Fillable Official Form 122C1 First Name Middle Name Last (US Courts)

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Official Form 122C1 First Name Middle Name Last (US Courts)

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Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 1
Official Form 122C–1
Chapter 13 Statement of Your Current Monthly Income
and Calculation of Commitment Period 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).
Part 1: Calculate Your Average Monthly Income
1.
What is your marital and filing status?
Check one only.
Not married. Fill out Column A, lines 2-11.
Married. Fill out both Columns A and B, lines 2-11.
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.
$__________ $__________
4. All amounts from any source which are
regularly paid for household expenses of
you or your dependents, including child support. In
clude regular contributions from
an unmarried partner, members of your household, your dependents, parents, and
roommates. Do not include payments from a spouse. 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
$_________
$__________
Check as directed in lines 17 and 21:
According to the calculations required by
this Statement:
1. Disposable income is not determined
under 11 U.S.C. § 1325(b)(3).
2. Disposable income is determined
under 11 U.S.C. § 1325(b)(3).
3. The commitment period is 3 years.
4. The commitment period is 5 years.
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 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 2
Column A
Debtor 1
Column B
Debtor 2 or
non-filing spouse
7. Interest, dividends, and royalties
$____________ $__________
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-relate
d 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.
__________________________________________________________________
$____________
$___________
__________________________________________________________________
$____________
$___________
Total amounts from separate pages, if any.
+ $____________
+ $__________
11. Calculate your total average monthly income. Add lines 2 through 10 for each
column. Then add the total for Column A to the total for Column B.
$____________
+
$___________
=
$________
Total average
monthly income
Part 2: Determine How to Measure Your Deductions from Income
12. Copy your total average monthly income from line 11. ..........................................................................................................................
$_____________
13. Calculate the marital adjustment. Check one:
You are not married. Fill in 0 below.
You are married and your spouse is filing with you. Fill in 0 below.
You are married and your spouse is not filing with you.
Fill in the amount of the income listed in line 11, Column B, that was NOT regularly paid for the household expenses of
you or your dependents,
such as payment of the spouse’s tax liability or the spouse’s support of someone other than
you or your dependents.
Below, specify the basis for excluding this income and the amount of income devoted to each purpose. If necessary,
list additional adjustments on a separate page
.
If this adjustment does not apply, enter 0 below.
__________________________________________________________________________
$___________
__________________________________________________________________________
$___________
__________________________________________________________________________
+ $___________
Total ................................................................................................................................................
$___________
Copy here
─____________
14. Your current monthly income. Subtract the total in line 13 from line 12. $ __________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 3
15. Calculate your current monthly income for the year. Follow these steps:
15a. Copy line 14 here ...........................................................................................................................................................................................
$ ____________
Multiply line 15a by 12 (the number of months in a year).
x 12
15b. The result is your current monthly income for the year for this part of the form. ....................................................................................
$___________
16. Calculate the median family income that applies to you. Follow these steps:
16a. Fill in the state in which you live. _________
16b. Fill in the number of people in your household. _________
16c. Fill in the median family income for your state and size of household. ................................................................................................
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.
$___________
17. How do the lines compare?
17a.
Line 15b is less than or equal to line 16c. On the top of page 1 of this form, check box 1,
Disposable income is not determined under
11 U.S.C. § 1325(b)(3). Go to Part 3.
Do NOT fill out Calculation of Your Disposable Income (Official Form 122C–2).
17b.
Line 15b is more than line 16c. On the top of page 1 of this form, check box 2,
Disposable income is determined under
11 U.S.C. § 1325(b)(3). Go to Part 3
and fill out Calculation of Your Disposable Income (Official Form 122C–2).
On line 39 of that form, copy your current monthly income from line 14 above.
Part 3: Calculate Your Commitment Period Under 11 U.S.C. § 1325(b)(4)
18. Copy your total average monthly income from line 11. ............................................................................................................................
$__________
19. Deduct the marital adjustment if it applies. If you are married, your spouse is not filing with you, and you contend that
calculating the commitment period under 11 U.S.C. § 1325(b)(4) allows you to deduct part of your spouse’s income, copy
the amount from line 13.
19a. If the marital adjustment does not apply, fill in 0 on line 19a. .............................................................................................
─
$__________
19b. Subtract line 19a from line 18. $__________
20. Calculate your current monthly income for the year. Follow these steps:
20a. Copy line 19b.. ...............................................................................................................................................................................................
$___________
Multiply by 12 (the number of months in a year).
x 12
20b. The result is your current monthly income for the year for this part of the form.
$___________
20c. Copy the median family income for your state and size of household from line 16c.......................................................................
$___________
21.
How do the lines compare?
Line 20b is less than line 20c. Unless otherwise ordered by the court, on the top of page 1
of this form, check box 3,
The commitment period is 3 years. Go to Part 4.
Line 20b is more than or equal to line 20c. Unless otherwise ordered by the court, on the top of page 1
of this form,
check box 4, The commitment period is 5 years. Go to Part 4.
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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 4
Part 4: Sign Below
B
y signing here, under penalty of perjury I declare 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
I
f you checked 17a, do NOT fill out or file Form 122C–2.
If you checked 17b, fill out Form 122C–2 and file it with this form.
On line 39 of that form, copy your current monthly income from line 14 above.
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Official Form 122C1 First Name Middle Name Last (US Courts)

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Completed 4 November 2020

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