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 B 22A1 Chapter 7 Statement of Your Current Monthly Income page 1
OFFICIAL FORM B 22A1
Chapter 7 Statement of Your Current Monthly Income 12/14
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 22A-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
pa
yr
oll deductions).
$_________ $__________
3. Alimony and maintenance payments. Do not include payments from a spouse if
Column B is fille
d 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 unm
arried partner, members of your household, your depe
ndents, parents,
and roomma
tes. Include regular contributions from a spouse only if
Column B is not
filled in. Do not include pa
yments you listed on line 3.
$_________ $________
__
5. Net income from operating a business, profession, or farm
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
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
$_________
$__________
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 22A–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 22A-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:
Check if this is an amended filing
___________________________ District of ________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form B 22A1 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.
$__________
$__________
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 or payments received
as a victim of a war crime, a crime against humanity, or international or domestic
terrorism. If necessary, list other sources on a separate page and put the total on line 10c.
10a. _______________________________________
$_________
$__________
10b. ______________________________________ $_________
$__________
10c. Total amounts from separate pages, if any.
+$_________
+ $__________
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 here12a.
$__________
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.
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 22A-2.
Go to Part 3 and fill out Form 22A–2.
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 22A–2.
If you checked line 14b, fill out Form 22A–2 and file it with this form.
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Completed 3 August 2021

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