50,000,001-$100 million
$100,000,001-$500 million
$500,000,001-$1 billion
$1,000,000,001-$10 billion
$10,000,000,001-$50 billion
More than $50 billion
Part 7:
Sign Below
For you
I have examined this petition, and I declare under penalty of perjury that the information provided is true and
correct.
If I have chosen to file under Chapter 7, I am aware that I may proceed, if eligible, under Chapter 7, 11,12, or 13
of title 11, United States Code. I understand the relief available under each chapter, and I choose to proceed
under Chapter 7.
If no attorney represents me and I did not pay or agree to pay someone who is not an attorney to help me fill out
this document, I have obtained and read the notice required by 11 U.S.C. § 342(b).
I request relief in accordance with the chapter of title 11, United States Code, specified in this petition.
I understand making a false statement, concealing property, or obtaining money or property by fraud in connection
with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both.
18 U.S.C. §§ 152, 1341, 1519, and 3571.
______________________________________________ _____________________________
Signature of Debtor 1 Signature of Debtor 2
Executed on _________________ Executed on __________________
MM / DD / YYYY MM / DD / YYYY
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 8
For your attorney, if you are
represented by one
If you are not represented
by an attorney, you do not
need to file this page.
I, the attorney for the debtor(s) named in this petition, declare that I have informed the debtor(s) about eligibility
to proceed under Chapter 7, 11, 12, or 13 of title 11, United States Code, and have explained the relief
available under each chapter for which the person is eligible. I also certify that I have delivered to the debtor(s)
the notice required by 11 U.S.C. § 342(b) and, in a case in which § 707(b)(4)(D) applies, certify that I have no
knowledge after an inquiry that the information in the schedules filed with the petition is incorrect.
_________________________________ Date _________________
Signature of Attorney for Debtor MM / DD / YYYY
_________________________________________________________________________________________________
Printed name
_________________________________________________________________________________________________
Firm name
_________________________________________________________________________________________________
Number Street
_________________________________________________________________________________________________
______________________________________________________ ____________ ______________________________
City State ZIP Code
Contact phone _____________________________________ Email address ______________________________
______________________________________________________ ____________
Bar number State
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 9
For you if you are filing this
bankruptcy without an
attorney
If you are represented by
an attorney, you do not
need to file this page.
The law allows you, as an individual, to represent yourself in bankruptcy court, but you
should understand that many people find it extremely difficult to represent
themselves successfully. Because bankruptcy has long-term financial and legal
consequences, you are strongly urged to hire a qualified attorney.
To be successful, you must correctly file and handle your bankruptcy case. The rules are very
technical, and a mistake or inaction may affect your rights. For example, your case may be
dismissed because you did not file a required document, pay a fee on time, attend a meeting or
hearing, or cooperate with the court, case trustee, U.S. trustee, bankruptcy administrator, or audit
firm if your case is selected for audit. If that happens, you could lose your right to file another
case, or you may lose protections, including the benefit of the automatic stay.
You must list all your property and debts in the schedules that you are required to file with the
court. Even if you plan to pay a particular debt outside of your bankruptcy, you must list that debt
in your schedules. If you do not list a debt, the debt may not be discharged. If you do not list
property or properly claim it as exempt, you may not be able to keep the property. The judge can
also deny you a discharge of all your debts if you do something dishonest in your bankruptcy
case, such as destroying or hiding property, falsifying records, or lying. Individual bankruptcy
cases are randomly audited to determine if debtors have been accurate, truthful, and complete.
Bankruptcy fraud is a serious crime; you could be fined and imprisoned.
If you decide to file without an attorney, the court expects you to follow the rules as if you had
hired an attorney. The court will not treat you differently because you are filing for yourself. To be
successful, you must be familiar with the United States Bankruptcy Code, the Federal Rules of
Bankruptcy Procedure, and the local rules of the court in which your case is filed. You must also
be familiar with any state exemption laws that apply.
Are you aware that filing for bankruptcy is a serious action with long-term financial and legal
consequences?
No
Yes
Are you aware that bankruptcy fraud is a serious crime and that if your bankruptcy forms are
inaccurate or incomplete, you could be fined or imprisoned?
No
Yes
Did you pay or agree to pay someone who is not an attorney to help you fill out your bankruptcy forms?
No
Yes. Name of Person_____________________________________________________________________.
Attach Bankruptcy Petition Preparer’s Notice, Declaration, and Signature (Official Form 119).
By signing here, I acknowledge that I understand the risks involved in filing without an attorney. I
have read and understood this notice, and I am aware that filing a bankruptcy case without an
attorney may cause me to lose my rights or property if I do not properly handle the case.
_______________________________________________ ______________________________
Signature of Debtor 1 Signature of Debtor 2
Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY
Contact phone ______________________________________ Contact phone ________________________________
Cell phone ______________________________________ Cell phone ________________________________
Email address ______________________________________ Email address ________________________________
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MML-1
United States Bankruptcy Court
District of Arizona
MASTER MAILING LIST REQUIREMENTS
The ba
nkruptcy rules require that debtor file with the petition a list containing the names and
address of all creditors. The list must conform to the following requirements:
1.
The mailing list must be typed in black ink. Handwritten lists will not be accepted.
2.
Include the debtor name and case number in the one inch top margin.
3.
The list must be typed in a straight column on the left margin, using ALL CAPS
.
4.
Typing on each line shall not exceed 40 charac
ters.
5.
Each name and address must consist of no more than five (5) total lines
.
6.
Include the City, State and Zip Code on the last line of each address.
The State must
be ab
breviated using the U.S. Postal Codes below.
7.
Single space the list with at least one blank line between creditors.
8.
Do not include the name and address of the debtor, joint debtor, attorney for debt
or,
U.S. Truste
e or Case Trustee. This information is added by the court.
9.
Complete and submit the attached Declaration page with the mailing
list.
10.
Attorneys refer to the ECF Procedural Manuals and Guides on the court’s webs
ite
for add
itional requirem
ents.
Supplemental (Amen
ded) Mailing Lists
Pursu
ant to Local Rule of Bankruptcy Procedure 1007-1(a)(2) “When an addition or change
is made to the master mailing list, the entire master mailing list shall not be filed or
electronically submitted. Only a supplemental master mailing list, in the required format,
containing only the newly added or changed creditors shall be filed and electronically
submitted.”
Incomplete Addresses
An ad
dress that does not include a Street Address or PO Box, City, State and Zip Code
may not be mailed.
Notice of Returned Mail
Notic
es that are mailed by the Bankruptcy Noticing Center, but returned by the post office
as undeliverable, are returned to the debtor or debtor’s attorney. The debtor or their
attorney may correct the address on the notice and file it with the Clerk's Office. The debtor
or their attorney must mail the returned notice to that creditor at the corrected address.
Notice of Undeliverable Mail
The Ban
kruptcy Noticing Center will send to the debtor and debtor’s attorney a Notice of
Undeliverable Mail stating why a notice was not mailed to a particular creditor. The debtor
or their attorney may correct the address on the notice and file it with the Clerk's Office. The
address will then be corrected for any future notices. The debtor or their attorney must mail
the non-mailed notice to that creditor at the corrected address.
MML-2
JONES, JOHN AND JANE 18-00000
ABC COMPANY
C/O JOHN DOE
ATTORNEY AT LAW
1234 MAIN ST #567
ANYWHERE AZ 85000
XYZ COMPANY
ATTN: BANKRUPTCY DEPT
1234 CENTRAL AVE
ANYWHERE AZ 85000
JANE DOE
3456 CENTRAL AVE
ANYWHERE AZ 85000
STATE/TERRITORY ABBREVIATIONS
Alabama AL Kentucky KY Oklahoma OK
A
laska
A
K Louisiana L
A
Oregon OR
A
rizona
A
Z Maine ME Pennsylvania P
A
A
rkansas
A
R Maryland MD Puerto Rico PR
California C
A
Massachusetts M
A
Rhode Island RI
Colorado CO Michigan MI South Carolina SC
Connecticut CT Minnesota MN South Dakota SD
Delaware DE Mississippi MS Tennessee TN
District of Missouri MO Texas TX
Columbia DC Montana MT Utah UT
Florida FL Nebraska NE Vermont VT
Georgia G
A
Nevada NV Virginia V
A
Guam GU New Hampshire NH Virgin Islands VI
Hawaii HI New Jersey NJ Washington W
A
Idaho ID New Mexico NM West Virginia WV
Illinois IL New York NY Wisconsin WI
Indiana IN North Carolina NC Wyoming WY
Iowa I
A
North Dakota ND
Kansas KS Ohio OH
MML-3
MAILING LIST DECLARATION
Debtor(s)' Name(s) Case No._________________________________
_______________________________________
_______________________________________
I, ________________________________, do hereby certify, under penalty of perjury, that the
Mailing List, consisting of ________ page(s), is complete, correct and consistent with the debtor(s)'
Schedules.
Dated: _________________________________ ______________________________________
(Debtor)
_______________________________________ _______________________________________
(Attorney, if applicable) (Joint Debtor)
MML_Requirements_4-2018
□ Check if this is an
Amended/Supplemental Mailing List
(Include only newly added or
changed creditors.)
Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2
Official Form 106Sum
Summary of Your Assets and Liabilities and Certain Statistical Information 12/15
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information. Fill out all of your schedules first; then complete the information on this form.
If you are filing amended schedules after you file
your original forms, you must fill out a new Summary and check the box at the top of this page.
Part 1: Summarize Your Assets
Your assets
Value of what you own
1. Schedule A/B: Property (Official Form 106A/B)
1a. Copy line 55, Total real estate, from Schedule A/B ..........................................................................................................
$ ________________
1b. Copy line 62, Total personal property, from Schedule A/B ...............................................................................................
$ ________________
1c. Copy line 63, Total of all property on Schedule A/B .........................................................................................................
$ ________________
Part 2: Summarize Your Liabilities
Your liabilities
Amount you owe
2. Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D)
2a. Copy the total you listed in Column A, Amount of claim, at the bottom of the last page of Part 1 of Schedule D ............
$ ________________
3. Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F)
3a. Copy the total claims from Part 1 (priority unsecured claims) from line 6e of Schedule E/F ............................................
$ ________________
3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F .......................................
+ $ ________________
Your total liabilities
$ ________________
Part 3: Summarize Your Income and Expenses
4. Schedule I: Your Income (Official Form 106I)
Copy your combined monthly income from line 12 of Schedule I ..........................................................................................
$ ________________
5. Schedule J: Your Expenses (Official Form 106J)
Copy your monthly expenses from line 22c of Schedule J ....................................................................................................
$ ________________
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 Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 2 of 2
Part 4: Answer These Questions for Administrative and Statistical Records
6.
Are you filing for bankruptcy under Chapters 7, 11, or 13?
No. You have nothing to report on this part of the form. Check this box and submit this form to the court with your other schedules.
Yes
7. What kind of debt do you have?
Your debts are primarily consumer debts. Consumer debts are those “incurred by an individual primarily for a personal,
family, or household purpose.” 11 U.S.C. § 101(8).
Fill out lines 8-9g for statistical purposes. 28 U.S.C. § 159.
Your debts are not primarily consumer debts. You have nothing to report on this part of the form. Check this box and submit
this form to the court with your other schedules.
8. From the Statement of Your Current Monthly Income: Copy your total current monthly income from Official
Form 122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14.
$ _________________
9. Copy the following special categories of claims from Part 4, line 6 of Schedule E/F:
Total claim
From Part 4 on Schedule E/F, copy the following:
9a. Domestic support obligations (Copy line 6a.)
$_____________________
9b. Taxes and certain other debts you owe the government. (Copy line 6b.)
$_____________________
9c. Claims for death or personal injury while you were intoxicated. (Copy line 6c.)
$_____________________
9d. Student loans. (Copy line 6f.)
$_____________________
9e. Obligations arising out of a separation agreement or divorce that you did not report as
priority claims. (Copy line 6g.)
$_____________________
9f. Debts to pension or profit-sharing plans, and other similar debts. (Copy line 6h.)
+ $_____________________
9g. Total. Add lines 9a through 9f.
$_____________________
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Official Form 106A/B Schedule A/B: Property page 1
Official Form 106A/B
Schedule A/B: Property 12/15
In each category, separately list and describe items. List an asset only once. If an asset fits in more than one category, list the asset in the
category where you think it fits best. 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). Answer every question.
Part 1: Describe Each Residence, Building, Land, or Other Real Estate You Own or Have an Interest In
1. Do you own or have any legal or equitable interest in any residence, building, land, or similar property?
No. Go to Part 2.
Yes. Where is the property?
1.1. _________________________________________
Street address, if available, or other description
_________________________________________
_________________________________________
City State ZIP Code
_________________________________________
County
What is the property? Check all that apply.
Single-family home
Duplex or multi-unit building
Condominium or cooperative
Manufactured or mobile home
Land
Investment property
Timeshare
Other __________________________________
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$_______________
Describe the nature of your ownership
interest (such as fee simple, tenancy by
the entireties, or a life estate), if known.
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
__________________________________________
Check if this is community property
(see instructions)
Other in
formation you wish to add about this item, such as local
property identification number: _______________________________
If you own or have more than one, list here:
1.2. ________________________________________
Street address, if available, or other description
________________________________________
________________________________________
City State ZIP Code
________________________________________
County
What is the property? Check all that apply.
Single-family home
Duplex or multi-unit building
Condominium or cooperative
Manufactured or mobile home
Land
Investment property
Timeshare
Other __________________________________
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$_________________
Describe the nature of your ownership
interest (such as fee simple, tenancy by
the entireties, or a life estate), if known.
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
__________________________________________
Check if this is community property
(see instructions)
Other in
formation you wish to add about this item, such as local
property identification number: _______________________________
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 ___________________________________________
Fill in this information to identify your case and this filing:
Check if this is an
amended filing
District of Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 2
1.3. ________________________________________
Street address, if available, or other description
________________________________________
________________________________________
City State ZIP Code
________________________________________
County
What is the property? Check all that apply.
Single-family home
Duplex or multi-unit building
Condominium or cooperative
Manufactured or mobile home
Land
Investment property
Timeshare
Other __________________________________
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$_________________
Describe the nature of your ownership
interest (such as fee simple, tenancy by
the entireties, or a life estate), if known.
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
__________________________________________
Check if this is community property
(see instructions)
Other in
formation you wish to add about this item, such as local
property identification number: _______________________________
2. Add the dollar value of the portion you own for all of your entries from Part 1, including any entries for pages
you have attached for Part 1. Write that number here.
......................................................................................
$_________________
Part 2:
Describe Your Vehicles
Do you own, lease, or have legal or equitable interest in any vehicles, whether they are registered or not? Include any vehicles
you own that someone else drives. If you lease a vehicle, also report it on Schedule G: Executory Contracts and Unexpired Leases.
3. Cars, vans, trucks, tractors, sport utility vehicles, motorcycles
No
Yes
3.1.
Make: ______________
Model: ______________
Year: ____________
Approximate mileage: ____________
Other information:
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this is community property (see
instructions)
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$________________
If you own or have more than one, describe here:
3.2.
Make: ______________
Model: ______________
Year: ____________
Approximate mileage: ____________
Other information:
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this is community property (see
instructions)
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 3
3.3.
Make: ______________
Model: ______________
Year: ____________
Approximate mileage: ____________
Other information:
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this is community property (see
instructions)
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$________________
3.4.
Make: ______________
Model: ______________
Year: ____________
Approximate mileage: ____________
Other information:
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this is community property (see
instructions)
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$________________
4. Watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories
Examples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle accessories
No
Yes
4.1.
Make: ____________________
Model: ____________________
Year: ____________
Other information:
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this is community property (see
instructions)
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$________________
If you own or have more than one, list here:
4.2.
Make: ____________________
Model: ____________________
Year: ____________
Other information:
Who has an interest in the property? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this is community property (see
instructions)
Do not deduct secured claims or exemptions. Put
the amount of any secured claims on Schedule D:
Creditors Who Have Claims Secured by Property.
Current value of the
entire property?
$________________
Current value of the
portion you own?
$________________
5. Add the dollar value of the portion you own for all of your entries from Part 2, including any entries for pages
you have attached for Part 2. Write that number here
........................................................................................................................
$_________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 4
Part 3: Describe Your Personal and Household Items
Do you own or have any legal or equitable interest in any of the following items?
Current value of the
portion you own?
Do not deduct secured claims
or exemptions.
6. Household goods and furnishings
Examples: Major appliances, furniture, linens, china, kitchenware
No
Yes. Describe. ........
$___________________
7. Electronics
Examples: Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music
collections; electronic devices including cell phones, cameras, media players, games
No
Yes. Describe. .........
$____________
_______
8. Collectibles of value
Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects;
stamp, coin, or baseball card collections; other collections, memorabilia, collectibles
No
Yes. Describe. .........
$____________
_______
9. Equipment for sports and hobbies
Examples: Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes
and kayaks; carpentry tools; musical instruments
No
Yes. Describe. .........
$____________
_______
10. Firearms
Examples: Pistols, rifles, shotguns, ammunition, and related equipment
No
Yes. Describe. .........
.
$____________
_______
11. Clothes
Examples: Everyday clothes, furs, leather coats, designer wear, shoes, accessories
No
Yes. Describe. .........
.
$____________
_______
12. Jewelry
Examples: Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems,
gold, silver
No
Yes. Describe. ..........
$____________
_______
13. Non-farm animals
Examples: Dogs, cats, birds, horses
No
Yes. Describe. ..........
$____________
_______
14. Any other personal and household items you did not already list, including any health aids you did not list
No
Yes. Give specific
information.
..............
$____________
_______
15. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached
for Part 3. Write that number here
....................................................................................................................................................
$______________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 5
Part 4: Describe Your Financial Assets
Do you own or have any legal or equitable interest in any of the following?
Current value of the
portion you own?
Do not deduct secured claims
or exemptions.
16. Cash
Examples: Money you have in your wallet, in your home, in a safe deposit box, and on hand when you file your petition
 No
 Yes ................................................................................................................................................................
Cash: .......................
$__________________
17. Deposits of money
Examples: Checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerage houses,
and other similar institutions. If you have multiple accounts with the same institution, list each.
No
Yes .....................
Institution name:
17.1. Checking account: _________________________________________________________
17.2. Checking account: _________________________________________________________
17.3. Savings account: _________________________________________________________
17.4. Savings account: _________________________________________________________
17.5. Certificates of deposit: _________________________________________________________
17.6. Other financial account: _________________________________________________________
17.7. Other financial account: _________________________________________________________
17.8. Other financial account: _________________________________________________________
17.9. Other financial account: _________________________________________________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
18. Bonds, mutual funds, or publicly traded stocks
Examples: Bond funds, investment accounts with brokerage firms, money market accounts
 No
 Yes .................
Institution or issuer name:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
$__________________
$__________________
$__________________
19. Non-publicly traded stock and interests in incorporated and unincorporated businesses, including an interest in
an LLC, partnership, and joint venture
No
Yes. Give specific
information about
them
.........................
Name of entity: % of ownership:
_____________________________________________________________________ ___________%
_____________________________________________________________________ ___________%
_____________________________________________________________________ ___________%
$__________________
$__________________
$__________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 6
20. Government and corporate bonds and other negotiable and non-negotiable instruments
Negotiable instruments include personal checks, cashiers’ checks, promissory notes, and money orders.
Non-negotiable instruments are those you cannot transfer to someone by signing or delivering them.
 No
Yes. Give specific
information abou
t
them
.......................
Issuer name:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
$__________________
$__________________
$__________________
21. Retirement or pension accounts
Examples: Interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sharing plans
No
Yes. List each
account separately.
