Fillable Chapter 7 Statement of Your Current Monthly Income (US Courts)

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Chapter 7 Statement of Your Current Monthly Income (US Courts)

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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 12/19
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
$______ $______
$_________
$__________
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
$______
$______
$_________
$__________
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 __________
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
benef
it 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 t
he
U
nited 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 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 Unit
ed
S
tates 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.
______________________________________ $_________ $___________
______________________________________ $_________ $___________
Total amounts from separate pages, if any.
+
$_________
+
$___________
11. Calculate your total current monthly income. Add lines 2 through 10 for each
c
olumn. 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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Completed 12 April 2022

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