Fill - Pro Se Bankruptcy Clinic (US Courts)

Pro Se Bankruptcy Clinic

Free 1-Hour Chapter 7 Legal Advice and

Assistance for People without a Lawyer at the

U.S. Bankruptcy Court for the District of Colorado

ü Determining chapter 7 eligibility

ü Preparing court lings

ü Navigating the court system

ü and more

We see individuals by appointment.

To get started, visit our website at cobar.org/bankruptcy or call 720-633-8866.

*Please note the Clinic cannot assist with non-chapter 7 issues,

adversary proceedings, state cases or appeals.*

U.S. Custom House | 721 19th St. | Denver, CO 80202 | 720-633-8866

CONTA

CT US TODAY FOR HELP WITH

Clínica de Bancarrota

por derecho propio

La clínica de bancarrota del Capítulo 7 es para personas que se

presentan por derecho propio, sin abogados.

Recibirá una hora de asesoramiento legal gratuito en la

Corte de Bancarrota de Colorado

ü

Calicación para la bancarrota del Capítulo 7

ü Preparación de documentos

ü Explicación del sistema legal

ü…y más

Es obligatorio programar una cita.

Para empezar, visite nuestro sitio web: cobar.org/bankruptcy

o llame al 720-633-8866.

*Tenga en cuenta que la clínica no puede prestar ayuda con procedimientos contenciosos, casos estatales,

apelaciones o bancarrotas que no son del Capítulo 7.*

U.S. Custom House | 721 19th St. | Denver, CO 80202 | 720-633-8866

CONTÁCTENOS HOY PARA AYUDA CON

When submitting your documents to the Court:

Please do not staple or paper clip your documents. They will be scanned in by the Court.

Be sure to take the credit counseling course prior to filing your case. A list of agencies offering the

course is located on our website, under the “Filing Without an Attorney” tab, then “Credit Counseling.”

This can be done over the phone or online.

Documents Required for an Individual Filing Chapter 7

Filing Fee (check one)

 Payment made online at https://www.cob.uscourts.gov/online-payments

 Payment enclosed (cash, money order, cashier’s check)

 Application for Installment Payments

 Application for Waiver

List of Creditors (check one)

 List of Creditors uploaded at https://www.cob.uscourts.gov/efile/sam/signup.aspx

 List of Creditors enclosed on disc or drive

Documents (starred items required to open a new case)

 Voluntary Petition for Individuals Filing for Bankruptcy*

 Certificate of Credit Counseling*

 Statement of Financial Affairs

 Summary of Assets and Liabilities & Certain Statistical Info

 Schedules A/B, C, D, E/F, G, H, I and J

 Declaration About an Individual Debtor’s Schedules

 Employee Income Records OR Statement Concerning No Employee Income Record

 L.B.F. 9036-1.1, Consent for Electronic Notice and Service

 Photo or copy of Driver’s License or other Government Issued ID of the filer

 Statement About Your Social Security Numbers*

 Bankruptcy Petition Preparer Notice, Declaration, and Signature

 Disclosure of Compensation of Petition Preparer

 Chapter 7 Statement of Your Current Monthly Income

 Chapter 7 Means Test Exemption, if applicable

 Chapter 7 Means Test Calculation, if applicable

 Statement of Intention

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

are you choosing to file under?

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

2. You may apply to pay the filing fee in up to

four installments. Fill in the amounts you

propose to pay and the dates you plan to

pay them. Be sure all dates are business

days. Then add the payments you propose

to pa

y.

You must propose to pay the entir

e fee no

later than 120 days after you file this

bankruptcy case. If the court approves your

application, the cour

t will set your

final

payment timetable.

You propose 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 __________

Order Approving Payment of Filing Fee in Installments

After considering the Application for Individuals to Pay the Filing Fee in Installments (Official Form 103A), the

court orders that:

[ ] The debtor(s) may pay the filing fee in installments on the terms proposed in the application.

[ ] The debtor(s) must pay the filing fee according to the following terms:

You must pay…

On or before this date…

$_____________

_____________

Month / day / year

$_____________

_____________

Month / day / year

$_____________

_____________

Month / day / year

+ $_____________

_____________

Month / day / year

Total

$_____________

Until the filing

fee is paid in

full, the debtor(s) must not make any additional payment or transfer any

additional property to an attorney or to anyone else for services in connection with this case.

_____________ By the court: _____________________________________

Month / day / year United States Bankruptcy Judge

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)

Chapter filing under:

 Chapter 7

 Chapter 11

 Chapter 12

 Cha

p

ter 13

Fill in this information to identify the case:

__________ District of __________

Print

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Official Form 103B

Application to Have the Chapter 7 Filing Fee Waived page 1

Official Form 103B

Application to Have the Chapter 7 Filing Fee Waived 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 a separate sheet to this form. On the top of any additional pages, write your name and case number

(if known).

Part 1: Tell the Court About Your Family and Your Family’s Income

1. What is the size of your family?

Your family includes y

ou, your

spouse, and any dependents listed

on Schedule J: Your Expenses

(Official Form 106J).

Check all that apply:

 You

 Your spouse

 Your dependents ___________________

How many dependents?

_

_____

_

______________

Total number of people

2. Fill in your family’s average

monthly income.

Include your spouse’s income if

your spouse is living with you, even

if your spouse is not filing.

Do not include your spouse’s

income if you are separated and

your spouse is not filing with you.

That person’s average

monthly net income

(take-home pay)

Add your income and your spouse’s income. Include the

value (if known) of any non-cash governmental assistance

that you receive, such as food stamps (benefits under the

Supplemental Nutrition Assistance Program) or housing

subsidies.