Type of account: Institution name:
401(k) or similar plan: ___________________________________________________________________
Pension plan: ___________________________________________________________________
IRA: ____________
_______________________________________________________
Retirement account: ___________________________________________________________________
Keogh: ___________________________________________________________________
Additional account: ___________________________________________________________________
Additional account: ___________________________________________________________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
22. Security deposits and prepayments
Your share of all unused deposits you have made so that you may continue service or use from a company
Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications
companies, or others
No
Yes ..........................
Institution name or individual:
Electric: ______________________________________________________________________
Gas: ______________________________________________________________________
Heating oil: ______________________________________________________________________
Security deposit on rental unit: _____________________________________________________________
Prepaid rent: ______________________________________________________________________
Telephone: ______________________________________________________________________
Water: ______________________________________________________________________
Rented furniture: ______________________________________________________________________
Other: ______________________________________________________________________
$___________________
$___________________
$___________________
$___________________
$___________________
$___________________
$___________________
$___________________
$___________________
23. Annuities (A contract for a periodic payment of money to you, either for life or for a number of years)
No
Yes ..........................
Issuer name and description:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
$__________________
$__________________
$__________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 7
24. Interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program.
26 U.S.C. §§ 530(b)(1), 529A(b), and 529(b)(1).
No
Yes ....................................
Institution name and description. Separately file the records of any interests.11 U.S.C. § 521(c)
:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
$_________________
$_________________
$_________________
25. Trusts, equitable or future interests in property (other than anything listed in line 1), and rights or powers
exercisable for your benefit
No
Yes. Give specific
information about them
. ...
$__________________
26. Patents, copyrights, trademarks, trade secrets, and other intellectual property
Examples: Internet domain names, websites, proceeds from royalties and licensing agreements
No
Yes. Give specific
information about them
. ...
$__________________
27. Licenses, franchises, and other general intangibles
Examples: Building permits, exclusive licenses, cooperative association holdings, liquor licenses, professional licenses
No
Yes. Give specific
information about them
. ...
$__________________
Money or property owed to you?
Current value of the
portion you own?
Do not deduct secured
claims or exemptions.
28. Tax refunds owed to you
No
Yes. Give specific information
about them, including whether
you already filed the returns
and the tax years. .......................
Federal: $_________________
State:
$_________________
Local:
$_________________
29. Family support
Examples: Past due or lump sum alimony, spousal support, child support, maintenance, divorce settlement, property
settlement
No
Yes. Give specific information. .............
Alimony:
Maintenan
ce:
Support:
Div
o
rce settlement:
Property settlement:
$________________
$________________
$________________
$________________
$________________
30. Other amounts someone owes you
Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compensation,
Social Security benefits; unpaid loans you made to someone else
No
Yes. Give specific information. ..............
$______________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 8
31. Interests in insurance policies
Examples: Health, disability, or life insurance; health savings account (HSA); credit, homeowner’s, or renter’s insurance
No
Yes. Name the insurance company
of each policy and list its value
. ..
.
Company name: Beneficiary:
___________________________________________ ____________________________
___________________________________________ ____________________________
___________________________________________ ____________________________
Surrender or refund value:
$__________________
$__________________
$__________________
32. Any interest in property that is due you from someone who has died
If you are the beneficiary of a living trust, expect proceeds from a life insurance policy, or are currently entitled to receiv
e
property because someone has died.
No
Yes. Give specific information. .............
$_____________________
33. Claims against third parties, whether or not you have filed a lawsuit or made a demand for payment
Exam
ples: Accidents, employment disputes, insurance claims, or rights to sue
No
Yes. Describe each claim. ....................
$______________________
34. Other contingent and unliquidated claims of every nature, including counterclaims of the debtor and rights
to set off claims
No
Yes. Describe each claim. ....................
$_____________________
35. Any financial assets you did not already list
No
Yes. Give specific information. ...........
$_____________________
36. Add the dollar value of all of your entries from Part 4, including any entries for pages you have attached
for Part 4. Write that number here
....................................................................................................................................................
$_____________________
Part 5:
Describe Any Business-Related Property You Own or Have an Interest In. List any real estate in Part 1.
37. Do you own or have any legal or equitable interest in any business-related property?
No. Go to Part 6.
Yes. Go to line 38.
Current value of the
portion you own?
Do not deduct secured claims
or exemptions.
38. Accounts receivable or commissions you already earned
 No
Yes. Describe .......
$_______
_
_____________
39. Office equipment, furnishings, and supplies
Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, electronic devices
No
Yes. Describe .......
$__________
_
__________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 9
40. Machinery, fixtures, equipment, supplies you use in business, and tools of your trade
No
Yes. Describe .......
$______
_
______________
41. Inventory
No
Yes. Describe .......
$
_____
_
_______________
42. Interests in partnerships or joint ventures
No
Yes. Describe .......
Name of entity: % of ownership:
______________________________________________________________________ ________%
______________________________________________________________________ ________%
______________________________________________________________________ ________%
$_____________________
$________
_____________
$_____________________
43. Customer lists, mailing lists, or other compilations
No
 Yes. Do your lists include personally identifiable information (as defined in 11 U.S.C. § 101(41A))?
No
Yes. Describe. .......
$____________________
44. Any business-related property you did not already list
No
Yes. Give specific
information .........
______________________________________________________________________________________
$____________________
______________________________________________________________________________________
$____________________
______________________________________________________________________________________
$____________________
______________________________________________________________________________________
$____________________
______________________________________________________________________________________
$____________________
______________________________________________________________________________________
$____________________
45. Add the dollar value of all of your entries from Part 5, including any entries for pages you have attached
for Part 5. Write that number here
....................................................................................................................................................
$____________________
Part 6: Describe Any Farm- and Commercial Fishing-Related Property You Own or Have an Interest In.
If you own or have an interest in farmland, list it in Part 1.
46. Do you own or have any legal or equitable interest in any farm- or commercial fishing-related property?
No. Go to Part 7.
Yes. Go to line 47.

Current value of the
portion you own?
Do not deduct secured claims
or exemptions.
47. Farm animals
Examples: Livestock, poultry, farm-raised fish
No
Yes ..........................
$___________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 10
48. Crops—either growing or harvested
No
Yes. Give specific
information
. ............
$___________________
49. Farm and fishing equipment, implements, machinery, fixtures, and tools of trade
No
Yes ..........................
$___________________
50. Farm and fishing supplies, chemicals, and feed
No
Yes ..........................
$___________________
51. Any farm- and commercial fishing-related property you did not already list
 No
Yes. Give specific
information
. ............
$___________________
52. Add the dollar value of all of your entries from Part 6, including any entries for pages you have attached
for Part 6. Write that number here
....................................................................................................................................................
$___________________
Part 7:
Describe All Property You Own or Have an Interest in That You Did Not List Above
53. Do you have other property of any kind you did not already list?
Examples: Season tickets, country club membership
No
Yes. Give specific
information
. ............
$________________
$________________
$________________
54. Add the dollar value of all of your entries from Part 7. Write that number here .................................................................
$________________
Part 8:
List the Totals of Each Part of this Form
55. Part 1: Total real estate, line 2 ..............................................................................................................................................................
$________________
56. Part 2: Total vehicles, line 5 $________________
57. Part 3: Total personal and household items, line 15 $________________
58. Part 4: Total financial assets, line 36 $________________
59. Part 5: Total business-related property, line 45 $________________
60. Part 6: Total farm- and fishing-related property, line 52 $________________
61. Part 7: Total other property not listed, line 54
+ $________________
62. Total personal property. Add lines 56 through 61. .................... $________________
Copy personal property total
+ $_________________
63. Total of all property on Schedule A/B. Add line 55 + line 62. ......................................................................................... $_________________
0.00
0.00
0.00
0.00
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Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __
Official Form 106C
Schedule C: The Property You Claim as Exempt 04/19
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information.
Using the property you listed on Schedule A/B: Property (Official Form 106A/B) as your source, list the property that you claim as exempt. If more
space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On the top of any additional pages, write
your name and case number (if known).
For each item of property you claim as exempt, you must specify the amount of the exemption you claim. One way of doing so is to state a
specific dollar amount as exempt. Alternatively, you may claim the full fair market value of the property being exempted up to the amount
of any applicable statutory limit. Some exemptions—such as those for health aids, rights to receive certain benefits, and tax-exempt
retirement funds—may be unlimited in dollar amount. However, if you claim an exemption of 100% of fair market value under a law that
limits the exemption to a particular dollar amount and the value of the property is determined to exceed that amount, your exemption
would be limited to the applicable statutory amount.
Part 1: Identify the Property You Claim as Exempt
1. Which set of exemptions are you claiming? Check one only, even if your spouse is filing with you.
You are claiming state and federal nonbankruptcy exemptions. 11 U.S.C. § 522(b)(3)
You are claiming federal exemptions. 11 U.S.C. § 522(b)(2)
2. For any property you list on Schedule A/B that you claim as exempt, fill in the information below.
Brief description of the property and line on
Schedule A/B that lists this property
Current value of the
portion you own
Copy the value from
Schedule A/B
Amount of the exemption you claim
Check only one box for each exemption.
Specific laws that allow exemption
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
any applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
any applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
_________________________
$________________
$ ____________
100% of fair market value, up to
any applicable statutory limit
____________________________
____________________________
____________________________
____________________________
Line from
Schedule A/B:
______
3. Are you claiming a homestead exemption of more than $170,350?
(Subject to adjustment on 4/01/22 and every 3 years after that for cases filed on or after the date of adjustment.)
No
Yes. Did you acquire the property covered by the exemption within 1,215 days before you filed this case?
No
Yes
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 Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106C Schedule C: The Property You Claim as Exempt page ___ of __
Part 2: Additional Page
Brief description of the property and line
on Schedule A/B that lists this property
Current value of the
portion you own
Copy the value from
Schedule A/B
Amount of the exemption you claim
Check only one box for each exemption
Specific laws that allow exemption
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
any applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
an
y applicable statutory limit
____________________________
____________________________
____________________________
____________________________ ______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
an
y applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
any applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
an
y applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
an
y applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
any applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
an
y applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
an
y applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
any applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
an
y applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
Brief
description:
Line from
Schedule A/B:
_________________________
$________________
$ ____________
100% of fair market value, up to
an
y applicable statutory limit
____________________________
____________________________
____________________________
____________________________
______
2
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Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___
Official Form 106D
Schedule D: Creditors Who Have Claims Secured by Property 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, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any
additional pages, write your name and case number (if known).
1. Do any creditors have claims secured by your property?
No. Check this box and submit this form to the court with your other schedules. You have nothing else to report on this form.
Yes. Fill in all of the information below.
Part 1: List All Secured Claims
2. List all secured claims. If a creditor has more than one secured claim, list the creditor separately
for each claim. If more than one creditor has a particular claim, list the other creditors in Part 2.
As much as possible, list the claims in alphabetical order according to the creditor’s name.
Column A
Amount of claim
Do not deduct the
value of collateral.
Column B
Value of collateral
that supports this
claim
Column C
Unsecured
portion
If any
2.1
______________________________________
Creditor’s Name
______________________________________
Number Street
______________________________________
______________________________________
City State ZIP Code
Describe the property that secures the claim:
$_________________ $________________$____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Nature of lien. Check all that apply.
An agreement you made (such as mortgage or secured
car loan)
Statutory lien (such as tax lien, mechanic’s lien)
Judgment lien from a lawsuit
Other (including a right to offset) ____________________
Who owes the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim relates to a
community debt
Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___
2.2
______________________________________
Creditor’s Name
______________________________________
Number Street
______________________________________
______________________________________
City State ZIP Code
Describe the property that secures the claim:
$_________________ $________________$____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Nature of lien
. Check all that apply.
An agreement you made (such as mortgage or secured
car loan)
Statutory lien (such as tax lien, mechanic’s lien)
Judgment lien from a lawsuit
Other (including a right to offset) ____________________
Who owes the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim relates to a
community debt
Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___
Add the dollar value of your entries in Column A on this page. Write that number here:
$________________
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 Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___
Part 1:
Additional Page
After listing any entries on this page, number them beginning with 2.3, followed
by 2.4, and so forth.
Column A
Amount of claim
Do not deduct the
value of collateral.
Column B
Value of collateral
that supports this
claim
Column C
Unsecured
portion
If any
______________________________________
Creditor’s Name
______________________________________
Number Street
______________________________________
______________________________________
City State ZIP Code
Describe the property that secures the claim:
$_________________ $________________$____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Nature of lien. Check all that apply.
An agreement you made (such as mortgage or secured
car loan)
Statutory lien (such as tax lien, mechanic’s lien)
Judgment lien from a lawsuit
Other (including a right to offset) ____________________
Who owes the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim relates to a
community debt
Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___
______________________________________
Creditor’s Name
______________________________________
Number Street
______________________________________
______________________________________
City State ZIP Code
Describe the property that secures the claim: $_________________ $________________$____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Nature of lien. Check all that apply.
An agreement you made (such as mortgage or secured
car loan)
Statutory lien (such as tax lien, mechanic’s lien)
Judgment lien from a lawsuit
Other (including a right to offset) ____________________
Who owes the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim relates to a
community debt
Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___
______________________________________
Creditor’s Name
______________________________________
Number Street
______________________________________
______________________________________
City State ZIP Code
Describe the property that secures the claim:
$_________________ $________________$____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Nature of lien. Check all that apply.
An agreement you made (such as mortgage or secured
car loan)
Statutory lien (such as tax lien, mechanic’s lien)
Judgment lien from a lawsuit
Other (including a right to offset) ____________________
Who owes the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim relates to a
community debt
Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___
Add the dollar value of your entries in Column A on this page. Write that number here:
$_________________
If this is the last page of your form, add the dollar value totals from all pages.
Write that number here:
$_________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106D Part 2 of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___
Part 2: List Others to Be Notified for a Debt That You Already Listed
Use this page only if you have others to be notified about your bankruptcy for a debt that you already listed in Part 1. For example, if a collection
agency is trying to collect from you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection agency here. Similarly, if
you have more than one creditor for any of the debts that you listed in Part 1, list the additional creditors here. If you do not have additional persons to
be notified for any debts in Part 1, do not fill out or submit this page.
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
_____________________________________________________________________
City State ZIP Code
On which line in Part 1 did you enter the creditor? _____
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
_____________________________________________________________________
City State ZIP Code
On which line in Part 1 did you enter the creditor? _____
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
_____________________________________________________________________
City State ZIP Code
On which line in Part 1 did you enter the creditor? _____
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
_____________________________________________________________________
City State ZIP Code
On which line in Part 1 did you enter the creditor? _____
Last 4 digits of account number ___ ___ ___ ___
___________________________
__________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
_____________________________________________________________________
City State ZIP Code
On which line in Part 1 did you enter the creditor? _____
Last 4 digits of account number ___ ___ ___ ___
___________________________
__________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
_____________________________________________________________________
City State ZIP Code
On which line in Part 1 did you enter the creditor? _____
Last 4 digits of account number ___ ___ ___ ___
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Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___
Official Form 106E/F
Schedule E/F: Creditors Who Have Unsecured Claims 12/15
Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY claims and Part 2 for creditors with NONPRIORITY claims.
List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule
A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any
creditors with partially secured claims that are listed in Schedule D: Creditors Who Have Claims Secured by Property. If more space is
needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of
any additional pages, write your name and case number (if known).
Part 1: List All of Your PRIORITY Unsecured Claims
1. Do any creditors have priority unsecured claims against you?
No. Go to Part 2.
Yes.
2. List all of your priority unsecured claims. If a creditor has more than one priority unsecured claim, list the creditor separately for each claim. For
each claim listed, identify what type of claim it is. If a claim has both priority and nonpriority amounts, list that claim here and show both priority and
nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor’s name. If you have more than two priority
unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.
(For an explanation of each type of claim, see the instructions for this form in the instruction booklet.)
Total claim Priority
amount
Nonpriority
amount
2.1
____________________________________________
Priority Creditor’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Last 4 digits of account number ___ ___ ___ ___
$_____________ $___________ $____________
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply
.
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
2.2
____________________________________________
Priority Creditor’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply
.
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
$_____________ $___________ $____________
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 Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 1: Your PRIORITY Unsecured Claims ─ Continuation Page
After listing any entries on this page, number them beginning with 2.3, followed by 2.4, and so forth.
Total claim Priority
amount
Nonpriority
amount
____________________________________________
Priority Creditor’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is:
Check all that apply.
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
$____________ $__________ $____________
____________________________________________
Priority Creditor’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
$____________ $__________ $____________
____________________________________________
Priority Creditor’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
$____________ $__________ $____________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 2: List All of Your NONPRIORITY Unsecured Claims
3. Do any creditors have nonpriority unsecured claims against you?
No. You have nothing to report in this part. Submit this form to the court with your other schedules.
Yes
4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one
nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already
included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured
claims fill out the Continuation Page of Part 2.
Total claim
4.1
_____________________________________________________________
Nonpriority Creditor’s Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Last 4 digits of account number ___ ___ ___ ___
$__________________
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce
that you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify ______________________________________
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
4.2
_____________________________________________________________
Nonpriority Creditor’s Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Last 4 digits of account number ___ ___ ___ ___
$__________________
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce
that you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify ______________________________________
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
4.3
_____________________________________________________________
Nonpriority Creditor’s Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Last 4 digits of account number ___ ___ ___ ___
$_________________
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce
that you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify ______________________________________
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page
After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth.
Total claim
_____________________________________________________________
Nonpriority Creditor’s Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce that
you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify________________________________
$____________
_____________________________________________________________
Nonpriority Creditor’s Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce that
you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify________________________________
$____________
_____________________________________________________________
Nonpriority Creditor’s Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce that
you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify________________________________
$____________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 3: List Others to Be Notified About a Debt That You Already Listed
5. Use this page only if you have others to be notified about your bankruptcy, for a debt that you already listed in Parts 1 or 2. For
example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or
2, then list the collection agency here.
Similarly, if you have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the
additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill out or submit this page.
_______________
______________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 4: Add the Amounts for Each Type of Unsecured Claim
6. Total the amounts of certain types of unsecured claims. This information is for statistical reporting purposes only. 28 U.S.C. § 159.
Add the amounts for each type of unsecured claim.
Total claim
Total claims
from Part 1
6a. Domestic support obligations 6a.
$_________________________
6b. Taxes and certain other debts you owe the
government 6b.
$_________________________
6c. Claims for death or personal injury while you were
intoxicated 6c.
$_________________________
6d. Other. Add all other priority unsecured claims.
Write that amount here. 6d.
+ $_________________________
6e. Total. Add lines 6a through 6d. 6e.
$_________________________
Total claim
Total claims
from Part 2
6f. Student loans 6f.
$_________________________
6g. Obligations arising out of a separation agreement
or divorce that you did not report as priority
claims 6g.
$_________________________
6h. Debts to pension or profit-sharing plans, and other
similar debts 6h.
$_________________________
6i. Other. Add all other nonpriority unsecured claims.
Write that amount here. 6i.
+ $_________________________
6j. Total. Add lines 6f through 6i. 6j.
$_________________________
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Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___
Official Form 106G
Schedule G: Executory Contracts and Unexpired Leases 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, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any
additional pages, write your name and case number (if known).
1. Do you have any executory contracts or unexpired leases?
No. Check this box and file this form with the court with your other schedules. You have nothing else to report on this form.
Yes. Fill in all of the information below even if the contracts or leases are listed on Schedule A/B: Property (Official Form 106A/B).
2. List
separately each person or company with whom you have the contract or lease. Then state what each contract or lease is for (for
example, rent, vehicle lease, cell phone). See the instructions for this form in the instruction booklet for more examples of executory contracts and
unexpired leases.
