Official Form 103A Application for Individuals to Pay the Filing Fee in Installments
Official Form 103A
Application for Individuals to Pay the Filing Fee in Installments 12/15
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information.
Part 1: Specify Your Proposed Payment Timetable
1. Which chapter of the Bankruptcy Code
a
re you choosing to file unde
r?
Chapter 7
Chapter 11
Chapter 12
Chapter 13
2. You may apply to pay the filing fee in up to
four i
nstallments. Fill in the amounts yo
u
prop
ose to pay and the dates you plan to
pay them. Be sure all dates are busin
ess
da
ys. Then add the payments you prop
ose
to pa
y.
You must propose to pay the entir
e fee no
later than 120
days after you file th
is
bankruptc
y case. If the court approves yo
ur
application, the cour
t will set your
final
pa
yment timeta
ble.
You pr
opose to pay…
$_____________
With the filing of the
petition
On or before this date .......
______________
MM / DD / YYYY
$_____________
On or before this date ...........
______________
MM / DD / YYYY
$_____________
On or before this date ...........
______________
MM / DD / YYYY
+ $_____________
On or before this date ...........
______________
MM / DD / YYYY
Total
$______________
◄ Your total must equal the entire fee for the chapter you checked in line 1.
Part 2: Sign Below
By signing here, you state that you are unable to pay the full filing fee at once, that you want to pay the fee in installments, and that you
understand that:
You must pay your entire filing fee before you make any more payments or transfer any more property to an attorney, bankruptcy petition
preparer, or anyone else for services in connection with your bankruptcy case.
You must pay the entire fee no later than 120 days after you first file for bankruptcy, unless the court later extends your deadline. Your
debts will not be discharged until your entire fee is paid.
If you do not make any payment when it is due, your bankruptcy case may be dismissed, and your rights in other bankruptcy proceedings
may be affected.
_________________________________ ___________________________________ _______________________________________
Signature of Debtor 1 Signature of Debtor 2 Your attorney’s name and signature, if you used one
Date _________________ Date ________________ Date _________________
MM / DD / YYYY 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 __________