If you have already filled out Schedule I: Your Income, see

line 10 of that schedule.

You .................. $_________________

Your spouse ....

+ $_________________

Subtotal ............. $_________________

Subtract any non-cash governmental assistance that you

included above.

– $_________________

Your family’s average monthly net income

Total ..................

$_________________

3. Do you receive non-cash

governmental assistance?

 No

 Yes. Describe. ...........

Type of assistance

4. Do you expect your family’s

average monthly net income to

increase or decrease by more than

10% during the next 6 months?

 No

 Yes. Explain. .............

5. Tell the court why you are unable to pay the filing fee in

installments within 120 days. If you have some additional

circumstances that cause you to not be able to pay your filing

fee in installments, explain them.

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 103B

Application to Have the Chapter 7 Filing Fee Waived page 2

Part 2: Tell the Court About Your Monthly Expenses

6. Estimate your average monthly expenses.

Include amounts paid by any government assistance that yo

u

reported on line 2.

If you have already filled out Schedule J, Your Expenses, copy

line 22 from that form.

$___________________

7. Do these expenses cover anyone

who is not included in your family

as reported in line 1?

 No

 Yes. Identify who ........

8. Does anyone other than you

regularly pay any of these

expenses?

If you have already filled out

Schedule I: Your Income, copy the

total from line 11.

 No

 Yes. How much do you regularly receive as contributions? $_________ monthly

9. Do you expect your average

monthly expenses to increase or

decrease by more than 10% during

the next 6 months?

 No

 Yes. Explain ................

Part 3: Tell the Court About Your Property

If you have already filled out Schedule A/B: Property (Official Form 106A/B) attach copies to this application and go to Part 4.

10. How much cash do you have?

Examples: Money

you have in

your wallet, in your home, and on

hand when you file this application

Cash: $_________________

11. Bank accounts and other deposits

of money?

Examples: Checking, savings,

money market, or other financial

accounts; certificates of deposit;

shares in banks, credit unions,

brokerage houses, and other

similar institutions. If you have

more than one account with the

same institution, list each. Do not

include 401(k) and IRA accounts.

Institution name:

Checking account: __________________________________________________

Savings account: __________________________________________________

Other financial accounts: __________________________________________________

Amount:

$__________________

12. Your home? (if you own it outright or

are purchasing it)

Examples: House, condominium,

manufactured home, or mobile home

_______________________________________________________

Number Street

_______________________________________________________

City State ZIP Code

Current value:

Amount you owe

on mortgage and

liens:

$_________________

13. Other real estate?

_______________________________________________________

Number Street

_______________________________________________________

City State ZIP Code

Current value:

Amount you owe

on mortgage and

liens:

$_________________

14. The vehicles you own?

Examples: Cars, vans, trucks,

sports utility vehicles, motorcycles,

tractors, boats

Make: _____________________

Model: _____________________

Year: ____________

Mileage _____________________

Current value:

Amount you ow

e

on liens:

$_________________

Make: _____________________

Model: _____________________

Year: ____________

Mileage _____________________

Current value:

Amount you ow

e

on liens:

$_________________

Order on the Application to Have the Chapter 7 Filing Fee Waived

After considering the debtor’s Application to Have the Chapter 7 Filing Fee Waived (Official Form 103B), the court

orders that the application is:

[ ] Granted. However, the court may order the debtor to pay the fee in the future if developments in

administering the bankruptcy case show that the waiver was unwarranted.

[ ] Denied

. The debtor must pay the filing fee according to the following terms:

You mu

st pay…

On or before this date…

$_____________

_____________

Month / day / year

$_____________

_____________

Month / day / year

$_____________

_____________

Month / day / year

+ $_____________

_____________

Month / day / year

Total

If the debtor would like to propose a different payment timetable, the debtor must file a

motion promptly with a payment proposal. The debtor may use Application for Individuals to

Pay the Filing Fee in Installments (Official Form 103A) for this purpose. The court will

consider it.

The debtor must pay the entire filing fee before making any more payments or transferring any

more property to an attorney, bankruptcy petition preparer, or anyone else in connection with the

bankruptcy case. The debtor must also pay the entire filing fee to receive a discharge. If the

debtor does not make any payment when it is due, the bankruptcy case may be dismissed and

the debtor’s rights in future bankruptcy cases may be affected.

[ ] Scheduled for hearing.

A hearing to consider the debtor’s application will be held

on _____________ at _________ AM / PM at _________________________________________.

Month / day / year Address of courthouse

If the debtor does not appear at this hearing, the court may deny the application.

_____________ By the court: _____________________________________

Month / day / year United States Bankruptcy Judge

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 the case:

__________ District of __________

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L.B.F. 9036-1.1 (12/18) Page 1

Fill in this information to identify your case

UNITED STATES BANKRUPTCY COURT DISTRICT OF COLORADO

Debtor 1:

Case #:

First Name

Middle Name

Last Name

Debtor 2:

Chapter:

First Name

Middle Name

Last Name

Local Bankruptcy Form 9036-1.1

Consent for Electronic Notice and Service in a Bankruptcy Case

Complete applicable sections.

I __________________________ [name and party type, e.g. John Smith, Debtor] hereby consent to receive notices

electronically (i.e., by e-mail at: __________________________ [email address]) and waive my right to receive them by

United States mail. I also consent to electronic service of any motions and other documents that may be filed in this case,

and waive personal service or service by United States mail. Finally, I consent to electronic service and notice of any

orders or judgments entered in this case, and waive service and notice by United States mail.

I understand that by signing this form I waive my right to receive documents filed or served in my bankruptcy case by

United States mail, and that the ONLY copies I receive will be electronic copies attached to e-mail messages, not paper

copies.