Person or company with whom you have the contract or lease State what the contract or lease is for
2.1
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2.2
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2.3
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2.4
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2.5
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
Debtor __________________________________________________________________
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 Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106G
Schedule G: Executory Contracts and Unexpired Leases page ___ of ___
Additional Page if You Have More Contracts or Leases
Person or company with whom you have the contract or lease What the contract or lease is for
2._
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2._
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2._
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2._
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2._
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2._
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2._
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
2._
_____________________________________________________________________
Name
_____________________________________________________________________
Number Street
_____________________________________________________________________
City State ZIP Code
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Official Form 106H Schedule H: Your Codebtors page 1 of ___
Official Form 106H
Schedule H: Your Codebtors 12/15
Codebtors are people or entities who are also liable for any debts you may have. 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, copy the Additional Page, fill it out,
and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and
case number (if known). Answer every question.
1. Do you have any codebtors? (If you are filing a joint case, do not list either spouse as a codebtor.)
No
Yes
2. Within the last 8 years, have you lived in a community property state or territory? (Community property states and territories include
Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)
No. Go to line 3.
Yes. Did your spouse, former spouse, or legal equivalent live with you at the time?
No
Yes. In which community state or territory did you live? __________________. Fill in the name and current address of that person.
______________________________________________________________________
Name of your spouse, former spouse, or legal equivalent
______________________________________________________________________
Number Street
______________________________________________________________________
City State ZIP Code
3. In Column 1, list all of your codebtors. Do not include your spouse as a codebtor if your spouse is filing with you. List the person
shown in line 2 again as a codebtor only if that person is a guarantor or cosigner. Make sure you have listed the creditor on
Schedule D (Official Form 106D), Schedule E/F (Official Form 106E/F), or Schedule G (Official Form 106G). Use Schedule D,
Schedule E/F, or Schedule G to fill out Column 2.
Column 1: Your codebtor Column 2: The creditor to whom you owe the debt
Check all schedules that apply:
3.1
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3.2
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3.3
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
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 Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106H Schedule H: Your Codebtors page ___ of ___
Additional Page to List More Codebtors
Column 1: Your codebtor Column 2: The creditor to whom you owe the debt
Check all schedules that apply:
3._
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3._
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3._
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3._
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3._
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3._
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3._
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
3
._
________________________________________________________________________________
Name
________________________________________________________________________________
Number Street
________________________________________________________________________________
City State ZIP Code
Schedule D, line ______
Schedule E/F, line ______
Schedule G, line ______
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Official Form 106I Schedule I: Your Income page 1
Official Form 106I
Schedule I: Your Income 12/15
Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for
supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your spouse.
If you are separated and your spouse is not filing with you, do not include information about your spouse. 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). Answer every question.
Part 1: Describe Employment
1. Fill in your employment
information.
If you have more
than one job,
attach a separate page with
information about additional
employers.
Include part-time, seasonal, or
self-employed work.
Occupation may include student
or homemaker, if it applies.
Debtor 1 Debtor 2 or non-filing spouse
Employment status
Employed
Not employed
Employed
Not employed
Occupation
__________________________________ __________________________________
Employer’s name __________________________________ __________________________________
Employer’s address
_
____
_
_________________________________
Number Street
_
_______________
_
______________________
_
___________
_
__________________________
_
__________
_
___________________________
City State ZIP Code
_
_____
_
_________________________________
Number Street
_
________________
_
______________________
__
___________
_
__________________________
__
__________
_
___________________________
City State ZIP Code
How long employed there?
_______ _______
Part 2: Give Details About Monthly Income
Estimate monthly income as of the date you file this form. If you have nothing to report for any line, write $0 in the space. Include your non-filing
spouse unless you are separated.
If you or your non-filing spouse have more than one employer, combine the information for all employers for that person on the lines
below. If you need more space, attach a separate sheet to this form.
For Debtor 1 For Debtor 2 or
non-filing spouse
2. List monthly gross wages, salary, and commissions (before all payroll
deductions). If not paid monthly, calculate what the monthly wage would be. 2.
$___________
$____________
3. Estimate and list monthly overtime pay. 3.
+ $___________ + $____________
4. Calculate gross income. Add line 2 + line 3. 4. $__________ $____________
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
A supplement showing postpetition chapter 13
income as of the following date:
________________
MM / DD / YYYY
District of Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106I Schedule I: Your Income page 2
For Debtor 1
For Debtor 2 or
non-filin
g
s
p
ouse
Copy line 4 here ............................................................................................... 4.
$___________ $_____________
5. List all payroll deductions:
5a. Tax, Medicare, and Social Security deductions 5a.
$____________
$_____________
5b. Mandatory contributions for retirement plans 5b. $____________ $_____________
5c. Voluntary contributions for retirement plans 5c. $____________ $_____________
5d. Required repayments of retirement fund loans 5d. $____________ $_____________
5e. Insurance 5e. $____________ $_____________
5f. Domestic support obligations 5f. $____________ $_____________
5g. Union dues 5g.
$____________ $_____________
5h. Other deductions. Specify: __________________________________ 5h.
+ $____________ + $_____________
6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h. 6.
$____________ $_____________
7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $____________ $_____________
8. List all other income regularly received:
8a. Net income from rental property and from operating a business,
profession, or farm
Attach a statement for each property and business showing gross
receipts, ordinary and necessary business expenses, and the total
monthly net income.
8a.
$____________ $_____________
8b. Interest and dividends 8b.
$____________
$_____________
8c. Family support payments that you, a non-filing spouse, or a dependent
regularly receive
Include alimony, spousal support, child support, maintenance, divorce
settlement, and property settlement. 8c.
$____________ $_____________
8d. Unemployment compensation 8d.
$____________ $_____________
8e. Social Security 8e.
$____________ $_____________
8f. Other government assistance that you regularly receive
Include cash assistance and the value (if known) of any non-cash assistance
that you receive, such as food stamps (benefits under the Supplemental
Nutrition Assistance Program) or housing subsidies.
Specify: ___________________________________________________ 8f.
$____________ $_____________
8g. Pension or retirement income 8g.
$____________ $_____________
8h. Other monthly income. Specify: _______________________________ 8h.
+ $____________ + $_____________
9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h. 9.
$____________
$_____________
10. Calculate monthly income. Add line 7 + line 9.
Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse. 10
.
$___________
+
$_____________
=
$_____________
11. State all other regular contributions to the expenses that you list in Schedule J.
Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and other
friends or relatives.
Do not include any amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J.
Specify: _______________________________________________________________________________ 11. +
$_____________
12. Add the amount in the last column of line 10 to the amount in line 11. The result is the combined monthly income.
Write that amoun
t on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies 12.
$_____________
Combined
monthly income
13. Do you expect an increase or decrease within the year after you file this form?
No.
Yes. Explain:
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Official Form 106J Schedule J: Your Expenses page 1
Official Form 106J
Schedule J: Your Expenses 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 another sheet to this form. On the top of any additional pages, write your name and case number
(if known). Answer every question.
Part 1: Describe Your Household
1. Is this a joint case?
No. Go to line 2.
Yes. Does Debtor 2 live in a separate household?
No
Yes. Debtor 2 must file Official Form 106J-2, Expenses for Separate Household of Debtor 2.
2. Do you have dependents?
Do not list Debtor 1 and
Debtor 2.
Do not state the dependents’
names.
No
Yes. Fill out this information for
each dependent ..........................
Dependent’s relationship to
Debtor 1 or Debtor 2
Dependent’s
age
Does dependent live
with you?
_________________________ ________
No
Y
es
_________________________ ________
No
Yes
_____________
____________ ________
No
Yes
_________________________ ________
No
Yes
_____________
____________ ________
No
Yes
3. Do your expenses include
expenses of people other than
yourself and your dependents?
No
Yes
Part 2: Estimate Your Ongoing Monthly Expenses
Estimate your expenses as of your bankruptcy filing date unless you are using this form as a supplement in a Chapter 13 case to report
expenses as of a date after the bankruptcy is filed. If this is a supplemental Schedule J, check the box at the top of the form and fill in the
applicable date.
Include expenses paid for with non-cash government assistance if you know the value of
such assistance and have included it on Schedule I: Your Income (Official Form 106I.)
Your expenses
4. The rental or home ownership expenses for your residence. Include first mortgage payments and
any rent for the ground or lot.
4.
$____________
_________
If not included in line 4:
4a. Real estate taxes 4a. $_____________________
4b. Property, homeowner’s, or renter’s insurance 4b. $_____________________
4c. Home maintenance, repair, and upkeep expenses 4c. $_____________________
4d. Homeowner’s association or condominium dues 4d. $_____________________
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 identif
y
y
our case:
Check if this is:
An amended filing
A supplement showing postpetition chapter 13
expenses as of the following date:
________________
MM / DD / YYYY
District of Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106J Schedule J: Your Expenses page 2
Your expenses
5. Additional mortgage payments for your residence, such as home equity loans 5.
$________
_____________
6. Utilities:
6a. Electricity, heat, natural gas 6a. $_____________________
6b. Water, sewer, garbage collection 6b. $_____________________
6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $_____________________
6d. Other. Specify: _______________________________________________ 6d. $_____________________
7. Food and housekeeping supplies 7. $_____________________
8. Childcare and children’s education costs 8. $_____________________
9. Clothing, laundry, and dry cleaning 9. $_____________________
10. Personal care products and services 10. $_____________________
11. Medical and dental expenses 11. $_____________________
12. Transportation. Include gas, maintenance, bus or train fare.
Do not include car payments.
12.
$_____________________
13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $_____________________
14. Charitable contributions and religious donations 14. $_____________________
15. Insurance.
Do not include insurance deducte
d from
your pay or included in lines 4 or 20.
1
15a. Life insurance 15a. $_____________________
15b. Health insurance 15b. $_____________________
15c. Vehicle insurance 15c. $_____________________
15d. Other insurance. Specify:_______________________________________ 15d. $_____________________
16. Taxes. Do not include taxes deducted from your pay or included in lines 4 or 20.
Specify: ________________________________________________________ 16.
$_____________________
17. Installment or lease payments:
17a. Car payments for Vehicle 1 17a.
$_____________________
17b. Car payments for Vehicle 2 17b.
$_____________________
17c. Other. Specify:_______________________________________________ 17c.
$_____________________
17d. Other. Specify:_______________________________________________ 17d.
$_____________________
18. Your payments of alimony, maintenance, and support that you did not report as deducted from
your pay on line 5, Schedule I, Your Income (Official Form 106I).
18.
$_____________________
19. Other payments you make to support others who do not live with you.
Specify:_______________________________________________________ 19. $_____________________
20. Other real property expenses not included in lines 4 or 5 of this form or on Schedule I: Your Income.
20a. Mortgages on other property 20a.
$_____________________
20b. Real estate taxes 20b.
$_____________________
20c. Property, homeowner’s, or renter’s insurance 20c.
$_____________________
20d. Maintenance, repair, and upkeep expenses 20d.
$_____________________
20e. Homeowner’s association or condominium dues 20e.
$_____________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106J Schedule J: Your Expenses page 3
21. Other. Specify: _________________________________________________ 21.
+$_____________________
22. Calculate your monthly expenses.
22a. Add lines 4 through 21.
22a.
22b. Copy line 22 (monthly expenses for Debtor 2), if any, from Official Form 106J-2
22b.
22c. Add line 22a and 22b. The result is your monthly expenses.
22c.
$_____________________
$_____________________
$_____________________
23. Calculate your monthly net income.
23a. Copy line 12 (your combined monthly income) from Schedule I.
23a.
$_____________________
23b. Copy your monthly expenses from line 22c above. 23b.
– $_____________________
23c. Subtract your monthly expenses from your monthly income.
The result is your monthly net income.
23c.
$_____________________
24. Do you expect an increase or decrease in your expenses within the year after you file this form?
For e
xample, do you expect to finish paying for your car loan within the year or do you expect
your
mortgage payment to increase or decrease because of a modification to the terms of your mortgage?
No.
Yes.
Explain here:
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Official Form 106Dec Declaration About an Individual Debtor’s Schedules
Official Form 106Dec
Declaration About an Individual Debtor’s Schedules 12/15
If two married people are filing together, both are equally responsible for supplying correct information.
You must file this form whenever you file bankruptcy schedules or amended schedules. Making a false statement, concealing property, or
obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20
years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
Sign Below
Did you pay or agree to pay someone who is NOT an attorney to help you fill out bankruptcy forms?
No
Yes. Name of person__________________________________________________. Attach Bankruptcy Petition Preparer’s Notice, Declaration, and
Signature (Official Form 119).
Under penalty of perjury, I declare that I have read the summary and schedules filed with this declaration and
that they are true and correct.
______________________________________________ _____________________________
Signature of Debtor 1 Signature of Debtor 2
Date
_________________ Date _________________
MM / DD / YYYY MM / DD / YYYY
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 Arizona
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Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1
Official Form 107
Statement of Financial Affairs for Individuals Filing for Bankruptcy 04/19
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). Answer every question.
Part 1: Give Details About Your Marital Status and Where You Lived Before
1. What is your current marital status?
Married
Not married
2. During the last 3 years, have you lived anywhere other than where you live now?
No
Yes. List all of the places you lived in the last 3 years. Do not include where you live now.
Debtor 1: Dates Debtor 1
lived there
Debtor 2: Dates Debtor 2
lived there
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
From ________
To ________
Same as Debtor 1
___________________________________________
Number Street
___________________________________________
___________________________________________
City State ZIP Code
Same as Debtor 1
From ________
To ________
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
From ________
To ________
Same as Debtor 1
___________________________________________
Number Street
___________________________________________
___________________________________________
City State ZIP Code
Same as Debtor 1
From ________
To _
_______
3. Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory? (Community property
states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)
No
Yes. Make sure you fill out Schedule H: Your Codebtors (Official Form 106H).
Part 2:
Explain the Sources of Your Income
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 Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 2
4. Did you have any income from employment or from operating a business during this year or the two previous calendar years?
Fill in the total amount of income you received from all jobs and all businesses, including part-time activities.
If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.
No
Yes. Fill in the details.
Debtor 1 Debtor 2
Sources of income
Check all that apply.
Gross income
(before deductions and
exclusions)
Sources of income
Check all that apply.
Gross income
(before deductions and
exclusions)
From January
1 of current year until
the date you filed for bankruptcy:
Wages, commissions,
bonuses, tips
Operating a business
$________________
Wages, commissions,
bonuses, tips
Operating a business
$________________
For last calendar year:
(January 1 to December 31, _________)
YYYY
Wages, commissions,
bonuses, tips
Operating a business
$________________
Wages, commissions,
bonuses, tips
Operating a business
$________________
For the calendar year before that:
(January 1 to December 31, _________)
YYYY
Wages, commissions,
bonuses, tips
Operating a business
$________________
Wages, commissions,
bonuses, tips
Operating a business
$________________
5. Did you receive any other income during this year or the two previous calendar years?
Include income regardless of whether that income is taxable. Examples of other income are alimony; child support; Social Security
,
unemploy
ment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; roy
alties; and
gambling and lottery
winnings. If you are filing a joint case and you have income that you received together, list it only once
under Debtor 1.
List each source and the gross income from each source separately
. Do not include income that y
ou listed in line 4.
No
Yes. Fill in the details.
Debtor 1 Debtor 2
Sources of income
Describe below.
Gross income from
each source
(before deductions and
exclusions)
Sources of income
Describe below.
Gross income from
each source
(before deductions and
exclusions)
From January 1 of current year until
the date you filed for bankruptcy:
__________________
__________________
__________________
$_________________
$_________________
$_________________
_____________________
_____________________
_____________________
$_________________
$_________________
$
_________________
For last calendar year:
(January 1 to December 31, ______)
YYYY
__________________
__________________
__________________
$_________________
$_________________
$_________________
_____________________
_____________________
_____________________
$_________________
$_________________
$_________________
For the calendar year before that:
(January 1 to December 31, ______)
YYYY
__________________
__________________
__________________
$_________________
$_________________
$_________________
_____________________
_____________________
_____________________
$_________________
$_________________
$_________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3
Part 3: List Certain Payments You Made Before You Filed for Bankruptcy
6. Are either Debtor 1’s or Debtor 2’s debts primarily consumer debts?
No. Neither Debtor 1 nor Debtor 2 has primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8) as
“incurred by an individual primarily for a personal, family, or household purpose.”
During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,825* or more?
No. Go to line 7.
Yes. List below each creditor to whom you paid a total of $6,825* or more in one or more payments and the
total amount you paid that creditor. Do not include payments for domestic support obligations, such as
child support and alimony. Also, do not include payments to an attorney for this bankruptcy case.
*Subjec
t to adjustment on 4/01/22 and every 3 years after that for cases filed on or after the date of adjustment.
 Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts.
During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more?
No. Go to line 7.
Yes. List below each creditor to whom you paid a total of $600 or more and the total amount you paid that
creditor. Do not include payments for domestic support obligations, such as child support and
alimony. Also, do not include payments to an attorney for this bankruptcy case.
____________________________________
Creditor’s Name
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Dates of
payment
Total amount paid Amount you still owe Was this payment for…
_________
_________
_________
$_________________ $__________________
Mortgage
Car
Credit card
Loan repayment
Suppliers or vendors
Other ____________
____________________________________
Creditor’s Name
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
_________
_________
_________
$_________________ $__________________
Mortgage
Car
Credit card
Loan repayment
Suppliers or vendors
Other ____________
____________________________________
Creditor’s Name
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
_________
_________
_________
$_________________ $__________________
Mortgage
Car
Credit card
Loan repayment
Suppliers or vendors
Other ____________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 4
7. Within 1 year before you filed for bankruptcy, did you make a payment on a debt you owed anyone who was an insider?
Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner;
corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing
agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations,
such as child support and alimony.
No
Yes. List all payments to an insider.
____________________________________________
Insider’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Dates of
payment
Total amount
paid
Amount you still
owe
Reason for this payment
_________
_________
_________
$____________ $____________
____________________________________________
Insider’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
_________
_________
_________
$____________ $____________
8. Within 1 year before you filed for bankruptcy, did you make any payments or transfer any property on account of a debt that benefited
an insider?
Include payments on debts guaranteed or cosigned by an insider.
No
Yes. List all payments that benefited an insider.
____________________________________________
Insider’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Dates of
payment
Total amount
paid
Amount you still
owe
Reason for this payment
Include creditor’s name
_________
_________
_________
$____________ $____________
____________________________________________
Insider’s Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
_________
_________
_________
$____________ $____________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 5
Part 4: Identify Legal Actions, Repossessions, and Foreclosures
9. Within 1 year before you filed for bankruptcy, were you a party in any lawsuit, court action, or administrative proceeding?
List all such matters, including personal injury cases, small claims actions, divorces, collection suits, paternity actions, support or custody modifications,
and contract disputes.
No
Yes. Fill in the details.
Case title_____________________________
____________________________________
Case number ________________________
Nature of the case Court or agency Status of the case
________________________________________
Court Name
________________________________________
Number Street
________________________________________
City State ZIP Code
Pending
On appeal
Concluded
Case title_____________________________
____________________________________
Case number ________________________
________________________________________
Court Name
________________________________________
Number Street
________________________________________
City State ZIP Code
Pending
On appeal
Concluded
10. Within 1 year before you filed for bankruptcy, was any of your property repossessed, foreclosed, garnished, attached, seized, or levied?
Check all that apply and fill in the details below.
No. Go to line 11.
Yes. Fill in the information below.
_________________________________________
Creditor’s Name
_________________________________________
Number Street
_________________________________________
_________________________________________
City State ZIP Code
Describe the property Date Value of the property
__________ $______________
Explain what happened
Property was repossessed.
Property was foreclosed.
Property was garnished.
Property was attached, seized, or levied.
