Fillable Schedule I: Your Income 12/15 (US Courts)

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Schedule I: Your Income 12/15 (US Courts)

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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
infor
mation.
If you have more
than one job,
attach a separat
e page wi
th
information about additional
emplo
yers.
Include part-time
, seasonal, or
self-
employed work
.
Occupation ma
y
include student
or homemake
r, 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 no
t 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
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,
profes
sion, 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 unm
arried partner, members of your household, your dependents, your roommates,
and other
friends or relative
s
.
Do not include a
ny 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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Schedule I: Your Income 1215 (US Courts)

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Completed 13 October 2020

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