I understand I have only one free look at any orders, notices, motions, and other documents sent to my e-mail. It is my

responsibility to print or download documents immediately. I understand any additional document view(s) or download(s)

after the first free look will require a PACER account (www.pacer.gov) and I may be charged a fee.

Dated: _________________________________ By: ______________________________

Signature

Mailing Address: ____________________

Telephone number: __________________

Facsimile number: ___________________

E-mail address: _____________________

Part 1

Consent

Part 2

Signature

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 __ __ __ __ __ __ __ __

 You do not have an ITIN.

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 _________________

MM / 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 _________________

MM / DD / YYYY

__________ District of __________

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Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 1

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 12/17

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 1:

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)

__________________________________________________

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

__________________________________________________

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 – ____ ____ ____ ____

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 __________

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 1:

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

 I have not used any business names or EINs.

_________________________________________________

Business name

_________________________________________________

Business name

___ ___ – ___ ___ ___ ___ ___ ___ ___

EIN

___ ___ – ___ ___ ___ ___ ___ ___ ___

EIN

5. Where you live

_________________________________________________

Number Street

_________________________________________________

City State ZIP Code

_________________________________________________

County

If your mailing address is different from the one

above, fill it in here. Note that the court will send

any notices to you at this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________

City State ZIP Code

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?

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 so that it

can set appropriate deadlines. If you indicate that you are a small business debtor, 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 and I am a small business debtor according to the definition in the

Bankruptcy Code.

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 building

that 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 5

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 6

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 7

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 8

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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Official Form 101A Initial Statement About an Eviction Judgment Against You

Official Form 101A

Initial Statement About an Eviction Judgment Against You 12/15

File this form with the court and serve a copy on your landlord when you first file bankruptcy only if:

 you rent your residence; and

 your landlord has obtained a judgment for possession in an eviction, unlawful detainer action, or

similar proceeding (called eviction judgment) against you to possess your residence.

Landlord’s name __________________________________________________

Landlord’s address __________________________________________________

Number Street

_______________________________ _________ ___________

City State ZIP Code

If you want to stay in your rented residence after you file your case for bankruptcy, also complete the certification below.

Certification About Applicable Law and Deposit of Rent

I certify under penalty of perjury that:

 Under the state or other nonbankruptcy law that applies to the judgment for possession (eviction judgment),

I have the right to stay in my residence by paying my landlord the entire delinquent amount.

 I have given the bankruptcy court clerk a deposit for the rent that would be due during the 30 days after I file

the Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101).

____________________________________________ ____________________________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

Stay of Eviction: (a) First 30 days after bankruptcy. If you checked both boxes above, signed the form to certify that both apply,

and served your landlord with a copy of this statement, the automatic stay under 11 U.S.C. § 362(a)(3) will

apply to the continuation of the eviction against you for 30 days after you file your Voluntary Petition for

Individuals Filing for Bankruptcy (Official Form 101).

(b) Stay after the initial 30 days. If you wish to stay in your residence after that 30-day period and continue to

receive the protection of the automatic stay under 11 U.S.C. § 362(a)(3), you must pay the entire delinquent

amount to your landlord as stated in the eviction judgment before the 30-day period ends. You must also fill

out Statement About Payment of an Eviction Judgment Against You (Official Form 101B), file it with the

bankruptcy court, and serve your landlord a copy of it before the 30-day period ends.

Check the Bankruptcy Rules ( http://www.uscourts.gov/rules-policies/current-rules-practice-procedure) and the local court’s website (to find

your court’s website, go to http://www.uscourts.gov/court-locator) for any specific requirements that you might have to meet to serve this

statement. 11 U.S.C. §§ 362(b)(22) and 362(l)

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 ____________

(State)

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

meet to s

erve this statement.

O

fficial Form 101B

Statement About Payment of an Eviction Judgment Against You

Official Form 101B

Statement About Payment of an Eviction Judgment Against You 12/15

Fill out this form only if:

 you filed

Initial Statement About an Eviction Judgment Against You (Official Form 101A); and

 you served a copy of Form 101A on your landlord; and

 you want to stay in your rented residence for more than 30 days after you file your Voluntary Petition

for Individuals Filing for Bankruptcy (Official Form 101).

File this form within 30 days after you file your Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101).

Also serve a copy on your landlord within that same time period.

Certif

ication About Applicable Law and Payment of Eviction Judgment

I certify under penalty of perjury that (Check all that apply):

 Under the state or other nonbankruptcy law that applies to the judgment for possession (eviction

judgm

ent), I have the right to stay in my residence by paying my landlord the entire delinquent amount

.

 Within 30 days after I filed my Voluntary Petition for Individuals Filing for Bankruptcy (Official

Form 101), I have paid my landlord the entire amount I owe as stated in the judgment for possession

(eviction judgment).

____________________________________________ ____________________________________________

Signature of Debtor 1 Signature of Debtor 2

Date

_________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

You must serve your landlord with a copy of this form.

Check the Bankruptcy Rules (www.uscourts.gov/rulesandpolicies/rules.aspx) and the court’s local website (go to

http://www.uscourts.gov/Court_Locator.aspx to find your court’s website) for any specific requirements that you might have to

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 __________

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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 __________

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 y

ear 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,

unemployment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; 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, groundwater, 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).