_________________________________________
Creditor’s Name
_________________________________________
Number Street
_________________________________________
_________________________________________
City State ZIP Code
Describe the property Date
V
alue of the propert
y
__________ $______________
Explain what happened
Property was repossessed.
Property was foreclosed.
Property was garnished.
Property was attached, seized, or levied.
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 6
11. Within 90 days before you filed for bankruptcy, did any creditor, including a bank or financial institution, set off any amounts from your
accounts or refuse to make a payment because you owed a debt?
No
Yes. Fill in the details.
______________________________________
Creditor’s Name
______________________________________
Number Street
______________________________________
______________________________________
City State ZIP Code
Describe the action the creditor took Date action
was taken
Amount
____________ $________________
Last 4 digits of account number: XXXX–___ ___ ___ ___
12. Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of
creditors, a court-appointed receiver, a custodian, or another official?
No
Yes
Part 5: List Certain Gifts and Contributions
13. Within 2 years before you filed for bankruptcy, did you give any gifts with a total value of more than $600 per person?
No
Yes. Fill in the details for each gift.
Gifts with a total value of more than $600
per person
Describe the gifts Dates you gave
the gifts
Value
______________________________________
Person to Whom You Gave the Gift
______________________________________
______________________________________
Number Street
______________________________________
City State ZIP Code
Person’s relationship to you ______________
_________
_________
$_____________
$_____________
Gifts with a total value of more than $600
per person
Describe the gifts Dates you gave
the gifts
Value
______________________________________
Person to Whom You Gave the Gift
______________________________________
______________________________________
Number Street
______________________________________
City State ZIP Code
Person’s relationship to you ______________
_________
_________
$_____________
$_____________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 7
14. Within 2 years before you filed for bankruptcy, did you give any gifts or contributions with a total value of more than $600 to any charity?
No
Yes. Fill in the details for each gift or contribution.
Gifts or contributions to charities
that total more than $600
Describe what you contributed Date you
contributed
Value
_____________________________________
Charity’s Name
_____________________________________
_____________________________________
Number Street
_____________________________________
City State ZIP Code
_________
_________
$_____________
$_____________
Part 6: List Certain Losses
15. Within 1 year before you filed for bankruptcy or since you filed for bankruptcy, did you lose anything because of theft, fire, other
disaster, or gambling?
No
Yes. Fill in the details.
Describe the property you lost and
how the loss occurred
Describe any insurance coverage for the loss
Include the amount that insurance has paid. List pending insurance
claims on line 33 of Schedule A/B: Property.
Date of your
loss
Value of property
lost
_________ $_____________
Part 7: List Certain Payments or Transfers
16. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone
you consulted about seeking bankruptcy or preparing a bankruptcy petition?
Include any attorneys, bankruptcy petition preparers, or credit counseling agencies for services required in your bankruptcy.
No
Yes. Fill in the details.
___________________________________
Person Who Was Paid
___________________________________
Number Street
___________________________________
___________________________________
City State ZIP Code
____________________________________________
Email or website address
Description and value of any property transferred Date payment or
transfer was
made
Amount of payment
_________
_________
$_____________
$_____________
___________________________________
Person Who Made the Payment, if Not You
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 8
____________________________________
Person Who Was Paid
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
________________________________________________
Email or website address
Description and value of any property transferred Date payment or
transfer was made
Amount of
payment
_________
_________
$_____________
$_____________
___________________________________
Person Who Made the Payment, if Not You
17. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone who
promised to help you deal with your creditors or to make payments to your creditors?
Do not include any payment or transfer that you listed on line 16.
No
Yes. Fill in the details.
____________________________________
Person Who Was Paid
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Description and value of any property transferred Date payment or
transfer was
made
Amount of payment
_________
_________
$____________
$____________
18. Within 2 years before you filed for bankruptcy, did you sell, trade, or otherwise transfer any property to anyone, other than property
transferred in the ordinary course of your business or financial affairs?
Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property).
Do not include gifts and transfers that you have already listed on this statement.
No
Yes. Fill in the details.
___________________________________
Person Who Received Transfer
___________________________________
Number Street
___________________________________
___________________________________
City State ZIP Code
Description and value of property
transferred
Describe any property or payments received
or debts paid in exchange
Date transfer
was made
_________
Person’s relationship to you _____________
___________________________________
Person Who Received Transfer
___________________________________
Number Street
___________________________________
___________________________________
City State ZIP Code
_________
Person’s relationship to you _____________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 9
19. Within 10 years before you filed for bankruptcy, did you transfer any property to a self-settled trust or similar device of which you
are a beneficiary? (These are often called asset-protection devices.)
No
Yes. Fill in the details.
Name of trust __________________________
______________________________________
Description and value of the property transferred Date transfer
was made
_________
Part 8:
List Certain Financial Accounts, Instruments, Safe Deposit Boxes, and Storage Units
20. Within 1 year before you filed for bankruptcy, were any financial accounts or instruments held in your name, or for your benefit,
closed, sold, moved, or transferred?
Include checking, savings, money market, or other financial accounts; certificates of deposit; shares in banks, credit unions,
brokerage houses, pension funds, cooperatives, associations, and other financial institutions.
No
Yes. Fill in the details.
____________________________________
Name of Financial Institution
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Last 4 digits of account number Type of account or
instrument
Date account was
closed, sold, moved,
or transferred
Last balance before
closing or transfer
XXXX–___ ___ ___ ___
Checking
Savings
Money market
Brokerage
Other__________
_________ $___________
____________________________________
Name of Financial Institution
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
XXXX–___ ___ ___ ___
Checking
Savings
Money market
Brokerage
Other__________
_________ $___________
21. Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for
securities, cash, or other valuables?
No
Yes. Fill in the details.
____________________________________
Name of Financial Institution
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Who else had access to it? Describe the contents Do you still
have it?
_______________________________________
Name
_______________________________________
Number Street
_______________________________________
City State ZIP Code
No
Yes
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 10
22. Have you stored property in a storage unit or place other than your home within 1 year before you filed for bankruptcy?
No
Yes. Fill in the details.
___________________________________
Name of Storage Facility
___________________________________
Number Street
___________________________________
___________________________________
City State ZIP Code
Who else has or had access to it? Describe the contents Do you still
have it?
_______________________________________
Name
_______________________________________
Number Street
_______________________________________
City State ZIP Code
No
Yes
Part 9: Identify Property You Hold or Control for Someone Else
23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for,
or hold in trust for someone.
No
Yes. Fill in the details.
___________________________________
Owner’s Name
___________________________________
Number Street
___________________________________
___________________________________
City State ZIP Code
Where is the property? Describe the property Value
________________________________________
_
Number Street
________________________________________
_
________________________________________
_
City State ZIP Code
$__________
Part 10: Give Details About Environmental Information
For the purpose of Part 10, the following definitions apply:
Environmental law means any federal, state, or local statute or regulation concerning pollution, contamination, releases of
hazardous or toxic substances, wastes, or material into the air, land, soil, surface water, groundw
ater, or other medium,
including statutes or regulations controlling the cleanup of these substances, wastes, or material.
Site means any location, facility, or property as defined under any environmental law, whether you now own, operate, or
utilize it or used to own, operate, or utilize it, including disposal sites.
Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance, toxic
substance, hazardous material, pollutant, contaminant, or similar term.
Report all notices, releases, and proceedings that you know about, regardless of when they occurred.
24. Has any governmental unit notified you that you may be liable or potentially liable under or in violation of an environmental law?
No
Yes. Fill in the details.
____________________________________
Name of site
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Governmental unit Environmental law, if you know it Date of notice
_______________________________
Governmental unit
_______________________________
Number Street
_______________________________
City State ZIP Code
_________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 11
25. Have you notified any governmental unit of any release of hazardous material?
No
Yes. Fill in the details.
____________________________________
Name of site
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Governmental unit Environmental law, if you know it Date of notice
_______________________________
Governmental unit
_______________________________
Number Street
_______________________________
City State ZIP Code
_________
26. Have you been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders.
No
Yes. Fill in the details.
Case title______________________________
______________________________________
______________________________________
Case number
Court or agency Nature of the case
Status of the
case
________________________________
Court Name
________________________________
Number Street
________________________________
City State ZIP Code
Pending
On appeal
Concluded
Part 11: Give Details About Your Business or Connections to Any Business
27. Within 4 years before you filed for bankruptcy, did you own a business or have any of the following connections to any business?
A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time
A member of a limited liability company (LLC) or limited liability partnership (LLP)
A partner in a partnership
An officer, director, or managing executive of a corporation
An owner of at least 5% of the voting or equity securities of a corporation
No. None of the above applies. Go to Part 12.
Yes. Check all that apply above and fill in the details below for each business.
____________________________________
Business Name
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Describe the nature of the business Employer Identification number
Do not include Social Security number or ITIN.
EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
Name of accountant or bookkeeper Dates business existed
From _______ To _______
____________________________________
Business Name
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Describe the nature of the business Employer Identification number
Do not include Social Security number or ITIN.
EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
Name of accountant or bookkeeper Dates business existed
From _______ To _______
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 12
____________________________________
Business Name
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Describe the nature of the business
Employer Identification number
Do not include Social Security number or ITIN.
EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
Name of accountant or bookkeeper Dates business existed
From _______ To _______
28. Within 2 years before you filed for bankruptcy, did you give a financial statement to anyone about your business? Include all financial
institutions, creditors, or other parties.
No
Yes. Fill in the details below.
____________________________________
Name
____________________________________
Number Street
____________________________________
____________________________________
City State ZIP Code
Date issued
____________
MM / DD / YYYY
Part 12: Sign Below
I have read the answers on this Statement of Financial Affairs and any attachments, and I declare under penalty of perjury that the
answers are true and correct. I understand that making a false statement, concealing property, or obtaining money or property by fraud
in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both.
18 U.S.C. §§ 152, 1341, 1519, and 3571.
______________________________________________ _____________________________
Signature of Debtor 1 Signature of Debtor 2
Date ________________ Date _________________
Did you attach additional pages to Your Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107)?
No
Yes
Did you pay or agree to pay someone who is not an attorney to help you fill out bankruptcy forms?
No
Yes. Name of person_____________________________________________________________. Attach the Bankruptcy Petition Preparer’s Notice,
Declaration, and Signature (Official Form 119).
Print
Save As...
Add Attachment
Reset
Official Form 108 Statement of Intention for Individuals Filing Under Chapter 7 page 1
Official Form 108
Statement of Intention for Individuals Filing Under Chapter 7 12/15
If you are an individual filing under chapter 7, you must fill out this form if:
creditors have claims secured by your property, or
you have leased personal property and the lease has not expired.
You must file this form with the court within 30 days after you file your bankruptcy petition or by the date set for the meeting of credit
ors,
whichever is earlier, unless the court extends the time for cause. You must also send copies to the creditors and lessors you list on the form.
If t
wo married people are filing together in a joint case, both are equally responsible for supplying correct information.
Both debtors must sign and date the form.
Be as complete and accurate as possible. 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: List Your Creditors Who Have Secured Claims
1. For any creditors that you listed in Part 1 of Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D), fill in the
information below.
Identify the creditor and the property that is collateral What do you intend to do with the property that
secures a debt?
Did you claim the property
as exempt on Schedule C?
Creditor’s
name:
Surrender the property.
Retain the property and redeem it.
Retain the property and enter into a
Reaffirmation Agreement.
Retain the property and [explain]: __________
______________________________________
No
Yes
Description of
property
securing debt:
Creditor’s
name:
Surrender the property.
Retain the property and redeem it.
Retain the property and enter into a
Reaffirmation Agreement.
Retain the property and [explain]: __________
______________________________________
No
Yes
Description of
property
securing debt:
Creditor’s
name:
Surrender the property.
Retain the property and redeem it.
Retain the property and enter into a
Reaffirmation Agreement.
Retain the property and [explain]: __________
______________________________________
No
Yes
Description of
property
securing debt:
Creditor’s
name:
Surrender the property.
Retain the property and redeem it.
Retain the property and enter into a
Reaffirmation Agreement.
Retain the property and [explain]: __________
______________________________________
No
Yes
Description of
property
securing debt:
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 Arizona
Debtor 1 ______________________________________________________ Case number (If known)_____________________________________
First Name Middle Name Last Name
Official Form 108 Statement of Intention for Individuals Filing Under Chapter 7 page 2
Part 2: List Your Unexpired Personal Property Leases
For any unexpired personal property lease that you listed in Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G),
fill in the information below. Do not list real estate leases.
Unexpired leases are leases that are still in effect; the lease period has not yet
ended.
You may assume an unexpired personal property lease if the trustee does not assume it. 11 U.S.C. § 365(p)(2).
Describe your unexpired personal property leases Will the lease be assumed?
Lessor’s name:
No
Yes
Description of leased
property:
Lessor’s name:
No
Yes
Description of leased
property:
Lessor’s name:
No
Yes
Description of leased
property:
Lessor’s name:
No
Yes
Description of leased
property:
Lessor’s name:
No
Yes
Description of leased
property:
Lessor’s name:
No
Yes
Description of leased
property:
Lessor’s name:
No
Yes
Description of leased
property:
Part 3: Sign Below
Under penalty of perjury, I declare that I have indicated my intention about any property of my estate that secures a debt and any
personal property that is subject to an unexpired lease.
___________________________________________ ___________________________________________
Signature of Debtor 1 Signature of Debtor 2
Date
_________________ Date _________________
MM / DD / YYYY MM / DD / YYYY
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Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 1
Official Form 122A─1
Chapter 7 Statement of Your Current Monthly Income 04/20
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more
space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any
additional pages, write your name and case number (if known). If you believe that you are exempted from a presumption of abuse because you
do not have primarily consumer debts or because of qualifying military service, complete and file Statement of Exemption from Presumption of
Abuse Under § 707(b)(2) (Official Form 122A-1Supp) with this form.
Part 1:
Calculate Your Current Monthly Income
1. What is your marital and filing status? Check one only.
Not married. Fill out Column A, lines 2-11.
Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11.
Married and your spouse is NOT filing with you. You and your spouse are:
Living in the same household and are not legally separated. Fill out both Columns A and B, lines 2-11.
Living separately or are legally separated. Fill out Column A, lines 2-11; do not fill out Column B. By checking this box, you declare
under penalty of perjury that you and your spouse are legally separated under nonbankruptcy law that applies or that you and your
spouse are living apart for reasons that do not include evading the Means Test requirements. 11 U.S.C. § 707(b)(7)(B).
Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this
bankruptcy case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through
August 31. If the amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6.
Fill in the result. Do not include any income amount more than once. For example, if both spouses own the same rental property, put the
income from that property in one column only. If you have nothing to report for any line, write $0 in the space.
Column A
Debtor 1
Column B
Debtor 2 or
non-filing spouse
2. Your gross wages, salary, tips, bonuses, overtime, and commissions
(before all payroll deductions).
$_________ $__________
3. Alimony and maintenance payments. Do not include payments from a spouse if
Column B is filled in.
$_________ $__________
4. All amounts from any source which are regularly paid for household expenses
of you or your dependents, including child support. Include regular contributions
from an unmarried partner, members of your household, your dependents, parents,
and roommates. Include regular contributions from a spouse only if Column B is not
filled in. Do not include payments you listed on line 3.
$_________ $__________
5. Net income from operating a business, profession,
or farm
Debtor 1 Debtor 2
Gross receipts (before all deductions)
$______
$______
Ordinary and necessary operating expenses
– $______
–
$______
Net monthly income from a business, profession, or farm
$______ $______
Copy
here
$_________
$__________
6. Net income from rental and other real property
Debtor 1
Debtor 2
Gross receipts (before all deductions)
$______
$______
Ordinary and necessary operating expenses
– $______
– $______
Net monthly income from rental or other real property
$______
$______
Copy
here
$_________
$__________
7. Interest, dividends, and royalties
$_________
$__________
Check if this is an amended filing
1. There is no presumption of abuse.
2. The calculation to determine if a presumption of
abuse applies will be made under Chapter 7
Means Test Calculation (Official Form 122A–2).
3. The Means Test does not apply now because of
qualified military service but it could apply later.
Check one box only as directed in this form and in
Form 122A-1Supp:
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:
District of Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 2
Column A
Debtor 1
Column B
Debtor 2 or
non-filing spouse
8. Unemployment compensation
$__________ $___________
Do not enter the amount if you contend that the amount received was a benefit
under the Social Security Act. Instead, list it here:
................................
For you .................................................................................. $______________
For your spouse ..................................................................
$______________
9. Pension or retirement income. Do not include any amount received that was a
benefit under the Social Security Act. Also, except as stated in the next sentence, do
not include any compensation, pension, pay, annuity, or allowance paid by the
United States Government in connection with a disability, combat-related injury or
disability, or death of a member of the uniformed services. If you
received any retired
pay paid under chapter 61 of title 10, then include that pay only to the extent that it
does not exceed the amount of retired pay to which you
would otherwise be entitled if
retired under any provision of title 10 other than chapter 61 of that title.
$__________ $___________
10.
Income from all other sources not listed above. Specify the source and amount. Do
not include any benefits received under the Social Security Act; payments made under
the Federal law relating to the national emergency declared by the President under the
National Emergencies Act (50 U.S.C. 1601 et seq.) with respect to the coronavirus
disease 2019 (COVID-19); payments received as a victim of a war crime, a crime
against humanity, or international or domestic terrorism; or compensation, pension,
pay, annuity, or allowance paid by the United States Government in connection with a
disability, combat-related injury or disability, or death of a member of the uniformed
services. If necessary, list other sources on a separate page and put the total below.
10.
______________________________________ $_________ $___________
______________________________________ $_________ $___________
Total amounts from separate pages, if any.
+ $_________ + $___________
11. Calculate your total current monthly income. Add lines 2 through 10 for each
column. Then add the total for Column A to the total for Column B.
$_________
+
$___________
=
$__________
Total current
monthly income
Part 2: Determine Whether the Means Test Applies to You
12. Calculate your current monthly income for the year. Follow these steps:
12a. Copy your total current monthly income from line 11. ..................................................................................... Copy line 11 here
$__________
Multiply by 12 (the number of months in a year).
x 12
12b. The result is your annual income for this part of the form. 12b.
$__________
13. Calculate the median family income that applies to you. Follow these steps:
Fill in the state in which you live.
Fill in the number of people in your household.
Fill in the median family income for your state and size of household. ................................................................................................. 13.
To find a list of applicable median income amounts, go online using the link specified in the separate
instructions for this form. This list may also be available at the bankruptcy clerk’s office.
$__________
14. How do the lines compare?
14a. Line 12b is less than or equal to line 13. On the top of page 1, check box 1, There is no presumption of abuse.
Go to Part 3. Do NOT fill out or file Official Form 122A-2
14b. Line 12b is more than line 13. On the top of page 1, check box 2, The presumption of abuse is determined by Form 122A-2.
Go to Part 3 and fill out Form 122A–2.
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 3
Part 3: Sign Below
By signing here, I declare under penalty of perjury that the information on this statement and in any attachments is true and correct.
__________________________________________________________ ______________________________________
Signature of Debtor 1 Signature of Debtor 2
Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY
If you checked line 14a, do NOT fill out or file Form 122A–2.
If you checked line 14b, fill out Form 122A–2 and file it with this form.
¯¯¯¯¯
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Local Form 1007-2 (08/18) Declaration of Evidence of Payments Page 1
UNITED STATES BANKRUPTCY COURT
DISTRICT OF ARIZONA
In re:
,
Debtor(s).
Chapter
Case No.
Declaration of Evidence of Employers’ Payments Within 60 Days
☐ Attached hereto are copies of all payment advices, pay stubs or other evidence of payment
received by the debtor from any employer within 60 days prior to the filing of the petition;
☐ Debtor has received no payment advices, pay stubs or other evidence of payment
from any employer within 60 days prior to the filing of the petition; or
☐ Debtor has received the following payments from employers within 60 days prior
to the filing of the petition: $ .
Debtor declares the foregoing to be true and correct under penalty of perjury.
Dated: ______________ ____________________________________
Signature of Debtor
If attaching pay stubs or other payment advices, it is your responsibility to redact (black out) any social
security numbers, names of minor children, dates of birth or financial account numbers before attaching
them to this document.
Local Form 1007-3 (08/18) Declaration of Debtor Without An Attorney Page 1
UNITED STATES BANKRUPTCY COURT
DISTRICT OF ARIZONA
In re:
Debtor(s).
Chapter ______
Case No. _____________________
DECLARATION UNDER PENALTY OF
PERJURY FOR DEBTOR(S) WITHOUT AN ATTORNEY
The debtor(s) shall answer the following questions:
1. D
id you pay or promise to pay someone to help in preparing the documents for your bankruptcy filing:
[ ] Yes [ ] No
2. If
yes, please give the following information about that person(s)
:
N
ame: ____________________________________________________________
Address: __________________________________________________________
City/State/Zip: _____________________________________________________
Telephone No: _____________________________________________________
3. W
hat amount did you pay or promise to pay for this help? (Fill in the blanks)
M
oney: Paid: $______________ Will Pay: $______________
Pe
rsonal Property given to or Services provided to preparer (instead of, or in addition to, monetary payment
above) (please explain): __________________________________________________________________
______________________________________________________________________________________
4. D
id you make any payments to the preparer for Court costs in connection with the filing of the bankruptcy
(such as filing fees)
?
[ ] Yes [ ] No. If yes, how much $______________
I declare under penalty of perjury that the above statements are true.
_________
_______________________________ _______________________________________
Debtor’s Signature Joint Debtor’s Signature
________________________________________ _______________________________________
Print Name Print Name
________________________________________ _______________________________________
Address Address
War
ning: It is a federal crime to file a document containing false information in a federal court proceeding.
Penalty for false declarations: Fine of not more than $250,000 or imprisonment for not more than 5 years or
both. 18 U.S.C. § 152 and § 3571.
Instructions
Bankruptcy Forms for Individuals
U.S. Bankruptcy Court | December 2015 (Rev.
March 2019)
About this Booklet of Instructions ..................................................................................... 1
About the bankruptcy forms and filing bankruptcy ............................................................................................... 2
Understand the terms used in the forms ............................................................................................................. 2
Things to remember when filling out these forms ................................................................................................ 4
On what date was a debt incurred? .................................................................................................................... 4
About the Process for Filing a Bankruptcy Case for Individuals ........................................................ 5
Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) .............. 10
The types of bankruptcy that are available to individuals .................................................................................. 10
Bankruptcy crimes have serious consequences ............................................................................................... 13
Make sure the court has your mailing address .................................................................................................. 13
Understand which services you could receive from credit counseling agencies ................................................ 13
Instructions for Selected Forms ...................................................................................... 15
Schedule A/B: Property (Official Form 106A/B) ............................................................................... 16
Schedule C: The Property You Claim as Exempt (Official Form 106C)........................................... 18
Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D) ..................... 19
Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F) .............................. 22
Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G) ............................. 26
Schedule H: Your Codebtors (Official Form 106H) ......................................................................... 27
Schedule I: Your Income (Official Form 106I) ................................................................................. 28
Schedule J: Your Expenses (Official Form 106J) ............................................................................ 30
Summary of Your Assets and Liabilities and Certain Statistical Information (Official Form
106Sum) .......................................................................................................................................... 31
Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107) .................. 32
Chapter 7 Statement of Your Current Monthly Income and Means Test Calculation (Official
Forms 122A–1, 122A-1Supp, and 122A–2) .................................................................................... 33
Chapter 11 Statement of Your Current Monthly Income (Official Form 122B) ................................. 35
Chapter 13 Statement of Your Current Monthly Income, Calculation of Commitment Period
and Chapter 13 Calculation of Your Disposable Income (Official Forms 122C–1 and 122C–2) ...... 36
Statement of Intention for Individuals Filing Under Chapter 7 (Official Form 108) ........................... 37
Application for Individuals to Pay the Filing Fee in Installments (Official Form 103A) ..................... 39
Application to Have the Chapter 7 Filing Fee Waived (Official Form 103B) .................................... 40
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured
Claims Against You and Are Not Insiders (Official Form 104) ......................................................... 38
Glossary ................................................................................................................... 40
Definitions of Some Terms Used in the Forms for Individuals Filing for Bankruptcy ....................... 41
About this Booklet of Instructions page 1
About this Booklet of Instructions
This booklet provides instructions for
completing selected forms that individuals
filing for bankruptcy must submit to the U.S.
Bankruptcy Court. You can download all of the
required forms without charge from:
http://www.uscourts.gov/FormsAndFees/Forms/Bank
ruptcyForms.aspx.
The instructions are designed to accompany the
forms and are intended to help you understand
what information is required to properly file.
You are responsible for properly completing the
forms. These instructions are not intended to
provide, and should not be understood to
provide, legal advice. They are not designed to
fully explain, or to be relied upon in
interpreting, the law.
Completing the forms is only a part of the
bankruptcy process. You are strongly
encouraged to hire a qualified attorney not only
to help you complete the forms but also to give
you general advice about bankruptcy and to
represent you in your bankruptcy case. If you
cannot afford to pay an attorney, you might
qualify for free legal services if they are
provided in your area. Contact your state or
local bar association for help in obtaining free
legal services or in hiring an attorney.
Note: It is extremely difficult to succeed in a
chapter 11, 12, or 13 case without an
attorney.
If an attorney represents you, you must provide
information so the attorney can prepare your
forms. Once the attorney prepares the forms,
you must make sure that the forms are accurate
and complete. These instructions may help you
perform those tasks. If you are filing for
bankruptcy without the help of an attorney, this
booklet tells you which forms must be filed and
provides information about them.
You should carefully read this booklet and keep
it with your records. Review the individual
forms as you read the instructions for each.
Although bankruptcy petition preparers can
help you type the bankruptcy forms, they cannot
tell you how to complete the forms, they cannot
file the documents for you, and they cannot give
you legal advice. Court employees cannot give
you legal advice, either.
About this Booklet of Instructions page 2
Read These Important Warnings
Because bankruptcy can have serious long-term financial and legal consequences, including
loss of your property, you should hire an attorney and carefully consider all of your options
before you file. Only an attorney can give you legal advice about what can happen as a result
of filing for bankruptcy and what your options are. If you do file for bankruptcy, an attorney
can help you fill out the forms properly and protect you, your family, your home, and your
possessions.
Although the law allows you to represent yourself in bankruptcy court, you should understand
that many people find it difficult to represent themselves successfully. The rules are technical,
and a mistake or inaction may harm you. If you file without an attorney, you are still
responsible for knowing and following all of the legal requirements.
You should not file for bankruptcy if you are not eligible to file or if you do not intend to file
the necessary documents.
Bankruptcy fraud is a serious crime; you could be fined and imprisoned if you commit fraud in
your bankruptcy case. Making a false statement, concealing property, or obtaining money or
property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or
imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
A
bout the bankruptcy forms and
filing bankruptcy
Use the forms that are numbered in the 100
series to file bankruptcy for individuals or
married couples. Use the forms that are
numbered in the 200 series if you are preparing
a bankruptcy on behalf of a nonindividual, such
as a corporation, partnership, or limited liability
company (LLC). Sole proprietors must use the
forms that are numbered in the 100 series.
When a bankruptcy is filed, the U.S.
Bankruptcy Court opens a case. It is important
that the answers to the questions on the forms
be complete and accurate so that the case
proceeds smoothly. A person filing bankruptcy
who gives false information could be charged
with a federal crime or could lose all the
benefits of filing for bankruptcy.
You should understand that filing a bankruptcy
case is not private. Anyone has a right to see
your bankruptcy forms after you file them,
unless the court orders otherwise under
11 U.S.C. § 107. Certain information in court
filings, however, must be protected from public
disclosure under Bankruptcy Rule 9037.
Understand the terms used in the
forms
The forms for individuals use you and Debtor 1
About this Booklet of Instructions page 3
to refer to a debtor filing alone. A married
couple may file a bankruptcy case together—
called a joint case—and in joint cases, these
forms use you to ask for information from both
debtors.
About this Booklet of Instructions page 4
For example, if a form asks, “Do you own a
car?” the answer would be yes if either debtor
owns a car. When information is needed about
the spouses separately, the forms use Debtor 1
and Debtor 2 to distinguish between them. In
joint cases, one of the spouses must report
information as Debtor 1 and the other as
Debtor 2. The same person must be Debtor 1 in
all of the forms.
To understand other terms used in the forms and
the instructions, see the Glossary at the end of
this booklet.
Things to remember when filling
out these forms
Do not file these instructions with the
bankruptcy forms that you file with the
court
.
Be as complete and accurate as possible.
If more space is needed, attach a separate
s
heet to the form. On the top of any
additional pages, write your name and cas
e
number (if known). Also identify the form
and line number to which the additional
information applies
.
If two married people are filing together,
bot
h are equally responsible for supplying
correct informati
on.
Do not list a minor child’s full name.
Instead, fill in only the child’s initials and
the full name and address of the child’
s
parent or guardian. For example, write A.B.,
a
minor child (John Doe, parent, 123 Mai
n
St
., City, State). 11 U.S.C. § 112;
Bankruptcy Rule 1007(m) and 9037.
For your records, be sure to keep a copy of
your bankruptcy documents and all
attachments that you file.
On what date was a debt incurred?
When a debt was incurred on a single date, fill
in the actual date that the debt was incurred.
When a debt was incurred on multiple dates, fill
in the range of dates. For example, if the debt is
from a credit card, fill in the month and year of
the first and last transaction.
About the Process for Filing a Bankruptcy Case for Individuals page 5
About the Process for Filing a Bankruptcy Case for
Individuals
Before you file your bankruptcy case
Before you file for bankruptcy, you must do
several things:
Receive a briefing about credit counseling from
an approved agency
within 180 days before
you file. (If you and your spouse are filing
together, each of you must receive a briefing
before you file. Failure to do so may result in
the dismissal of your case.) You may have
a
br
iefing about credit counseling one-on-one
or in a group, by telephone, or by internet
.
For a list of approved providers, go to:
http://www.justice.gov/ust/eo/bapcpa/ccde/cc_appr
oved.htm
In Alabama and North Carolina, go to:
http://www.uscourts.gov/FederalCourts/Bankr
uptcy/BankruptcyResources/ApprovedCreditA
ndDebtCounselors.aspx.
After you finish the briefing, you will receive a
cer
tificate that you will need to file in your
bankruptcy case
.
Find out in which bankruptcy court you must
file your bankruptcy case. It is important that
y
ou file in the correct district within your
state. To find out which district you are in, g
o
to:
http://www.uscourts.gov/courtlinks
Check the local court’s website for any
specific local requirements that you migh
t
ha
ve to meet. Go to:
http://www.uscourts.gov/courtlinks
Find out which chapters of the Bankruptcy
Code you are eligible for. For descriptions of
each chapter, review the information
contained in the notice, Notice Required b
y
11 U.S.C. § 342(b) for Individuals Filing for
Bankruptcy (Form B2010), which is include
d
i
n this booklet
.
About the Process for Filing a Bankruptcy Case for Individuals page 6
When you file your bankruptcy case
There are several forms and documents that you
must give the court at the time you file.
Additional forms and documents must be filed no
later than 14 days after you file your bankruptcy
case, although they may be filed at the same time
you file your case.
You must file the forms listed below on the date
you open your bankruptcy case. For copies of the
forms listed here, go to
http://www.uscourts.gov/FormsAndFees/Forms/Bankru
ptcyForms.aspx. (The list continues on the next
page.):
Voluntary Petition for Individuals Filing for
Bankruptcy (Official Form 101). This form
opens the case. Directions for filling it out are
included in the form itself.
Statement About Your Social Security
Numbers (Official Form 121). This form gives
the court your full Social Security number or
federal Individual Taxpayer Identification
num
ber. To protect your privacy, the court
will make only the last four digits of your
number known to the general public.
H
owever, the court will make your full
number available to your creditors, the U.S
.
trustee or bankruptcy administrator, and the
trustee assigned to your case. This form has
no
sep
arate instructions.
Your filing fee. If you cannot pay the entire
f
iling fee, you must also include:
Application for Individuals to Pay the
Filing Fee in Installments (Official Form
103A), or
Application to Have the Chapter 7 Filing
F
ee Waived (Official Form 103B). U
se
t
his form only if you are filing under
chapter 7 and you meet the criteria to have
t
he chapter 7 filing fee waive
d.
A list of names and addresses of all of your
creditors, formatted as a mailing list according
to instructions from the bankruptcy court in
which you file. (Your court may call this a
creditor matrix or mailing matrix.)
Your credit counseling certificate from an
approved credit counseling agency. (S
ee
B
efore you file your bankruptcy case, above)
.
If you have received the briefing about credit
counseling but have not yet received th
e
cer
tificate, file it no later than 14 days after
you file for bankruptcy. If you have not
already received the briefing and believe y
ou
ar
e entitled to a temporary waiver from
receiving it or that you are not required to
r
eceive the briefing, see line 15 of the
Voluntary Petition for Individuals Filing for
Bankruptcy (Official Form 101).
For Individual Chapter 11 Cases: List of
Creditors Who Have the 20 Largest
Unsecured Claims Against You and Are Not
Insiders (Official Form 104). Fill out this form
only if you file under chapter
11.
Initial Statement About an Eviction Judgment
Against You (Official Form 101A) and
Statement About Payment of an Evictio
n
Judgment Against You (Official Form 101B).
Use Form 101A if your landlord has a
n
e
viction judgment against you. If y
ou
complete Form 101A and you want to stay in
y
our residence for the first 30 days after y
ou
f
ile, you must indicate that on the form. Use
Form 101B if you have completed Form 101A
and you want to stay in your rented residence
form more than 30 days after you file for
bankruptcy.
Bankruptcy Petition Preparer’s Notice,
Declaration, and Signature (Official Form 119
)
a
nd Disclosure of Compensation of Bankruptcy
Petition Preparer (Form 2800). Use these forms
About the Process for Filing a Bankruptcy Case for Individuals page 7
if a bankruptcy petition preparer typed your forms.
When you file your bankruptcy case or within 14 days after you file
You must file the forms listed below either when you file your bankruptcy case or within 14 days after
you file your Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101). If you do
not do so, your case may be dismissed. Although it is possible to open your case by submitting only
the documents that are listed under When you file your bankruptcy case, you should file the entire set
of forms at one time to help your case proceed smoothly.
Although some forms may ask you similar questions, you must fill out all of the forms completely to
protect your legal rights.
The list below shows the forms that all individuals must file as well as the forms that are specific to
each chapter. For copies of the official forms listed here, go to
http://www.uscourts.gov.
All individuals who file for bankruptcy
must file these forms and the forms for the
specific chapter:
Schedules of Assets and Liabilities (Official
Form 106) which includes these forms:
Schedule A/B: Property (Official
Fo
rm 106A/B)
Schedule C: The Property You Claim as
Exempt (Official Form 106C)
Schedule D: Creditors Who Have Claims
Secured by Your Property (Official Form
106D)
Schedule E/F: Creditors Who Have
Unsecured Claims (Official Form 106E/F)
Schedule G: Executory Contracts and
Unexpired Leases (Official Form 106G)
Schedule H: Your Codebtors (Official
Fo
rm 106H)
Schedule I: Your Income (Official
Form 106I)
Schedule J: Your Expenses (Official
Form 106J)
About the Process for Filing a Bankruptcy Case for Individuals page 8
Summary of Your Assets and Liabilities
and Certain Statistical Information
(Official Form 106Sum). This form gives
an overview of the totals on the schedules
Declaration About an Individual Debtor’s
Schedules (Official Form 106Dec)
Statement of Financial Affairs for Individuals
Filing for Bankruptcy (Official Form 107)
Disclosure of Compensation to Debtor’s
Attorney Unless local rules provid
e
ot
herwise, Director’s Form 2030 may be use
d.
Credit counseling certificate that you received
f
rom an approved credit counseling agency
Copies of all payment advices (pay stubs) or
ot
her evidence of payment that you receive
d
w
ithin 60 days before you filed your bankruptcy
case. Some local courts may require that you
submit these documents to the trustee assigned
to your case rather than filing them with the
court. Check the local court’s website to find
out
if local requirements apply. Go t
o
http://www.uscourts.gov/courtlinks.
About the Process for Filing a Bankruptcy Case for Individuals page 9
If you file under chapter 7, you must also file:
Statement of Intention for Individuals Filing
Under Chapter 7 (Official Form 108)
Chapter 7 Statement of Your Current Monthly
Income (Official Form 122A-1)
If necessary, Chapter 7 Means Test
Calculation (Official Form 122A-2)
If necessary, Statement of Exemption from
Presumption of Abuse Under § 707(b)(2)
(Official Form 122A-1Supp)
If you file under chapter 11, you must also file:
Chapter 11 Statement of Your Current
Monthly Income (Official Form 122-B)
If you file under chapter 11 and are a small
business debtor (that is, if you are self-employed
and your debts are less than $2,725,625*), within
7 days after you file your bankruptcy forms to
open your case, you must also file your most
recent:
Balance sheet
Statement of operations
Cash-flow statement
Federal income tax return
If you do not have these documents, you must
file a statement made under penalty of perjury
that you have not prepared either a balance sheet,
statement of operations, or cash-flow statement
or you have not filed a federal tax return.
If you file under chapter 11, you must file
additional documents beyond the scope of these
instructions. You should consult your attorney.
* Subject to adjustment on 4/01/22, and every 3 years
after that for cases begun on or after the date of
adjustment.
If you file under chapter 12, you must also file:
Chapter 12 Plan (within 90 days after you file
your bankruptcy forms to open your case)
If you file under chapter 13, you must also file:
Chapter 13 Statement of Your Current Monthly
Income and Calculation of Commitment Period
(Official Form 122C-1)
If necessary, Chapter 13 Calculation of Your
Disposable Income (Official Form 122C-2)
Chapter 13 Plan (Official Form 113, if in
effect). If Official Form 113 is not effective
when you file, many bankruptcy courts
require you to use a local form plan. Check
the local court’s website for any specific form
that you might have to use. Go to
http://www.uscourts.gov/courtlinks.)
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 10
Notice Required by 11 U.S.C. § 342(b) for
Individuals Filing for Bankruptcy
(Form 2010)
This notice is for you if:
You are an individual filing for
bankruptcy, and
Your debts are primarily consumer
debts. Consumer debts are defined in
11 U.S.C. § 101(8) as “incurred by an
individual primarily for a personal,
family, or household purpose.”
The types of bankruptcy that are
available to individuals
Individuals who meet the qualifications may file
under one of four different chapters of the
Bankruptcy Code:
Chapter 7 — Liquidation
Chapter 11 — Reorganization
Chapter 12 — Voluntary repayment plan
for family farmers or
fishermen
Chapter 13 — Voluntary repayment plan
for individuals with regular
income
You should have an attorney review your
decision to file for bankruptcy and the choice of
chapter.
Chapter 7: Liquidation
$245 filing fee
$75 administrative fee
+ $15 trustee surcharge
$335 total fee
Chapter 7 is for individuals who have financial
difficulty preventing them from paying their
debts and who are willing to allow their non-
exempt property to be used to pay their
creditors. The primary purpose of filing under
chapter 7 is to have your debts discharged. The
bankruptcy discharge relieves you after
bankruptcy from having to pay many of your
pre-bankruptcy debts. Exceptions exist for
particular debts, and liens on property may still
be enforced after discharge. For example, a
creditor may have the right to foreclose a home
mortgage or repossess an automobile.