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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 __________

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:

_____________________________________________________________________ ___________%

$____________

______

$__________________

0%

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 about

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: ___________________________________________________________________

$__________________

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. ......................................................................................... $_________________

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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 __________

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

any 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

any 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

any 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

any 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

any 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

any applicable statutory limit

____________________________

______

2

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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 __________

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 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 __________

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

2

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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 __________

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 __________

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

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 __________

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 106J-2 Schedule J-2: Expenses for Separate Household of Debtor 2 page 1

Official Form 106J-2

Schedule J-2: Expenses for Separate Household of Debtor 2 12/15

Use this form for Debtor 2’s separate household expenses ONLY IF Debtor 1 and Debtor 2 maintain separate households. If Debtor 1 and

Debtor 2 have one or more dependents in common, list the dependents on both Schedule J and this form. Answer the questions on this form

only with respect to expenses for Debtor 2 that are not reported on Schedule J. Be as complete and accurate as possible. 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. Do you and Debtor 1 maintain separate households?

 No. Do not complete this form.

 Yes

2. Do you have dependents?

Do not list Debtor 1 but list all

other dependents of Debtor 2

regardless of whether listed as a

dependent of Debtor 1 on

Schedule J.

Do not state the dependents’

names.

 No

 Yes. Fill out this information for

each dependent ..........................

Dependent’s relationship to

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, your dependents, an

d

Debtor 1?

 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.

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

an

y 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

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 __________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106J-2 Schedule J-2: Expenses for Separate Household of Debtor 2 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-2 Schedule J-2: Expenses for Separate Household of Debtor 2 page 3

21. Other. Specify: _________________________________________________ 21.

+$_____________________

22. Your monthly expenses. Add lines 5 through 21.

The result is the monthly expenses of Debtor 2. Copy the result to line 22b of Schedule J to calculate

the

total expenses for Debtor 1 and Debtor 2.

22.

$_____________________

23. Line not used on this form.

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 __________

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This statement is for information use only. Filing this statement with the Bankruptcy Court does not constitute an application for

or invoke the benefits and relief available under the Servicemembers’ Civil Relief Act of 2003.

B2020 (Form 2020) (12/15)

United States Bankruptcy Court

____________________ District of ____________________

In re _________________________ Case Number _______________________

Chapter _______________________

STATEMENT OF MILITARY SERVICE

The Servicemembers’ Civil Relief Act of 2003, Pub. L. No. 108-189, provides for the temporary

suspension of certain judicial proceedings or transactions that may adversely affect military servicemembers, their

dependents, and others. Each party to a bankruptcy case who might be eligible for relief under the act should

complete this form and file it with the Bankruptcy Court.

IDENTIFICATION OF SERVICEMEMBER

 Self (Debtor, Codebtor, Creditor, Other)

 Non-Filing Spouse of Debtor (name)________________________________________

 Other (Name of servicemember)__________________________________________

(Relationship of filer to servicemember)_______________________________

(Type of liability) ________________________________________________

TYPE OF MILITARY SERVICE

U.S. Armed Forces (Army, Navy, Air Force, Marine Corps, or Coast Guard) or commissioned officer

of the Public Health Service or the National Oceanic and Atmospheric Administration (specify type

of service) _____________________________________________________________

 Active Service since ____________________________________________(date)

 Inductee - ordered to report on ____________________________________________(date)

 Retired / Discharged ____________________________________________(date)

U.S. Military Reserves and National Guard

 Active Service since ____________________________________________(date)

 Impending Active Service -orders postmarked _______________________________(date)

Ordered to report on ____________________________________________(date)

 Retired /Discharged ____________________________________________(date)

U.S. Citizen Serving with U.S. ally in war or military action (specify ally and war or action)

______________________________________________________________________

 Active Service since ____________________________________________(date)

 Retired/Discharged ____________________________________________(date)

DEPLOYMENT

 Servicemember deployed overseas on _______________________________________(date)

Anticipated completion of overseas tour-of-duty ______________________________(date)

SIGNATURE

____________________________________ ___________________________

Date

____________________________________

(print name)

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

$______ $______

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 __________

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 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 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.

Official Form 122A-1Supp Statement of Exemption from Presumption of Abuse Under § 707(b)(2)

Official Form 122A─1Supp

Statement of Exemption from Presumption of Abuse Under § 707(b)(2) 12/15

File this supplement together with Chapter 7 Statement of Your Current Monthly Income (Official Form 122A-1), if you believe that you are

exempted from a presumption of abuse. Be as complete and accurate as possible. If two married people are filing together, and any of the

exclusions in this statement applies to only one of you, the other person should complete a separate Form 122A-1 if you believe that this is

required by 11 U.S.C. § 707(b)(2)(C).

Part 1: Identify the Kind of Debts You Have

1. 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.” Make sure that your answer is consistent with the answer you gave at line 16 of the Voluntary Petition for

Individuals Filing for Bankruptcy (Official Form 101

).

 No. Go to Form 122A-1; on the top of page 1 of that form, check box 1, There is no presumption of abuse, and sign Part 3. Then

submit this supplement with the signed Form 122A-1.

 Yes. Go to Part 2.

Part 2: Determine Whether Military Service Provisions Apply to You

2. Are you a disabled veteran (as defined in 38 U.S.C. § 3741(1))?

 No. Go to line 3.

 Yes. Did you incur debts mostly while you were on active duty or while you were performing a homeland defense activity?

10 U.S.C. § 101(d)(1); 32 U.S.C. § 901(1).

 No. Go to line 3.

 Yes. Go to Form 122A-1; on the top of page 1 of that form, check box 1, There is no presumption of abuse, and sign Part 3.

Then submit this supplement with the signed Form 122A-1.

3. Are you or have you been a Reservist or member of the National Guard?

No. Complete Form 122A-1. Do not submit this supplement.

Yes. Were you called to active duty or did you perform a homeland defense activity? 10 U.S.C. § 101(d)(1); 32 U.S.C. § 901(1).