However, if the court finds that you have
committed certain kinds of improper conduct
described in the Bankruptcy Code, the court
may deny your discharge.
You should know that even if you file
chapter 7 and you receive a discharge, some
debts are not discharged under the law.
Therefore, you may still be responsible to pay:
most taxes;
most student loans;
domestic support and property settlement
obligations;
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 11
most fines, penalties, forfeitures, and
c
riminal restitution obligations; and
certain debts that are not listed in your
bankruptcy papers.
You may also be required to pay debts arising
from:
fraud or theft;
fraud or defalcation while acting in breach
of
fiduciary capacity;
intentional injuries that you inflicted; and
death or personal injury caused by
operating a motor vehicle, vessel, or
aircraft while intoxicated from alcohol or
drugs.
I
f your debts are primarily consumer debts, the
court can dismiss your chapter 7 case if it finds
that you have enough income to repay
creditors a certain amount. You must file
Chapter 7 Statement of Your Current Monthly
Income (Official Form 122A–1) if you are an
individual filing for bankruptcy under
chapter 7. This form will determine your
current monthly income and compare whether
your income is more than the median income
that applies in your state.
If your income is not above the median for
your state, you will not have to complete the
other chapter 7 form, the Chapter 7 Means
Test Calculation (Official Form 122A–2).
If your income is above the median for your
state, you must file a second form —the
Chapter 7 Means Test Calculation (Official
Form 122A–2). The calculations on the form—
sometimes called the Means Test—deduct
from your income living expenses and
payments on certain debts to determine any
amount available to pay unsecured creditors. If
your income is more than the median income
for your state of residence and family size,
depending on the results of the Means Test, the
U.S. trustee, bankruptcy administrator, or
creditors can file a motion to dismiss your case
under § 707(b) of the Bankruptcy Code. If a
motion is filed, the court will decide if your
case should be dismissed. To avoid dismissal,
you may choose to proceed under another
chapter of the Bankruptcy Code.
If you are an individual filing for chapter 7
bankruptcy, the trustee may sell your property
to pay your debts, subject to your right to
exempt the property or a portion of the
proceeds from the sale of the property. The
property, and the proceeds from property that
your bankruptcy trustee sells or liquidates that
you are entitled to, is called exempt property.
Exemptions may enable you to keep your
home, a car, clothing, and household items or
to receive some of the proceeds if the property
is sold.
Exemptions are not automatic. To exempt
property, you must list it on Schedule C: The
Property You Claim as Exempt (Official Form
106C). If you do not list the property, the
trustee may sell it and pay all of the proceeds
to your creditors.
Chapter 11: Reorganization
$1,167 filing fee
+ $550 administrative fee
$1,717 total fee
Chapter 11 is often used for reorganizing a
business, but is also available to individuals.
The provisions of chapter 11 are too
complicated to summarize briefly.
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 12
Chapter 12: Repayment plan for family
farmers or fishermen
$200 filing fee
+ $75 administrative fee
$275 total fee
Similar to chapter 13, chapter 12 permits
family farmers and fishermen to repay their
debts over a period of time using future
earnings and to discharge some debts that are
not paid.
Chapter 13: Repayment plan for
individuals with regular
income
$235 filing fee
+ $75 administrative fee
$310 total fee
Chapter 13 is for individuals who have regular
income and would like to pay all or part of
their debts in installments over a period of time
and to discharge some debts that are not paid.
You are eligible for chapter 13 only if your
debts are not more than certain dollar amounts
set forth in 11 U.S.C. § 109.
Under chapter 13, you must file with the court
a plan to repay your creditors all or part of the
money that you owe them, usually using your
future earnings. If the court approves your
plan, the court will allow you to repay your
debts, as adjusted by the plan, within 3 years or
5 years, depending on your income and other
factors.
After you make all the payments under your
plan, many of your debts are discharged. The
debts that are not discharged and that you may
still be responsible to pay include:
domestic support obligations,
most student loans,
certain taxes,
debts for fraud or theft,
debts for fraud or defalcation while acting
in a fiduciary capacity,
most criminal fines and restitution
Read These Important Warnings
Because bankruptcy can have serious long-term financial and legal consequences, including loss of
your property, you should hire an attorney and carefully consider all of your options before you file.
Only an attorney can give you legal advice about what can happen as a result of filing for bankruptcy
and what your options are. If you do file for bankruptcy, an attorney can help you fill out the forms
properly and protect you, your family, your home, and your possessions.
Although the law allows you to represent yourself in bankruptcy court, you should understand that
many people find it difficult to represent themselves successfully. The rules are technical, and a
mistake or inaction may harm you. If you file without an attorney, you are still responsible for knowing
and following all of the legal requirements.
You should not file for bankruptcy if you are not eligible to file or if you do not intend to file the
necessary documents.
Bankruptcy fraud is a serious crime; you could be fined and imprisoned if you commit fraud in your
bankruptcy case.
Making a false statement, concealing property, or obtaining money or property by
fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to
20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 13
obligations,
certain debts that are not listed in your
bankruptcy papers
,
certain debts for acts that caused death or
personal injury, a
nd
certain long-term secured debts.
B
ankruptcy crimes have serious
consequences
If you knowingly and fraudulently conceal
assets or make a false oath or statement
under penalty of perjury—either orally or
in writing—in connection with a
bankruptcy case, you may be fine
d,
i
mprisoned, or both.
All information you supply in connection
w
ith a bankruptcy case is subject to
examination by the Attorney General acting
through the Office of the U.S. Trustee, the
Office of the U.S. Attorney, and other
offices and employees of the U.S
.
Department of Justice.
Make sure the court has your
mailing address
The bankruptcy court sends notices to the
mailing address you list on Voluntary Petition
for Individuals Filing for Bankruptcy (Official
Form 101). To ensure that you receive
information about your case, Bankruptcy
Rule 4002 requires that you notify the court of
any changes in your address.
A married couple may file a bankruptcy case
together—called a joint case. If you file a joint
case and each spouse lists the same mailing
address on the bankruptcy petition, the
bankruptcy court generally will mail you and
your spouse one copy of each notice, unless
you file a statement with the court asking that
each spouse receive separate copies.
Understand which services you
could receive from credit
counseling agencies
The law generally requires that you receive a
credit counseling briefing from an approved
credit counseling agency. 11 U.S.C. § 109(h).
If you are filing a joint case, both spouses must
receive the briefing. With limited exceptions,
you must receive it within the 180 days
before
you file your bankruptcy petition. This briefing
is usually conducted by telephone or on the
Internet.
In addition, after filing a bankruptcy case, you
generally must complete a financial
management instructional course before you
can receive a discharge. If you are filing a joint
case, both spouses must complete the course.
You can obtain the list of agencies approved to
provide both the briefing and the instructional
course from:
http://justice.gov/ust/eo/hapcpa/ccde/cc_approved.html.
Warning: File Your Forms on Time
Section 521(a)(1) of the Bankruptcy Code
requires that you promptly file detailed information
about your creditors, assets, liabilities, income,
expenses and general financial condition. The
court may dismiss your bankruptcy case if you do
not file this information within the deadlines set by
the Bankruptcy Code, the Bankruptcy Rules, and
the local rules of the court.
For more information about the documents and
their deadlines, go to:
http://www.uscourts.gov/bkforms/bankruptcy_form
s.html#procedure.
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 14
In Alabama and North Carolina, go to:
http://www.uscourts.gov/FederalCourts/Bankruptcy/
BankruptcyResources/ApprovedCredit
AndDebtCounselors.aspx.
If you do not have access to a computer, the
clerk of the bankruptcy court may be able to
help you obtain the list.
Instructions for Selected Forms page 15
Instructions for Selected Forms
Schedule A/B: Property (Official Form 106A/B) page 16
Schedule A/B: Property (Official Form 106A/B)
Schedule A/B: Property (Official Form 106A/B)
lists property interests that are involved in a
bankruptcy case. All individuals filing for
bankruptcy must list everything they own or
have a legal or equitable interest in. Legal or
equitable interest is a broad term and includes
all kinds of property interests in both tangible
and intangible property, whether or not anyone
else has an interest in that property.
The information in this form is grouped by
category and includes several examples for
many items. Note that those examples are meant
to give you an idea of what to include in the
categories. They are not intended to be
complete lists of everything within that
category. Make sure you list everything you
own or have an interest in.
You must verify under penalty of perjury that
the information you provide is complete and
accurate. Making a false statement, concealing
property, or obtaining money or property by
fraud in connection with a bankruptcy case can
result in fines up to $250,000, or imprisonment
for up to 20 years, or both. 18 U.S.C. §§ 152,
1341, 1519, and 3571.
Understand the terms used in this form
Community property — Type of property
ownership available in certain states for
property owned by spouses and, in some
instances, legal equivalents of spouses.
Community property states and territories
include Arizona, California, Idaho, Louisiana,
Nevada, New Mexico, Puerto Rico, Texas,
Washington, and Wisconsin.
Current value — In this form, report the current
value of the property that you own in each
category. Current value is sometimes called fair
market value and, for this form, is the fair
market value as of the date of the filing of the
petition. Current value is how much the
property is worth, which may be more or less
than when you purchased the property. Property
you own includes property you have purchased,
even if you owe money on it, such as a home
with a mortgage or an automobile with a lien.
Report the current value of the portion
you own
For each question, report the current value of
the portion of the property that you own. To do
this, you would usually determine the current
value of the entire property and the percentage
of the property that you own. Multiply the
current value of the property by the percentage
that you own. Report the result where the form
asks for Current value of the portion you own.
For example:
If you own a house by yourself, you own
100% of that house. Report the entire
current value of the house.
If you and a sister own the house equally,
report 50% of the value of the house (or half
of the value of the house).
In certain categories, current value may be
difficult to figure out. When you cannot find the
value from a reputable source (such as a pricing
guide for your car), estimate the value and be
prepared to explain how you determined it.
Schedule A/B: Property (Official Form 106A/B) page 17
List items once on this form
List items only once on this form; do not list
them in more than one category. List all real
estate in Part 1 and other property in the other
parts of the form.
Where you list similar items of minimal value
(such as clothing), add the value of the items
and report a total.
Be specific when you describe each item. If you
have an item that you think could fit into more
than one category, select the most suitable
category and list the item there.
Separately describe and list individual items
worth more than $500.
Match the values to the other schedules
Make sure that the values you report on this form
match the values you report on Schedule D:
Creditors Who Have Claims Secured by Your
Property (Official Form 106D) and Schedule C:
The Property You Claim as Exempt (Official
Form 106C).
Schedule C: The Property You Claim as Exempt (Official Form 106C) page 18
Schedule C: The Property You Claim as Exempt
(Official Form 106C)
How exemptions work
If you are an individual filing for bankruptcy, the
law may allow you to keep some property, or it
may entitle you to part of the proceeds if the
property is sold after your case is filed. Property
that the law permits you to keep is called exempt
property. For example, exemptions may enable
you to keep your home, a car, clothing, and
household items.
Exemptions are not automatic. For property to be
considered exempt, you must list the property on
Schedule C: The Property You Claim as Exempt
(Official Form 106C). If you do not list the
property, the trustee may sell it and pay all of the
proceeds to your creditors.
You may unnecessarily lose property if you
do not claim exemptions to which you are
entitled. You are strongly encouraged to
hire a qualified attorney to advise you.
Determine which set of exemptions you
will use
Before you fill out this form, you must learn
which set of exemptions you can use. In general,
exemptions are determined on a state-by-state
basis. Some states permit you to use the
exemptions provided by the Bankruptcy Code.
11 U.S.C. § 522.
The Bankruptcy Code provides that you use the
exemptions in the law of the state where you had
your legal home for 730 days before you file for
bankruptcy. Special rules may apply if you did
not have the same home state for 730 days before
you file.
You may lose property if you do not use the best
set of exemptions for your situation.
If your spouse is filing with you and you are
filing in a state in which you may choose
between state and federal sets of bankruptcy
exemptions, you both must use the same set of
exemptions.
Claiming exemptions
Using the property and values that you listed on
Schedule A/B: Property (Official Form 106A/B)
as your source, list on this form the property that
you claim as exempt.
Listing the amount of each exemption
For each item of property you claim as exempt,
you must specify the amount of the exemption
you claim. Usually, a specific dollar amount is
claimed as exempt, but in some circumstances,
the amount of the exemption claimed might be
indicated as 100% of fair market value. For
example, a debtor might claim 100% of fair
market value for an exemption that is unlimited
in dollar amount, such as some exemptions for
health aids.
Listing which laws apply
In the last column of the form, you must identify
the laws that allow you to claim the property as
exempt. If you have questions about exemptions,
consult a qualified attorney.
Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D) page 19
Schedule D: Creditors Who Have Claims Secured by
Property (Official Form 106D)
The people or organizations to whom you owe
money are called your creditors. A claim is a
creditor’s right to payment. When you file for
bankruptcy, the court needs to know who all
your creditors are and what types of claims they
have against you.
Typically in bankruptcy cases, there are more
debts than assets to pay those debts. The court
must know as much as possible about your
creditors to make sure that their claims are
properly treated according to the rules.
Creditors may have different types of claims:
Secured claims. Report these on Schedule D:
C
reditors Who Have Claims Secured b
y
P
roperty (Official Form 106D).
Unsecured claims. Report these on
Schedule E/F: Creditors Who Have
Unsecured Claims (Official Form 106E/F).
If your debts are not paid, a creditor with a
secured claim may be able to get paid from
specific property in which that creditor has an
interest, such as a mortgage or a lien. That
property is sometimes called collateral for your
debt and could include items such as your house,
your car, or your furniture. Creditors with
unsecured claims do not have rights against
specific property.
Many creditors’ claims have a specific amount,
which you do not dispute. However, some claims
are uncertain when you file for bankruptcy, or
they become due only after you file. You must
list the claims of all your creditors in your
schedules, even if the claims are contingent,
unliquidated, or disputed.
Claims may be contingent, unliquidated,
or disputed
Claims may be:
Contingent claims,
Unliquidated claims, or
Disputed claims.
A claim is contingent if you are not obligated to
pay it unless a particular event occurs after you
file for bankruptcy. For example, if you cosigned
someone else’s note, you may not have to pay
unless that other person later fails to repay the
loan.
A claim is unliquidated if the amount of the debt
cannot be readily determined, such as by
referring to an agreement or by a simple
computation. An unliquidated claim is one for
which there may be a definite liability but where
the value has not been set. For instance, if you
were involved in a car accident, the victim may
have an unliquidated claim against you because
the amount of damages has not been determined.
A claim is disputed if you disagree about
whether you owe the debt. For instance, if a bill
collector demands payment for a bill you believe
you already fully paid, you may describe the
claim as disputed.
A single claim can have one, more than one, or
none of these characteristics.
On Schedule D: Creditors Who Have Claims
Secured by Property (Official Form 106D), list
all creditors who have a claim that is secured by
your property.
Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D) page 20
Do not leave out any secured creditors
In alphabetical order (as much as possible), list
anyone who has judgment liens, garnishments,
statutory liens, mortgages, deeds of trust, and
other security interests against your property.
When listing creditors who have secured claims,
be sure to include all of them. For example,
include the following:
Your relatives or friends who have a lien or
security interest in your property;
Car or truck lenders, stores, banks, credit
unions, and others who made loans to enabl
e
y
ou to finance the purchase of property a
nd
w
ho have a lien against that property;
Anyone who has a mortgage or deed of trust
on real estate that you own;
Contractors or mechanics who have liens on
property you own because they did work
on
t
he property and were not paid;
Someone who won a lawsuit against you and
ha
s a judgment lien;
Another parent or a government agency that
has a lien for unpaid child support;
Doctors or attorneys who have liens on the
out
come of a lawsuit;
Federal, state, or local government agencies
su
ch as the IRS that have tax liens against
property for unpaid taxes; and
Anyone who is trying to collect a secured
de
bt from you, such as collection agencies
and attorneys.
List the debt in Part 1 only once and list any
others that should be notified about that debt in
Part 2. For example, if a collection agency or an
attorney is trying to collect from you for a debt
you owe to someone else, list the person to
whom you owe the debt in Part 1, and list the
collection agency in Part 2. If you are not sure
who the creditor is, list the person you are paying
in Part 1 and list anyone else who has contacted
you about this debt in Part 2.
If a creditor’s full claim is more than the value of
your property securing that claim—for instance,
a car loan in an amount greater than the value of
the car—the creditor’s claim may be partly
secured and partly unsecured. In that situation,
list the claim only once on Schedule D:
Creditors Who Have Claims Secured by
Property (Official Form 106D). Do not repeat it
on Schedule E/F: Creditors Who Have
Unsecured Claims (Official Form 106E/F). List
a creditor in Schedule D even if it appears that
there is no value to support that creditor’s
secured claim.
Determine the unsecured portion of
secured claims
To determine the amount of a secured claim,
compare the amount of the claim to the value of
your portion of the property that supports the
claim. If that value is greater than the amount of
the claim, then the entire amount of the claim is
secured. But if that value is less than the amount
of the claim, the difference is an unsecured
portion. For example, if the outstanding balance
of a car loan is $10,000 and the car is worth
$8,000, the car loan has a $2,000 unsecured
portion.
Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D) page 21
If there is more than one secured claim against
the same property, the claim that is entitled to be
paid first must be subtracted from the property
value to determine how much value remains for
the next claim.
For example, if a home worth $300,000 has a
first mortgage of $200,000 and a second
mortgage of $150,000, the first mortgage would
be fully secured, and there would be $100,000 of
property value for the second mortgage, which
would have an unsecured portion of $50,000.
$300,000 value of a home
- $200,000 first mortgage
$100,000 remaining property value
$150,000 second mortgage
- $100,000 remaining property value
$ 50,000 unsecured portion of second mortgage
Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F) page 22
Schedule E/F: Creditors Who Have Unsecured
Claims (Official Form 106E/F)
The people or organizations to whom you owe
money are called your creditors. A claim is a
creditor’s right to payment. When you file for
bankruptcy, the court needs to know who all
your creditors are and what types of claims they
have against you.
Typically in bankruptcy cases, there are more
debts than assets to pay those debts. The court
must know as much as possible about your
creditors to make sure that their claims are
properly treated according to the rules.
Use Schedule E/F: Creditors Who Have
Unsecured Claims (Official Form 106E/F) to
identify everyone who has an unsecured claim
against you when you file your bankruptcy
petition, unless you have already listed them on
Schedule D: Creditors Who Have Claims
Secured by Your Property (Official Form
106D).
Creditors may have different types of claims:
Secured claims. Report these on Schedule D:
Creditors Who Have Claims Secured by
Property (Official Form 106D).
Unsecured claims. Report these on
Schedule E/F: Creditors Who Have
Unsecured Claims (Official Form 106E/F).
If your debts are not paid, creditors with
secured claims may be able to get paid from
specific property in which that creditor has an
interest, such as a mortgage or a lien. That
property is sometimes called collateral for your
debt and could include items such as your
house, your car, or your furniture. Creditors
with unsecured claims do not have rights
against specific property.
Many creditors’ claims have a specific amount,
which you do not dispute. However, some
claims are uncertain when you file for
bankruptcy, or they become due only after you
file. You must list the claims of all your
creditors in your schedules, even if the claims
are contingent, unliquidated, or disputed.
Claims may be contingent, unliquidated,
or disputed
Claims may be:
Contingent claims,
Unliquidated claims, or
Disputed claims.
A claim is contingent if you are not obligated to
pay it unless a particular event occurs after you
file for bankruptcy. For example, if you
cosigned someone else’s note, you may not
have to pay unless that person later fails to
repay the loan.