 No. Complete Form 122A-1. Do not submit this supplement.

 Yes. Check any one of the following categories that applies:

 I was called to active duty after September 11, 2001, for at least

90 days and remain on active duty.

 I was called to active duty after September 11, 2001, for at least

90 days and was released from active duty on _______________,

which is fewer than 540 days before I file this bankruptcy case.

 I am performing a homeland defense activity for at least 90 days.

 I performed a homeland defense activity for at least 90 days,

ending on _______________, which is fewer than 540 days

before I file this bankruptcy case.

If you checked one of the categories to the left, go to

Form 122A-1. On the top of page 1 of Form 122A-1,

check box 3, The Means Test does not apply now, and

sign Part 3. Then submit this supplement with the signed

Form 122A-1. You are not required to fill out the rest of

Official Form 122A-1 during the exclusion period. The

exclusion period means the time you are on active duty

or are performing a homeland defense activity, and for

540 days afterward. 11 U.S.C. § 707(b)(2)(D)(ii).

If your exclusion period ends before your case is closed,

you may have to file an amended form later.

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 __________

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Official Form 122A–2 Chapter 7 Means Test Calculation page 1

Official Form 122A–2

Chapter 7 Means Test Calculation 04/19

To fill out this form, you will need your completed copy of Chapter 7 Statement of Your Current Monthly Income (Official Form 122A-1).

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: Determine Your Adjusted Income

1. Copy your total current monthly income. ............................................................... Copy line 11 from Official Form 122A-1 here ...........

$_________

2. Did you fill out Column B in Part 1 of Form 122A–1?

 No. Fill in $0 for the total on line 3.

 Yes. Is your spouse filing with you?

 No. Go to line 3.

 Yes. Fill in $0 for the total on line 3.

3. Adjust your current monthly income by subtracting any part of your spouse’s income not used to pay for the

household expenses of you or your dependents. Follow these steps:

On line 11, Column B of Form 122A–1, was any amount of the income you reported for your spouse NOT

regularly used for the household expenses of you or your dependents?

 No. Fill in 0 for the total on line 3.

Yes. Fill in the information below:

State each purpose for which the income was used

For example, the income is used to pay your spouse’s tax debt or to support

people other than you or your dependents

Fill in the amount you

are subtracting from

your spouse’s income

___________________________________________________ $______________

___________________________________________________

+ $______________

Total. ................................................................................................. $______________

Copy total here ............... 

─ $_________

4. Adjust your current monthly income. Subtract the total on line 3 from line 1.

$_________

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:

According to the calculations required by

this Statement:

 1. There is no presumption of abuse.

 2. There is a presumption of abuse.

 Check if this is an amended filing

Check the appropriate box as directed in

lines 40 or 42

:

__________ District of __________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 122A–2 Chapter 7 Means Test Calculation page 2

Part 2: Calculate Your Deductions from Your Income

The Internal Revenue Service (IRS) issues National and Local Standards for certain expense amounts. Use these amounts to

answer the questions in lines 6-15. To find the IRS standards, go online using the link specified in the separate instructions for

this form. This information may also be available at the bankruptcy clerk’s office.

Deduct the expense amounts set out in lines 6-15 regardless of your actual expense. In later parts of the form, you will use some of your

actual expenses if they are higher than the standards. Do not deduct any amounts that you subtracted from your spouse’s income in line 3

and do not deduct any operating expenses that you subtracted from income in lines 5 and 6 of Form 122A–1.

If your expenses differ from month to month, enter the average expense.

Whenever this part of the form refers to you, it means both you and your spouse if Column B of Form 122A–1 is filled in.

5. The number of people used in determining your deductions from income

Fill in the number of people who could be claimed as exemptions on your federal income tax return,

plus the number of any additional dependents whom you support. This number may be different from

the number of people in your household.

National Standards You must use the IRS National Standards to answer the questions in lines 6-7.

6. Food, clothing, and other items: Using the number of people you entered in line 5 and the IRS National Standards, fill

in the dollar amount for food, clothing, and other items.

$________

7. Out-of-pocket health care allowance: Using the number of people you entered in line 5 and the IRS National Standards,

fill in the dollar amount for out-of-pocket health care. The number of people is split into two categoriespeople who are

under 65 and people who are 65 or olderbecause older people have a higher IRS allowance for health care costs. If your

actual expenses are higher than this IRS amount, you may deduct the additional amount on line 22.

People who are under 65 years of age

7a. Out-of-pocket health care allowance per person

$____________

7b. Number of people who are under 65

X ______

7c. Subtotal. Multiply line 7a by line 7b. $____________

Copy here

$___________

People who are 65 years of age or older

7d. Out-of-pocket health care allowance per person

$____________

7e. Number of people who are 65 or older

X ______

7f. Subtotal. Multiply line 7d by line 7e. $____________

Copy here

+ $___________

7g. Total. Add lines 7c and 7f. ..................................................................................... $___________

Copy total here

$________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 122A–2 Chapter 7 Means Test Calculation page 3

Local Standards

You must use the IRS Local Standards to answer the questions in lines 8-15.

Based on information from the IRS, the U.S. Trustee Program has divided the IRS Local Standard for housing for

bankruptcy purposes into two parts:

 Housing and utilities – Insurance and operating expenses

 Housing and utilities – Mortgage or rent expenses

To answer the questions in lines 8-9, use the U.S. Trustee Program chart.

To find the chart, go online using the link specified in the separate instructions for this form.

This chart may also be available at the bankruptcy clerk’s office.

8. Housing and utilities – Insurance and operating expenses: Using the number of people you entered in line 5, fill in the

dollar amount listed for your county for insurance and operating expenses. ........................................................................

$____________

9. Housing and utilities – Mortgage or rent expenses:

9a. Using the number of people you entered in line 5, fill in the dollar amount listed

for your county for mortgage or rent expenses. ......................................................................

$___________

9b. Total average monthly payment for all mortgages and other debts secured by your home.

To calculate the total average monthly payment, add all amounts that are

contractually due to each secured creditor in the 60 months after you file for

bankruptcy. Then divide by 60.

Name of the creditor Average monthly

payment

___________________________________

$____________

___________________________________

$____________

___________________________________

+ $____________

Total average monthly payment $____________

Copy

here



─ $___________

Repeat this

amount on

line 33a.

9c. Net mortgage or rent expense.

Subtract line 9b (total average monthly payment) from line 9a (mortgage or

rent expense). If this amount is less than $0, enter $0.

..................................................................

Copy

here



$___________

10. If you claim that the U.S. Trustee Program’s division of the IRS Local Standard for housing is incorrect and affects

the calculation of your monthly expenses, fill in any additional amount you claim.

$___________

Explain

why:

_________________________________________________________________

11. Local transportation expenses: Check the number of vehicles for which you claim an ownership or operating expense.

 0. Go to line 14.





1. Go to line 12.





2 or more. Go to line 12.

12. Vehicle operation expense: Using the IRS Local Standards and the number of vehicles for which you claim the

operating expenses, fill in the Operating Costs that apply for your Census region or metropolitan statistical area.

$___________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 122A–2 Chapter 7 Means Test Calculation page 4

13. Vehicle ownership or lease expense: Using the IRS Local Standards, calculate the net ownership or lease expense

for each vehicle below. You may not claim the expense if you do not make any loan or lease payments on the vehicle.

In addition, you may not claim the expense for more than two vehicles.

Vehicle 1

Describe Vehicle 1:

_______________________________________________________________

13a

. Ownership or leasing costs using IRS Local Standard. ...................................................

$___________

13b. Average monthly payment for all debts secured by Vehicle 1.

Do not include costs for leased vehicles.

To calculate the average monthly payment here and on line 13e, add all

amounts that are contractually due to each secured creditor in the 60 month

s

after you filed for bankruptcy. Then divide by 60.

Name of each creditor for Vehicle 1 Average monthly

payment

_____________________________________ $____________

_____________________________________

+ $____________

Total average monthly payment $____________

Copy

here



─ $____________

Repeat this

amount on

line 33b.

13c. Net Vehicle 1 ownership or lease expense

Subtract line 13b from line 13a. If this amount is less than $0, enter $0.

.............................

$____________

Copy net

Vehicle 1

expense

here .....



$_________

Vehicle 2

Describe Vehicle 2:

_______________________________________________________________

13d. Ownership or leasing costs using IRS Local Standard. .................................................

$____________

13e. Average monthly payment for all debts secured by Vehicle 2.

Do not include costs for leased vehicles.

Name of each creditor for Vehicle 2 Average monthly

payment

_____________________________________ $____________

_____________________________________

+ $____________

Total average monthly payment $____________

Copy

here



─ $____________

Repeat this

amount on

line 33c.

13f. Net Vehicle 2 ownership or lease expense

Subtract line 13e from 13d. If this amount is less than $0, enter $0.

.....................................

$____________

Copy net

Vehicle 2

expense

here ...



$________

14. Public transportation expense: If you claimed 0 vehicles in line 11, using the IRS Local Standards, fill in the

Public Transportation expense allowance regardless of whether you use public transportation.

$________

15. Additional public transportation expense: If you claimed 1 or more vehicles in line 11 and if you claim that you may also

deduct a public transportation expense, you may fill in what you believe is the appropriate expense, but you may not claim

more than the IRS Local Standard for Public Transportation.

$________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 122A–2 Chapter 7 Means Test Calculation page 5

Other Necessary Expenses In addition to the expense deductions listed above, you are allowed your monthly expenses for

the following IRS categories.

16. Taxes: The total monthly amount that you will actually owe for federal, state and local taxes, such as income taxes, self-

employment taxes, Social Security taxes, and Medicare taxes. You may include the monthly amount withheld from your

pay for these taxes. However, if you expect to receive a tax refund, you must divide the expected refund by 12 and

subtract that number from the total monthly amount that is withheld to pay for taxes.

Do not include real estate, sales, or use taxes.

$________

17. Involuntary deductions: The total monthly payroll deductions that your job requires, such as retirement contributions,

union dues, and uniform costs.

Do not include amounts that are not required by your job, such as voluntary 401(k) contributions or payroll savings.

$________

18. Life insurance: The total monthly premiums that you pay for your own term life insurance. If two married people are filing

together, include payments that you make for your spouse’s term life insurance. Do not include premiums for life

insurance on your dependents, for a non-filing spouse’s life insurance, or for any form of life insurance other than term.

$________

19. Court-ordered payments: The total monthly amount that you pay as required by the order of a court or administrative

agency, such as spousal or child support payments.

Do not include payments on past due obligations for spousal or child support. You will list these obligations in line 35.

$________

20. Education: The total monthly amount that you pay for education that is either required:

 as a condition for your job, or

 for your physically or mentally challenged dependent child if no public education is available for similar services.

$________

21. Childcare: The total monthly amount that you pay for childcare, such as babysitting, daycare, nursery, and preschool.

Do not include payments for any elementary or secondary school education.

$_______

22. Additional health care expenses, excluding insurance costs: The monthly amount that you pay for health care that

is required for the health and welfare of you or your dependents and that is not reimbursed by insurance or paid by a

health savings account. Include only the amount that is more than the total entered in line 7.