A claim is unliquidated if the amount of the
debt cannot be readily determined, such as by
referring to an agreement or by a simple
computation. An unliquidated claim is one for
which there may be a definite liability but
where the value has not been set. For instance,
if you were involved in a car accident, the
victim may have an unliquidated claim against
you because the amount of damages has not
been set.
Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F) page 23
A claim is disputed if you disagree about
whether you owe the debt. For instance, if a bill
collector demands payment for a bill you
believe you already fully paid, you may
describe the claim as disputed.
A single claim can have one, more than one, or
none of these characteristics.
Creditors with unsecured claims do not have
liens on or other security interests in your
property. Secured creditors have a right to take
property if you do not pay them. Common
examples are lenders for your car, your home,
or your furniture.
Do not leave out any unsecured
creditors
List all unsecured creditors in each part of the
form in alphabetical order as much as possible.
Even if you plan to pay a creditor, you must list
that creditor. When listing creditors who have
unsecured claims, be sure to include all of them.
For instance, include the following:
Your relatives or friends to whom you owe
money;
Your ex-spouse, if you are still obligated
under a divorce decree or settlement
agreement to pay joint debts;
A credit card company, even if you intend to
fully pay your credit card bill;
A lender, even if the loan is cosigned;
Anyone who has a loan or promissory note
that you cosigned for someone else;
Anyone who has sued or may sue you
because of an accident, dispute, or similar
event that has occurred; or
Anyone who is trying to collect a debt from
you such as a bill collector or attorney.
Unsecured claims could be priority or
nonpriority claims
What are priority unsecured claims?
In bankruptcy cases, priority unsecured claims
are those debts that the Bankruptcy Code
requires to be paid before most other unsecured
claims are paid. The most common priority
unsecured claims are certain income tax debts
and past due alimony or child support. Priority
unsecured claims include those you owe for:
Domestic support obligations—If you owe
domestic support to a spouse or former
spouse; a child or the parent, legal guardian,
or responsible relative of a child; or a
governmental unit to whom such a domestic
support claim has been assigned.
11 U.S.C. § 507(a)(1).
Taxes and certain other debts you owe the
government—If you owe certain federal,
state, or local government taxes, customs
duties, or penalties.
11 U.S.C. § 507(a)(8).
Claims for death or personal injury that you
caused while you were intoxicated—If you
have a claim against you for death or
personal injury that resulted from your
unlawfully operating a motor vehicle or
vessel while you were unlawfully
intoxicated from alcohol, drugs, or another
substance. This priority does not apply to
claims for property damage.
11 U.S.C. § 507(a)(10).
Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F) page 24
Other:
Deposits by individuals—If you received
money from someone for the purchase
,
l
ease, or rental of your property or the use
of your services but you never delivere
d
or performed. For the debt to have
priority, the property or services must
have been intended for personal, family,
or household use (only the first $3,025*
per person is a priority debt). 11
U
.S.C. § 507(a)(7).
Wages, salaries, and commissions—If
you owe wages, salaries, and
commissions, including vacati
on,
s
everance, and sick leave pay and those
amounts were earned within 180 days
before you filed your bankruptcy petition
or ceased business. In either instance
,
o
nly the first $13,650* per claim is
a
pr
iority debt. 11 U.S.C. § 507(a)(4).
Contributions to employee benefit
plans—If you owe contributions to an
e
mployee benefit plan for services an
employee rendered within 180 days
before you file your bankruptcy petition
,
o
r within 180 days before your business
ends. Count only the first $13,650* per
employee, less any amounts owed for
wages, salaries, and commissions.
11
U.S.C. § 507(a)(5).
* Subject to adjustment on 4/01/22, and every 3 years
after that for cases begun on or after the date of
adjustment.
What are nonpriority unsecured claims?
Nonpriority unsecured claims are those debts
that generally will be paid after priority
unsecured claims are paid. The most common
examples of nonpriority unsecured claims are
credit card bills, medical bills, and educational
loans.
What if a claim has both priority and
nonpriority amounts?
If a claim has both priority and nonpriority
amounts, list that claim in Part 2 and show both
priority and nonpriority amounts. Do not list it
again in Part 3.
In Part 3, list all of the creditors you have not
listed before. You must list every creditor that
you owe, regardless of the amount you owe and
even if you plan to pay a particular debt. If you
do not list a debt, it may not be discharged.
What is needed for statistical purposes?
For statistical reasons, the court must collect
information about some specific categories of
unsecured claims.
The categories for priority unsecured claims
are:
Domestic support obligations
Taxes and certain other debts you owe the
government
Claims for death or personal injury that you
caused while you were intoxicated
Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F) page 25
The categories for nonpriority unsecured claims
are:
Student loans—If you owe money for any
loans that you used to pay for your
education;
Obligations arising out of a separation
agreement or divorce that you did not report
as priority claims
—If you owe debts for
separation or divorce agreements or for
domestic support and you did not report
those debts in Part 2; and
Debts to pension or profit-sharing plans and
other similar debts—If you owe money to a
pension or profit-sharing plan.
Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G) page 26
Schedule G: Executory Contracts and Unexpired
Leases (Official Form 106G)
Use Schedule G: Executory Contracts and
Unexpired Leases (Official Form 106G) to
identify your ongoing leases and certain
contracts. List all of your executory contracts
and unexpired leases.
Executory contracts are contracts between you
and someone else in which neither you nor the
other party has performed all of the
requirements by the time you file for
bankruptcy. Unexpired leases are leases that
are still in effect; the lease period has not yet
ended.
You must list all agreements that may be
executory contracts or unexpired leases, even
if they are listed on Schedule A/B: Property
(Official Form 106A/B), including the
following:
Residential leases (for example, a rental
agreement for a place where you live or
vacation, even if it is only a verbal or
month-to-month arrangement);
Service provider agreements (for example,
contracts for cell phones and personal
electronic devices);
Internet and cable contracts;
Vehicle leases;
Supplier or service contracts (for example,
co
ntracts for lawn care or home alarm or
security systems);
Timeshare contracts or leases;
Rent-to-own contracts;
Employment contracts;
Real estate listing agreements;
Contracts to sell a residence, building, land,
or
other real property;
Equipment leases;
Leases for business or investment property;
Supplier and service contracts for your
business;
Copyright and patent license agreements;
a
nd
Development contracts.
Schedule H: Your Codebtors (Official Form 106H) page 27
Schedule H: Your Codebtors (Official Form 106H)
If you have any debts that someone else may
also be responsible for paying, these people or
entities are called codebtors. Use Schedule H:
Your Codebtors (Official Form 106H) to list
any codebtors who are responsible for any debts
you have listed on the other schedules.
To help fill out this form, use both Schedule D:
Creditors Who Have Claims Secured by
Property (Official Form 106D) and Schedule
E/F: Creditors Who Have Unsecured Claims
(Official Form 106E/F).
List all of your codebtors and the creditors to
whom you owe the debt. For example, if
someone cosigned for the car loan that you owe,
you must list that person on this form.
If you are filing a joint case, do not list either
spouse as a codebtor.
Other codebtors could include the following:
Cosigner;
Guarantor;
Former spouse;
Unmarried partner;
Joint contractor; or
Nonfiling spouse—even if the spouse is not
a c
osigner—where the debt is for necessities
(such as food or medical care) if state law
makes the nonfiling spouse legally
responsible for debts for necessities.
Schedule I: Your Income (Official Form 106I) page 28
Schedule I: Your Income (Official Form 106I)
In Schedule I: Your Income (Official Form 106I),
you will give the details about your employment
and monthly income as of the date you file this
form. If you are married and your spouse is living
with you, include information about your spouse
even if your spouse is not filing with you. If you are
separated and your spouse is not filing with you, do
not include information about your spouse.
How to report employment and income
If you have nothing to report for a line, write
$0.
In Part 1, line 1, fill in employment
information for you and, if appropriate, for a
non-filing spouse. If either person has more
than one employer, attach a separate page with
information about the additional employment.
In Part 2, give details about the monthly
income you currently expect to receive. Show
all totals as monthly payments, even if income
is not received in monthly payments.
If your income is received in another time
period, such as daily, weekly, quarterly,
annually, or irregularly, calculate how much
income would be by month, as described
below.
If either you or a non-filing spouse has more
than one employer, calculate the monthly
amount for each employer separately, and then
combine the income information for all
employers for that person on lines 2-7.
One easy way to calculate how much income
per month is to total the payments earned in a
year, then divide by 12 to get a monthly figure.
For example, if you are paid seasonally, you
would simply divide the amount you expect to
earn in a year by 12 to get the monthly amount
Below are other examples of how to calculate
monthly amount.
Example for weekly payments:
If you are paid $1,000 every week, figure your
monthly income in this way:
$1,000 income every week
X 52 number of pay periods in the year
$52,000 total income for the year
$52,000 (income for year)_________ = $4,333 monthly income
12 (number of months in year)
Example for bi-weekly payments:
If you are paid $2,500 every other week, figure
your monthly income in this way:
$2,500 income every other week
X 26 number of pay periods in the year
$65,000 total income for the year
$65,000 (income for year)_________ = $5,417 monthly income
12 (number of months in year)
Schedule I: Your Income (Official Form 106I) page 29
Example for daily payments:
If you are paid $75 a day and you work about 8
days a month, figure your monthly income in
this way:
$75 income a day
X 96 days a year
$7,200 total income for the year
$7,200 (income for year) = $600 monthly income
12 (number of months in year)
or this way:
$75
income a day
X 8 payments a month
$600 income for the month
Example for quarterly payments:
If you are paid $15,000 every quarter, figure
your monthly income in this way:
$15,000 income every quarter
X 4 pay periods in the year
$60,000 total income for the year
$60,000 (income for year) = $5,000 (number of months in year)
12 monthly income
Example for irregular payments:
If you are paid $4,000 8 times a year, figure
your monthly income in this way:
$4,000 income a payment
X 8 payments a year
$32,000 income for the year
$32,000 (income for year) = $2,667 monthly income
12 (number of months in year)
In Part 2, line 11, fill in amounts that other
people provide to pay the expenses you list on
Schedule J: Your Expenses. For example, if you
and a person to whom you are not married pay
all household expenses together and you list all
your joint household expenses on Schedule J,
you must list the amounts that person
contributes monthly to pay the household
expenses on line 11. If you have a roommate and
you divide the rent and utilities, do not list the
amounts your roommate pays on line 11 if you
have listed only your share of those expenses on
Schedule J. Do not list on line 11 contributions
that you already disclosed elsewhere on the
form.
Note that the income you report on Schedule I
may be different from the income you report on
other bankruptcy forms. For example, the
Chapter 7 Statement of Your Current Monthly
Income (Official Form 122A-1), Chapter 11
Statement of Your Current Monthly Income
(Official Form 122B), and the Chapter 13
Statement of Your Current Monthly Income and
Calculation of Commitment Period (Official
Form 122C-1) all use a different definition of
income and apply that definition to a different
period of time. Schedule I asks about the income
that you are now receiving, while the other
forms ask about income you received in the
applicable time period before filing. So the
amount of income reported in any of those forms
may be different from the amount reported here.
If, after filing Schedule I, you need to file an
estimate of income in a chapter 13 case for a
date after your bankruptcy, you may complete
a supplemental Schedule I. To do so you must
check the “supplement” box at the top of the
form and fill in the date.
Schedule J: Your Expenses (Official Form 106J) page 30
Schedule J: Your Expenses (Official Form 106J and 106J-2)
Schedule J: Your Expenses (Official Form
106J) provides an estimate of the monthly
expenses, as of the date you file for
bankruptcy, for you, your dependents, and the
other people in your household whose income
is included on Schedule I: Your Income
(Official Form 106I).
If you are married and are filing individually,
include your non-filing spouse’s expenses
unless you are separated.
If you are filing jointly and Debtor 1 and
Debtor 2 keep separate households, Debtor 2
must complete and include Schedule J-2:
Expenses for Separate Household of Debtor 2
(Official Form 106J-2).
Do not include expenses that other members of
your household pay directly from their income
if you did not include that income on
Schedule I. For example, if you have a
roommate and you divide the rent and utilities
and you have not listed your roommate’s
contribution to household expenses in line 11
of Schedule I, you would list only your share
of these expenses on Schedule J.
Show all totals as monthly payments. If you
have weekly, quarterly, or annual payments,
calculate how much you would spend on those
items every month.
Do not list as expenses any payments on credit
card debts incurred before filing bankruptcy.
Do not include business expenses on this form.
You have already accounted for those
expenses as part of determining net business
income on Schedule I.
On line 20, do not include expenses for your
residence or for any rental or business
property. You have already listed expenses for
your residence on lines 4 and 5 of this form.
You listed the expenses for your rental and
business property as part of the process of
determining your net income from that
property on Schedule I (line 8a).
If you have nothing to report for a line, write
$0.
If, after filing Schedule J, you need to file an
estimate of expenses in a chapter 13 case for a
date after your bankruptcy, you may complete
a supplemental Schedule J. To do so you must
check the “supplement” box at the top of the
form and fill in the date.
Summary of Your Assets and Liabilities and Certain Statistical Information (Official Form 106Sum) page 31
Summary of Your Assets and Liabilities and Certain
Statistical Information (Official Form 106Sum)
When you file for bankruptcy, you must
summarize certain information from the
following forms:
Schedule A/B: Property (Official
Fo
rm 106A/B)
Schedule D: Creditors Who Have Claims
Secured by Property (Official Form 106D)
Schedule E/F: Creditors Who Have
Unsecured Claims (Official Form 106E/F)
Schedule I: Your Income (Official
Form 106I)
Schedule J: Your Expenses (Official Form
106J)
Chapter 7 Statement of Your Current
Monthly Income (Official Form 122A-1)
,
C
hapter 11 Statement of Your Current
Monthly Income (Official Form 122B), or
Chapter 13 Statement of Your Current
Monthly Income and Calculation of
Commitment Period (Official Form 122C-1)
After you fill out all of the forms, complete
Summary of Your Assets and Liabilities and
Certain Statistical Information (Official Form
106Sum) to report the totals of certain
information that you listed in the forms.
If you are filing an amended version of any of
these forms at some time after you file your
original forms, you must fill out a new Summary
to ensure that your information is up to date and
you must check the box at the top.
Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107) page 32
Statement of Financial Affairs for Individuals Filing
for Bankruptcy (Official Form 107)
Your Statement of Financial Affairs for
Individuals Filing for Bankruptcy, provides a
summary of your financial history over certain
periods of time before you file for bankruptcy.
If you are an individual in a bankruptcy case,
you must fill out this statement.
11 U.S.C. § 521(a) and Bankruptcy Rule
1007(b)(1).
If you are in business as a sole proprietor,
partner, family farmer, or self-employed
professional, you must provide the information
about all of your business and personal financial
activities.
Although this statement may ask you questions
that are similar to some questions on the
schedules, you must fill out all of the forms
completely to protect your legal rights.
Understand the terms used in this form
Legal equivalent of a spouse — A person whom
applicable nonfederal law recognizes as having
a relationship with the debtor that grants legal
rights and responsibilities equivalent, in whole
or in part, to those granted to a spouse.
Chapter 7 Statement of Current Monthly Income; Means Test Calculation (Official Forms 122A-1, 122A-2) page 33
Chapter 7 Statement of Your Current Monthly Income
and Means Test Calculation
(Official Forms 122A–1, 122A-1Supp,
and 122A–2)
If you are filing under chapter 11,
12, or 13, do not fill out this form.
Official Forms 122A–1 and 122A–2 determine
whether your income and expenses create a
presumption of abuse that may prevent you
from obtaining relief from your debts under
chapter 7 of the Bankruptcy Code. Chapter 7
relief can be denied to a person who has
primarily consumer debts if the court finds that
the person has enough income to repay
creditors an amount that, under the Bankruptcy
Code, would be a sufficient portion of their
claims.
You must file Chapter 7 Statement of Your
Current Monthly Income (Official Form122A–1)
if you are an individual filing for bankruptcy
under chapter 7. This form will determine your
current monthly income and compare whether
your income is more than the median income for
households of the same size in your state. If your
income is not above the median, there is no
presumption of abuse and you will not have to
fill out the second form.
Similarly, Statement of Exemption from
Presumption of Abuse Under § 707(b)(2)
(Official Form 122A-1Supp) determines
whether you may be exempted from the
presumption of abuse because you do not have
primarily consumer debts or because you have
provided certain military or homeland defense
services. If one of these exemptions applies, you
should file a supplement, Form 122A-1Supp,
and verify the supplement by completing Part 3
of Form 122A-1. If you qualify for an
exemption, you are not required to fill out any
part of Form 122A-1 other than the verification.
If the exemptions do not apply, you should
complete all of the parts of Form 122A-1 and
file it without the supplemental form.
If you and your spouse are filing together, you
and your spouse may file a single Form 122A-1.
However, if an exemption on Form122A-1Supp
applies to only one of you, separate forms may
be required. 11 U.S.C. § 707(b)(2)(C).
If your completed Form 122A-1 shows income
above the median, you must file the second
form, Chapter 7 Means Test Calculation
(Official Form 122A –2). The calculations on
this form—sometimes called the Means Test—
reduce your income by living expenses and
payment of certain debts, resulting in an
amount available to pay other debts. If this
amount is high enough, it will give rise to a
presumption of abuse. A presumption of abuse
does not mean you are actually trying to abuse
the bankruptcy system. Rather, the
presumption simply means that you are
presumed to have enough income that you
should not be granted relief under chapter 7.
You may overcome the presumption by
showing special circumstances that reduce
your income or increase your expenses.
If you cannot obtain relief under chapter 7, you
may be eligible to continue under another
Chapter 7 Statement of Current Monthly Income; Means Test Calculation (Official Forms 122A-1, 122A-2) page 34
chapter of the Bankruptcy Code and pay
creditors over a period of time.
Read each question carefully. You may not be
required to answer every question on this form.
For example, your military status may
determine whether you must fill out the entire
form. The instructions will alert you if you
may skip questions.
If you have nothing to report for a line, write
$0.
Information for completing the forms
To fill out several lines of the forms, you must
look up information provided on websites or
from other sources. For information to
complete line 13 of Form 122A-1 and lines 6-
15, 30, and 36 of Form 122A-2, go to:
www.justice.gov/ust/eo/bapcpa/meanstesting.htm
If your case is filed in Alabama or North
Carolina, the administrative expense multiplier
mentioned at line 36 can be found at:
www.uscourts.gov/FederalCourts/Bankruptcy/Bankr
uptcyResources/AdministrativeExpensesMultiplier.a
spx .
For the Bankruptcy Basics information referred
to on line 36 of Form 122A-2, go to:
www.uscourts.gov/FederalCourts/Bankruptcy/Bankr
uptcyBasics.aspx.
If you do not have a computer with internet
access, you may be able to use a public
computer at the bankruptcy clerk’s office or at
a public library.
Chapter 11 Statement of Your Current Monthly Income (Official Form 122B) page 35
Chapter 11 Statement of Your Current Monthly
Income (Official Form 122B)
Y
ou must file the Chapter 11 Statement of Your
Current Monthly Income (Official Form 122B)
if you are an individual filing for bankruptcy
under chapter 11.
If you have nothing to report for a line, write
$0.
If you are filing under chapter 7,
12, or 13, do not fill out this form.
Chapter 13 Statement of Current Monthly Income, Calculation of Commitment Period and
Chapter 13 Calculation of Your Disposable Income (Official Forms 122C-1, 122C-2) page 36
Chapter 13 Statement of Your Current Monthly
Income, Calculation of Commitment Period and
Chapter 13 Calculation of Your Disposable Income
(Official Forms 122C–1 and 122C–2)
Official Forms 122C─1 and 122C─2
determine the commitment period for your
payments to creditors, how the amount you
may be required to pay to creditors is
established, and, in some situations, how much
you must pay.