Payments for health insurance or health savings accounts should be listed only in line 25.

$________

23. Optional telephones and telephone services: The total monthly amount that you pay for telecommunication services for

you and your dependents, such as pagers, call waiting, caller identification, special long distance, or business cell phone

service, to the extent necessary for your health and welfare or that of your dependents or for the production of income, if it

is not reimbursed by your employer.

Do not include payments for basic home telephone, internet and cell phone service. Do not include self-employment

expenses, such as those reported on line 5 of Official Form 122A-1, or any amount you previously deducted.

+ $_______

24. Add all of the expenses allowed under the IRS expense allowances.

Add lines 6 through 23.

$_______

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 122A–2 Chapter 7 Means Test Calculation page 6

Additional Expense Deductions These are additional deductions allowed by the Means Test.

Note: Do not include any expense allowances listed in lines 6-24.

25. Health insurance, disability insurance, and health savings account expenses. The monthly expenses for health

insurance, disability insurance, and health savings accounts that are reasonably necessary for yourself, your spouse, or your

dependents.

Health insurance

$____________

Disability insurance

$____________

Health savings account

+ $____________

Total

$____________

Copy total here .....................................

$________

Do you actually spend this total amount?

 No. How much do you actually spend?

 Yes

$___________

$________

$_______

+ $_______

26. Continuing contributions to the care of household or family members. The actual monthly expenses that you will

continue to pay for the reasonable and necessary care and support of an elderly, chronically ill, or disabled member of your

household or member of your immediate family who is unable to pay for such expenses. These expenses may include

contributions to an account of a qualified ABLE program. 26 U.S.C. § 529A(b).

27. Protection against family violence. The reasonably necessary monthly expenses that you incur to maintain the safety of

you and your family under the Family Violence Prevention and Services Act or other federal laws that apply.

By law, the court must keep the nature of these expenses confidential.

28. Additional home energy costs. Your home energy costs are included in your insurance and operating expenses on line 8.

If you believe that you have home energy costs that are more than the home energy costs included in expenses on line

8, then fill in the excess amount of home energy costs.

You must give your case trustee documentation of your actual expenses, and you must show that the additional amount

claimed is reasonable and necessary.

29. Education expenses for dependent children who are younger than 18. The monthly expenses (not more than $170.83*

per child) that you pay for your dependent children who are younger than 18 years old to attend a private or public

elementary or secondary school.

You must give your case trustee documentation of your actual expenses, and you must explain why the amount claimed is

reasonable and necessary and not already accounted for in lines 6-23.

* Subject to adjustment on 4/01/22, and every 3 years after that for cases begun on or after the date of adjustment.

30. Additional food and clothing expense. The monthly amount by which your actual food and clothing expenses are higher

than the combined food and clothing allowances in the IRS National Standards. That amount cannot be more than 5% of the

food and clothing allowances in the IRS National Standards.

To find a chart showing the maximum additional allowance, go online using the link specified in the separate instructions for

this form. This chart may also be available at the bankruptcy clerk’s office.

You must show that the additional amount claimed is reasonable and necessary.

31. Continuing charitable contributions. The amount that you will continue to contribute in the form of cash or financial

instruments to a religious or charitable organization. 26 U.S.C. § 170(c)(1)-(2).

32. Add all of the additional expense deductions.

Add lines 25 through 31.

$_______

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 122A–2 Chapter 7 Means Test Calculation page 7

Deductions for Debt Payment

33. For debts that are secured by an interest in property that you own, including home mortgages, vehicle

loans, and other secured debt, fill in lines 33a through 33e.

To calculate the total average monthly payment, add all amounts that are contractually due to each secured

creditor in the 60 months after you file for bankruptcy. Then divide by 60.

Mortgages on your home:

Average monthly

payment

33a. Copy line 9b here ................................................................................................................ 

$_____________

Loans on your first two vehicles:



33b. Copy line 13b here. ............................................................................................................ 

$_____________

33c. Copy line 13e here. .......................................................................................................... . 

$_____________

33d. List other secured debts:



Name of each creditor for other

secured debt

Identify property that

secures the debt

Does payment

include taxes

or insurance?

_______________________________ ________________________

 No

 Yes

$____________

_______________________________ ________________________

 No

 Yes

$____________

_______________________________ ________________________

 No

 Yes

+ $____________

33e. Total average monthly payment. Add lines 33a through 33d. .................................................... $____________

Copy total

here



$_________

34. Are

any debts that you listed in line 33 secured by your primary residence, a vehicle,

or other property necessary for your support or the support of your dependents?

 No. Go to line 35.

 Yes. State any amount that you must pay to a creditor, in addition to the payments

listed in line 33, to keep possession of your property (called the cure amount).

Next, divide by 60 and fill in the information below.

Name of the creditor Identify property that

secures the debt

Total cure

amount

Monthly cure

amount

_______________________ ____________________

$__________

÷ 60 =

$_____________

_______________________ ____________________

$__________

÷ 60 =

$_____________

_______________________ ____________________

$__________

÷ 60 =

+ $_____________

Total $_____________

Copy total

here



$________

35. Do you owe any priority claims such as a priority tax, child support, or alimony ─

that are past due as of the filing date of your bankruptcy case? 11 U.S.C. § 507.

 No. Go to line 36.

 Yes. Fill in the total amount of all of these priority claims. Do not include current or

ongoing priority claims, such as those you listed in line 19.

Total amount of all past-due priorit

y claims .................................................................

$____________

÷ 60 =

$_________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 119

Bankruptcy Petition Preparer’s Notice, Declaration, and Signature page 2

Part 2:

Declaration and Signature of the Bankruptcy Petition Preparer

Under penalty of perjury, I declare that:

 I am a bankruptcy petition preparer or the officer, principal, responsible person, or partner of a bankruptcy petition preparer;

 I or my firm prepared the documents listed below and gave the debtor a copy of them and the Notice to Debtor by Bankruptcy Petition

Preparer as required by 11 U.S.C. §§ 110(b), 110(h), and 342(b); and

 if rules or guidelines are established according to 11 U.S.C. § 110(h) setting a maximum fee for services that bankruptcy petition

preparers may charge, I or my firm notified the debtor of the maximum amount before preparing any document for filing or before

accepting any fee from the debtor.

________________________________ ______________________ _______________________________________________________

Printed name Title, if any Firm name, if it applies

______________________________________________________

Number Street

____________________________________ __________ ______________ ______________________________

City State ZIP Code Contact phone

I or my firm prepared the documents checked below and the completed declaration is made a part of each document that I check:

(Check all that apply.)

Voluntary Petition (Form 101)

Statement About Your Social Security Numbers

(Form 121)

Summary of Your Assets and Liabilities and

Certain Statistical Information (Form 106Sum)

Schedule A/B (Form 106A/B)

 Schedule C (Form 106C)

 Schedule D (Form 106D)

 Schedule E/F (Form 106E/F)

 Schedule G (Form 106G)

 Schedule H (Form 106H)

 Schedule I (Form 106I)

 Schedule J (Form 106J)

 Declaration About an Individual Debtor’s

Schedules (Form 106Dec)

 Statement of Financial Affairs (Form 107)

 Statement of Intention for Individuals Filing

Under Chapter 7 (Form 108)

 Chapter 7 Statement of Your Current

Monthly Income (Form 122A-1)

 Statement of Exemption from Presumption

of Abuse Under § 707(b)(2)

(Form 122A-1Supp)

 Chapter 7 Means Test Calculation

(Form 122A-2)

 Chapter 11 Statement of Your Current Monthly

Income (Form 122B)

 Chapter 13 Statement of Your Current Monthly

Income and Calculation of Commitment Period

(Form 122C-1)

 Chapter 13 Calculation of Your Disposable

Income (Form 122C-2)

 Application to Pay Filing Fee in Installments

(Form 103A)

 Application to Have Chapter 7 Filing Fee

Waived (Form 103B)

 A list of names and addresses of all creditors

(creditor or mailing matrix)

 Other _____________________________

Bankruptcy petition preparers must sign and give their Social Security numbers. If more than one bankruptcy petition preparer prepared the documents

to which this declaration applies, the signature and Social Security number of each preparer must be provided. 11 U.S.C. § 110.

8 _______________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ___ Date _________________

Signature of bankruptcy petition preparer or officer, principal, responsible

person, or partner

Social Security number of person who signed MM / DD / YYYY

_______________________________________________________________

Printed name

8 _______________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ___ Date _________________

Signature of bankruptcy petition preparer or officer, principal, responsible

person, or partner

Social Security number of person who signed MM / DD / YYYY

_______________________________________________________________

Printed name

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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 creditors,

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 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.

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 __________

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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Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 1

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 2

 most fines, penalties, forfeitures, and

criminal 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.

If 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 3

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

obligations,

 certain debts that are not listed in your

bankruptcy papers,

 certain debts for acts that caused death or

personal injury, and

 certain long-term secured debts.

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 4

Bankruptcy 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 fined,

imprisoned, or both.

 All information you supply in connection

with 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://www.uscourts.gov/services-

forms/bankruptcy/credit-counseling-and-debtor-

education-courses.

In Alabama and North Carolina, go to:

http://www.uscourts.gov/services-

forms/bankruptcy/credit-counseling-and-

debtor-education-courses.

If you do not have access to a computer, the

clerk of the bankruptcy court may be able to

help you obtain the list.

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/forms/bankruptcy-forms



L.B.F. 1007-6.1 (12/17) Page 1



Fill in this information to identify your case

UNITED STATES BANKRUPTCY COURT DISTRICT OF COLORADO

Debtor 1:

Case #:

First Name Middle Name Last Name

Debtor 2: Chapter:

First Name Middle Name Last Name

Local Bankruptcy Form 1007-6.1

Statement Under Penalty of Perjury Concerning Payment Advices

Complete the applicable sections and check the applicable boxes.

I, __________________________ [name]

1

state as follows:

I did not file with the court copies of some or all payment advices or other evidence of payment received within 60 days

before the date of the filing of the petition from any employer because:

☐

I was not employed during the period immediately preceding the filing of the above-referenced case:

_____________________________________________________________________________________

[insert the dates you were not employed].

☐

I was employed during the period immediately preceding the filing of the above referenced case but did not

receive any payment advices or other evidence of payment from my employer within 60 days before the date of

the filing of the petition.

☐

I am self-employed and do not receive any evidence of payment from an employer.

☐

Other: _____________________________________________________________________________________

[please provide explanation].



I declare under penalty of perjury that the foregoing is true and correct.

Dated: _________________________________ By: ______________________________

Signature of Debtor

Mailing Address: ____________________

Telephone number: __________________

Facsimile number: ___________________

E-mail address: _____________________

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1

A separate form must be completed and signed by each debtor.



Part 1

Statement

Part 2

Verification of Debtor

Fill Online, Printable, Fillable, Blank Pro Se Bankruptcy Clinic (US Courts) Form

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Fillable Pro Se Bankruptcy Clinic (US Courts)

Fill Online, Printable, Fillable, Blank Pro Se Bankruptcy Clinic (US Courts) Form

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