You must file the Chapter 13 Statement of
Your Current Monthly Income and Calculation
of Commitment Period (Official Form
122C─1) if you are an individual and you are
filing under chapter 13. This form will report
your current monthly income and determine
whether your income is at or below the median
income for households of the same size in your
state. If your income is equal to or less than the
median, you will not have to fill out the second
form. Form 122C-1 also will determine your
applicable commitment period—the time period
for making payments to your creditors, unless
the court orders otherwise.
If your income is above the median, you must file
the second form, Chapter13 Calculation of Your
Disposable Income (Official Form 122C─2). The
calculations on this form—sometimes called the
Means Test—reduce your income by living
expenses and payment of certain debts, resulting in
an amount available to pay unsecured debts. Your
chapter 13 plan may be required to provide for
payment of this amount toward unsecured debts.
Read each question carefully. You may not be
required to answer every question on this form. The
instructions will alert you if you may skip
questions.
Some of the questions require you to go to other
sources for information. In those cases, the form
has instructions for where to find the information
you need.
Generally, if you and your spouse are filing
together, you should file one statement together.
Information for completing the forms
To fill out several lines of the forms, you must look
up information provided on websites or from other
sources. For information to complete line 16c of
Form 122C-1 and lines 6-15, 30, and 36 of Form
122C-2, go to:
www.justice.gov/ust/eo/bapcpa/meanstesting.htm.
If your case is filed in Alabama or North Carolina,
the administrative expense multiplier mentioned at
line 36 can be found at:
www.uscourts.gov/FederalCourts/Bankruptcy/Bankruptcy
Resources/AdministrativeExpensesMultiplier.aspx .
If you do not have a computer with internet
access, you may be able to use a public
computer at the bankruptcy clerk’s office or at
a public library.
If you are filing under chapter 7,
11, or 12, do not fill out this form.
Statement of Intention for Individuals Filing Under Chapter 7 (Official Form 108) page 37
Statement of Intention for Individuals Filing Under
Chapter 7
(Official Form 108)
If you are an individual filing under chapter 7,
you must fill out the Statement of Intention for
Individuals Filing Under Chapter 7 (Official
Form 108) if:
creditors have claims secured by your
property, or
you have leased personal property and the
l
ease has not expired
.
The Bankruptcy Code requires you to state your
intentions about such claims and provides for
early termination of the automatic stay as to
personal property if the statement is not timely
filed. The same early termination of the
automatic stay applies to any unexpired lease of
personal property unless you state that you
intend to assume the unexpired lease if the
trustee does not do so.
To help fill out this form, use the information
you have already provided on the following
forms:
Schedule D: Creditors Who Have Claims
Secured by Property (Official Form 106D),
Schedule C: The Property You Claim as
Exempt (Official Form 106C), and
Schedule G: Executory Contracts and
Unexpired Leases (Official Form 106G).
Explain what you intend to do with your
property that is collateral for a claim
If you have property that is collateral (or
security) for a claim, you must state what you
intend to do with that property.
You may choose either to surrender the property
to the creditor, or retain the property. Below is
more information about each of these options.
You may surrender the property to the creditor. If
you surrender the property to the creditor, your
bankruptcy discharge will protect you from any
claim for the difference between what you owe
the creditor and what the creditor receives from a
sale of the property, unless the court determines
that the debt is nondischargeable.
You may want to retain the property. If you want
to retain your secured personal property, you may
be able to reaffirm the debt, redeem the property,
or take other action (for example, avoid a lien
using 11 U.S.C. § 522(f)).
You may be able to reaffirm the debt. You may
decide to remain legally obligated to pay a
de
bt so that you can keep the property
securing the debt. This is called reaffirmi
ng a
de
bt. You may reaffirm the debt in full on its
original terms or you and the creditor may
agree to change the terms. For example, if
you want to keep your car, you may reaffirm
a car loan, stating that you will continue to
make monthly payments for it.
Only reaffirm
those debts that you are confident you can
repay.
You may seek to reaffirm the debt if
you sign a Reaffirmation Agreement, which is
a contract between you and a creditor, a
nd
If you are filing under chapter 11,
12, or 13, do not fill out this form.
Statement of Intention for Individuals Filing Under Chapter 7 (Official Form 108) page 38
you follow the proper procedure for the
Reaffirmation Agreement. 11 U.S.C. § 524.
The procedure is explained in greater detail in
the Disclosures that are part of the
reaffirmation documents.
You may be able to redeem your property.
11 U.S.C. § 722. You can redeem property
only if all of the following apply:
The property secures a debt that is a
consumer debt ─ you incurred the debt
primarily for personal, family, or
household use.
The property is tangible personal
property ─ the property is physical, suc
h
as f
urniture, appliances, and cars.
You are either claiming the property as
exempt or the trustee has abandoned it.
To obtain court authorization to redeem your
property, you must file a motion with the
court. If the court grants your motion, you pay
the creditor the value of the property or the
amount of the claim, whichever is less. The
payment will be a single lump-sum payment.
Explain what you intend to do with your
leased personal property
If you lease personal property such as your car,
you may be able to continue your lease if the
trustee does not assume the lease. To continue
your lease, you can write to the lessor that you
want to assume your lease. The creditor may, at
its option, notify you that it is willing to have
you assume the lease and may condition the
assumption on cure of any outstanding default.
If the lessor notifies you that it is willing to have
you assume the lease, you must write to the
lessor within 30 days stating that you assume the
lease. 11 U.S.C. § 365(p)(2).
File the Statement of Intention before the
deadline
You must file this form either within 30 days
after you file your bankruptcy petition or by the
date set for the meeting of creditors, whichever is
earlier. You must also deliver copies of this
statement to the creditors and lessors you listed
on the form. Bankruptcy Rule 1007(b)(2).
If two married people are filing together in a
joint case, both are equally responsible for
supplying correct information. Both debtors must
sign and date the form.
Application for Individuals to Pay the Filing Fee in Installments (Official Form 103A) page 39
Application for Individuals to Pay the Filing Fee in
Installments
(Official Form 103A)
If you cannot afford to pay the full filing fee
when you first file for bankruptcy, you may
pay the fee in installments. However, in most
cases, you must pay the entire fee within 120
days after you file, and the court must approve
your payment timetable. Your debts will not be
discharged until you pay your entire fee.
Do not file this form if you can afford to pay
your full fee when you file.
If you are filing under chapter 7 and cannot afford
to pay the full filing fee at all, you may be
qualified to ask the court to waive your filing fee.
See Application to Have Your Chapter 7 Filing
Fee Waived (Official Form 103B).
If a bankruptcy petition preparer helped you
complete this form, make sure that person fills
out the Bankruptcy Petition Preparer’s Notice,
Declaration, and Signature (Official Form 119);
include a copy of it when you file this
application.
This form includes a proposed order for use by
the court in considering the application. The
court may modify the form of the order or use its
own version of the order.
Application to Have the Chapter 7 Filing Fee Waived (Official Form 103B) page 40
Application to Have the Chapter 7 Filing Fee
Waived
(Official Form 103B)
The fee for filing a bankruptcy case under
chapter 7 is $338. If you cannot afford to pay
the entire fee now in full or in installments
within 120 days, use this form. If you can
afford to pay your filing fee in installments,
see Application for Individuals to Pay the
Filing Fee in Installments (Official Form
103A).
If you file this form, you are asking the court
to waive your fee. After reviewing your
application, the court may waive your fee, set
a hearing for further investigation, or require
you to pay the fee in installments or in full.
For your fee to be waived, all of these
statements must be true:
You are filing for bankruptcy under
chapter 7.
You are an individual.
The total combined monthly income for
your family is less than 150% of the official
poverty guideline last published by the U.S.
Department of Health and Human Services
(DHHS). (For more information about the
guidelines, go to
http://www.uscourts.gov.)
You cannot afford to pay the fee in
installments.
Your family includes you, your spouse, and any
dependents listed on Schedule I. Your family
may be different from your household,
referenced on Schedules I and J. Your
household may include your unmarried partner
and others who live with you and with whom
you share income and expenses.
If a bankruptcy petition preparer helped you
complete this form, make sure that person fills
out Bankruptcy Petition Preparer’s Notice,
Declaration, and Signature (Official Form 119);
include a copy of it when you file this
application.
If you have already completed the following
forms, the information on them may help you
when you fill out this application:
Schedule A/B: Property (Official
Form 106A/B)
Schedule I: Your Income (Official
Form 106I)
Schedule J: Your Expenses (Official
Form 106J)
This form includes a proposed order for use by
the court in considering the application. The
court may modify the form of the order or use
its own version of the order.
Individual Chapter 11 Cases: Creditors Who Have 20 Largest Unsecured Claims (Official Form 104) page 38
For Individual Chapter 11 Cases: List of Creditors
Who Have the 20 Largest Unsecured Claims
Against You and Are Not Insiders (Official Form 104)
The people or organizations to whom you owe
money are called your creditors. A claim is a
creditor’s right to payment. If you are an
individual filing for bankruptcy under chapter 11,
you must fill out For Individual Chapter 11
Cases: List of Creditors Who Have the 20
Largest Unsecured Claims Against You and Are
Not Insiders (Official Form 104).
Creditors may have different types of claims:
Secured claims, or
Unsecured claims.
If your debts are not paid, creditors with
secured claims may be able to get paid from
specific property in which that creditor has an
interest, such as a mortgage or a lien. If a
creditor has security interest in your property,
but the value of the property available to pay
the creditor is less than the amount you owe the
creditor, the creditor has both a secured and an
unsecured claim against you. The amount of the
unsecured claim is the total claim minus the
value of the property that is available to pay the
creditor.
Generally, creditors with unsecured claims do
not have rights against specific property, or the
specific property in which the creditor has
rights is not worth enough to pay the creditor in
full. For example, if you owe a creditor $30,000
for your car and the creditor has a security
interest in your car but the car is worth only
$20,000, the creditor has a $20,000 secured
claim and a $10,000 unsecured claim.
$30,000 Total amount you owe creditor
─ $20,000 Amount your car is worth (amount of
secured claim)
$10,000 Amount of unsecured claim
Many claims have a specific amount, and you
clearly owe them. However, some claims are
uncertain when you file for bankruptcy, or they
become due only after you file. You must
include such claims when listing your 20 largest
unsecured claims on this list.
Claims may be contingent, unliquidated,
or disputed.
The form asks you to identify claims that are:
Contingent claims,
Unliquidated claims, or
Disputed claims.
A claim is contingent i
f you are not obligated to
pay it unless a particular event occurs after you
file for bankruptcy. You owe a contingent
claim, for example, if you cosigned someone
else’s loan. You may not have to pay unless that
person later fails to repay the loan.
If you are filing under chapter 7,
12, or 13, do not fill out this form.
Individual Chapter 11 Cases: Creditors Who Have 20 Largest Unsecured Claims (Official Form 104) page 39
A claim is unliquidated if the amount of the
debt cannot be readily determined, such as by
referring to an agreement or by a simple
computation. An unliquidated claim is one for
which there may be a definite liability but
where the amount has not been set. For
instance, if you were involved in a car accident,
the victim may have an unliquidated claim
against you because the amount of damages has
not been set.
A claim is disputed if you do not agree that you
owe the debt. For instance, your claim is
disputed if a bill collector demands payment for
a bill you believe you already fully paid.
A single claim can have one, more than one, or
none of these characteristics.
On this form, list the creditors with the
20 largest unsecured claims who are not
insiders
You must file this form when you file your
chapter 11 bankruptcy case with the court.
When you list the 20 largest unsecured
creditors, include all unsecured creditors, except
for the following two types of creditors, even if
you plan to pay them. Do not include:
Anyone who is an insider. Insiders include
relatives; general partners of you or your
relatives; corporations of which you are a
n
officer, director, or person in control; and
an
y managing agent. 11 U.S.C. § 101(31).
Secured creditors, unless the unsecured
claim resulting from inadequate collateral
value places the creditor among the holders
of the 20 largest unsecured claims.
Make sure that all of the creditors listed on this
form are also listed on either Schedule D: Creditors
Who Have Claims Secured by Property (Official
Form 106D) or Schedule E/F: Creditors Who Have
Unsecured Claims (Official Form 106E/F).
On the form, you will fill in what the claim is
for. Examples include trade debts, bank loans,
professional services, and government
contracts.
Glossary page 40
Glossary
Definitions Used in the Forms for Individuals Filing for Bankruptcy page 41
Definitions of Some Terms Used in the Forms for
Individuals Filing for Bankruptcy
Here are definitions of some of the important terms used in the forms for individuals who are filing for
bankruptcy. See Bankruptcy Basics (
www.uscourts.gov/FederalCourts) for more information about filing
for bankruptcy and other important terms you should know. These definitions are intended only to
provide guidance. They are not a substitute for legal advice.
Annuity — A contract for the periodic
payment of money to you, either for life or
for a number of years.
Bankruptcy petition preparer — A person or
business, other than a lawyer or someone
who works for a lawyer, that charges a fee to
prepare bankruptcy documents. Under your
direction and control, the bankruptcy petition
preparer generates bankruptcy forms for you
to file by typing them. Because they are not
attorneys, they cannot give legal advice or
represent you in bankruptcy court. Also
called typing services.
Business debt — A debt that you incurred to
obtain money for a business or investment or
incurred through the operation of the
business or investment.
Claim — A creditor’s right to payment, even
if contingent, disputed, unliquidated, or
unmatured.
Codebtor — A person or entity that may also
be responsible for paying a claim against the
debtor.
Collateral — Specific property subject to a
lien from which a creditor may be paid ahead
of other creditors without liens on that
property. Includes a mortgage, security
interest, judgment lien, statutory lien, or other
lien.
Community property — A type of property
ownership available in certain states for
property owned by spouses and, in some
instances, legal equivalents of spouses.
Community property states and territories
include Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Puerto
Rico, Texas, Washington, and Wisconsin.
Consumer debt — A debt you incurred
primarily for a personal, family, or household
purpose.
Contingent claim — A debt you are not
obligated to pay unless a particular event
occurs after you file for bankruptcy. You owe
a contingent claim, for example, if you
cosigned someone else’s loan. You may not
have to pay unless that person later fails to
repay the loan.
Definitions Used in the Forms for Individuals Filing for Bankruptcy page 42
Creditor matrix or mailing matrix — A list of
names and addresses of all of your creditors,
formatted as a mailing list according to
instructions from the bankruptcy court in
which you file.
Creditor — A person or organization to
whom you owe money or who claims that
you owe it money.
Current value, fair market value, or value —
The amount property is worth, which may be
more or less than when you purchased the
property. Absent specific instruction, the
value should be the price that could be
realized from a cash sale or liquidation
without duress within a reasonable time. See
the instructions for specific forms regarding
whether the value requested is as of the date
of the filing of the petition, the date you
complete the form, or some other date.
Debtor 1 — A debtor filing alone or one
person in married couple who is filing a
bankruptcy case with a spouse. The same
person retains this designation in all of the
forms.
Debtor 2 — A second person in a married
couple who is filing a bankruptcy case with a
spouse.
Dependent — A person who is economically
dependent on you regardless of whether the
person can be claimed as a dependent on your
federal tax return. However, Chapter 7 Means
Test Calculation (Official Form 122A-2) and
Chapter 13 Calculation of Your Disposable
Income (Official Form 122C-2) use the term in
a more limited way. See the instructions on
those forms.
Discharge — A discharge in bankruptcy
relieves you after your bankruptcy case is
over from having to pay debts that you owed
before you filed your bankruptcy case. Most
debts are covered by the discharge, but not
all. (The instruction booklet explains more
about common debts that are not discharged
in bankruptcy.) Only your personal liability is
removed by the discharge.
Disputed claim — A debt you do not agree
that you owe. For instance, your claim is
disputed if a bill collector demands payment
for a bill you believe you already fully paid.
Eviction judgment — A judgment for
possession that your landlord has obtained in
an eviction, unlawful detainer action, or
similar proceeding.
Executory contract — A contract between
you and someone else in which both of you
still have obligations to perform under the
contract at the time you file for bankruptcy.
Exempt property — Property, or the value of
a portion of it, that the law allows you to
keep for your use rather than surrender it for
the payment of your debts, provided that you
follow the correct procedure to claim the
exemption.
Garnishment — A procedure by which a
creditor can reach money of yours that is in
the hands of a third party to satisfy a debt.
Garnishments are sometimes used by
creditors to obtain money from your wages or
bank account.
Definitions Used in the Forms for Individuals Filing for Bankruptcy page 43
Individual debtor — A human being who is
filing for bankruptcy either alone or with a
spouse, whether or not the individual owns a
business.
Joint case
— A single case filed by a married
couple.
Judgment lien — A lien that arises as a result
of a judgment against you.
Legal equivalent of a spouse — A person
recognized by applicable nonfederal law as
having a relationship with the debtor that
grants legal rights and responsibilities
equivalent, in whole or in part, to those
granted to a spouse.
Legal or equitable interest
— A broad term
that includes all kinds of property interests in
both tangible and intangible property,
whether or not anyone else has an interest in
that property.
Negotiable instrument — A financial
instrument that you can transfer to someone
by signing or delivering it, including personal
checks, cashiers’ checks, promissory notes,
and money orders.
Non-individual debtor — A debtor that is not
a human being – for example, an artificial
entity such as a corporation, partnership, or
limited liability company (LLC).
Non-negotiable instrument
— A financial
instrument that you cannot transfer to
someone by signing or delivering it.
Nonpriority unsecured claim — A debt that
generally will be paid after priority unsecured
claims are paid. The most common examples
are credit card bills, medical bills, and
educational loans.
Payment advice — A statement such as a pay
stub or earnings statement from your
employer that shows all earnings and
deductions from your pay.
Presumption of abuse — A rebuttable legal
presumption that you have too much income
after allowed expenses to be granted relief
under chapter 7.
Priority unsecured claim — A debt that the
Bankruptcy Code requires to be paid before
most other unsecured claims are paid. The
most common examples are certain income
tax debts and past due alimony or child
support.
Property you own — Includes property you
have purchased, even if you owe money on
it, such as a home with a mortgage or an
automobile with a lien.
Reaffirming a debt — Agreeing to repay a
debt that would otherwise be discharged by
entering into a new written agreement with
the creditor. A reaffirmation agreement may
allow you to keep property that a creditor has
the right to take from you because it secures
the debt being reaffirmed. For a reaffirmation
agreement to be effective, there are many
procedural and legal requirements that must
be satisfied during the bankruptcy case.
Definitions Used in the Forms for Individuals Filing for Bankruptcy page 44
Secured claim — A claim that may be
satisfied in whole or in part either
by a charge against or an interest in
specific property of the debtor, or
by a right of setoff.
Common examples of creditors who have
secured claims are lenders from your car,
your home, or your furniture.
Sole proprietorship — A business you own as
an individual that is not a separate legal
entity such as a corporation, partnership, or
LLC. Sole proprietors must use the
bankruptcy forms that are numbered in the
100 series.
Statutory lien — A lien that arises as a result
of a statute.
Unexpired lease —A lease that is in effect at
the time you filed for bankruptcy.
Unliquidated claim — A debt with an amount
cannot be readily determined, such as by
referring to an agreement or by a simple
computation. An unliquidated claim is one
for which there may be a definite
liability but
where the value has not been set.
For instance,
if you were involved in a car accident, the
victim may have an unliquidated claim
against you because the amount of damages
has not been determined.
Unsecured claim — A claim held by a
creditor who does not have security interest
in or other lien on your property or a right of
setoff.
You — A debtor filing alone or one person in
married couple who is filing a bankruptcy
case with a spouse.
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