Fill - Free fillable for a Bare Bone Petition (US Courts) PDF form

Requirements

for a Bare

Bone Petition

– Pro Se –

Chapter 7

U. S. Bankruptcy Court

Northern District of

Illinois

Last Updated: February 19, 2020

CHAPTER 7 - INDIVIDUAL

DOCUMENTS

REQUIRED

AT TIME OF FILING

(Minimum Filing Requirements)

REMINDER: PLEASE SIGN ALL PAGES THAT REQUIRE A SIGNATURE

Chapter7IndividualDocumentsRequiredatTimeofFilingChecklist



When filing a Chapter 7, please complete all requirements listed below and submit with

your form of payment.



VoluntaryPetitionforIndividualsFilingforBankruptcy(OfficialForm101)



StatementAboutYourSocialSecurityNumbers(OfficialForm121).Requiredifthedebtoris

anindividual.MustbesubmittedWITHthepetition.Fed.R.Bankr.P.1007(f).



Namesandaddressesofallcreditorsofthedebtor.MustbefiledWITHthepetition.

Fed.R.Bankr.P.1007(a)(1).



FormofPayment–selectfromoneofthefollowing:

• FilingFeePaidinFull–CashorMoneyOrdermadepayableto“ClerkoftheU.S.

BankruptcyCourt”

• Application/OrderforIndividualstoPaytheFilingFeeinInstallments(OfficialForm

103A)

• Application/OrdertoHavetheChapter7FilingFeeWaived(OfficialForm103B)

 Chapter7StatementofYourCurrentMonthlyIncome(OfficialForm122A‐1)

 CertificateofCreditCounseling

Before you file for bankruptcy, you must receive a briefing about credit

counseling from an approved agency within 180 days before you file. If

you and your spouse are filing together, each of you must receive a briefing before

you file. Failure to do so will almost certainly result in the dismissal of your case.

You may have a briefing about credit counseling one-on-one or in a group, by

telephone, or by internet.



 PhotoI.D.LocalRule5005‐1E

Isrequiredforopeningabankruptcycase

Please Note: Pursuant to Local Rule 1009-1

If after the petition, the debtor files the creditor list or adds any creditors to the

schedules, the debtor must serve each such creditor, by first-class or certified mail, with a

copy of the original notice of the meeting of creditors and must file proof of such service

with the clerk.

REMINDER: PLEASE SIGN ALL PAGES THAT REQUIRE A SIGNATURE

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

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 02/20

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 – ____ ____ ____ ____

9 xx – xx – ____ ____ ____ ____

xxx – xx – ____ ____ ____ ____

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, I am a small business debtor according to the definition in the Bankruptcy

Code, and I do not choose to proceed under Subchapter V of Chapter 11.

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

 Yes. I am filing under Chapter 11, I am a small business debtor according to the definition in the

Bankruptcy Code, and I choose to proceed under Subchapter V of Chapter 11.

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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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS

EASTERN DIVISION

In Re:

Case No.

Debtor (s)

Chapter

List of Creditors



Debtor/Joint Debtor’s Name: 



Debtor 1

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 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

re you choosing to file unde

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

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

four i

nstallments. Fill in the amounts yo

prop

ose to pay and the dates you plan to

pay them. Be sure all dates are busin

ess

ys. Then add the payments you prop

ose

to pa

You must propose to pay the entir

e fee no

later than 120

days after you file th

bankruptc

y case. If the court approves yo

application, the cour

t will set your

final

yment timeta

ble.

You pr

opose to pay…

$_____________

 With the filing of the

petition

 On or before this date .......

______________

MM / DD / YYYY

$_____________

On or before this date ...........

______________

MM / DD / YYYY

$_____________

On or before this date ...........

______________

MM / DD / YYYY

+ $_____________

On or before this date ...........

______________

MM / DD / YYYY

Total

$______________

◄ Your total must equal the entire fee for the chapter you checked in line 1.

Part 2: Sign Below

By signing here, you state that you are unable to pay the full filing fee at once, that you want to pay the fee in installments, and that you

understand that:

 You must pay your entire filing fee before you make any more payments or transfer any more property to an attorney, bankruptcy petition

preparer, or anyone else for services in connection with your bankruptcy case.

 You must pay the entire fee no later than 120 days after you first file for bankruptcy, unless the court later extends your deadline. Your

debts will not be discharged until your entire fee is paid.

 If you do not make any payment when it is due, your bankruptcy case may be dismissed, and your rights in other bankruptcy proceedings

may be affected.

_________________________________ ___________________________________ _______________________________________

Signature of Debtor 1 Signature of Debtor 2 Your attorney’s name and signature, if you used one

Date _________________ Date ________________ Date _________________

MM / DD / YYYY MM / DD / YYYY MM / DD / YYYY

Debtor 1 ________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of ___________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

 Check if this is an

amended filing

__________ District of __________

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

ter 13

Fill in this information to identify the case:

__________ District of __________

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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 an

dependents listed

on Schedule J: Your Expenses

(Official Form 10

6J).

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 spou

se’s income if

your spo

use is living with you, even

if y

our spouse is not filing.

Do not include your spouse’s

income if y

ou are separated an

your spo

use 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

vernmental assistan

ce?

 No

 Yes. Describe. ...........

Type of assistance

4. Do you expect your family’s

verage monthly net income to

increase or decrease by more th

% during the next 6 mont

hs?

 No

 Yes. Explain. .............

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

install

ments within 120 days. If you have some a

dditional

circumstances th

at cause you to not be able to pay

your filing

fee in installment

s, 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

reporte

d on line

you have already filled out Schedule J, Your Expenses,

copy

line 22 from that

form.

$___________________

7. Do these expenses cover anyone

ho is not included in your family

as reported in line 1?

 No

 Yes. Identify who ........

8. Does anyone other than you

regularl

y pay any of th

ese

expenses?

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

mon

thly expenses to increase or

decrease by more than 10% dur

ing

the n

ext 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, an

d on

hand

when you file this application

Cash: $_________________

11. Bank accounts and other deposits

of m

oney?

Examples: Chec

king, savings,

mone

y market, or

other financial

accounts; certificates of deposit;

shares in banks, credit unions,

brokerage

houses

, and other

similar inst

itutions. If y

ou have

more than o

ne account wi

th the

same institution, list each. Do not

include 401(k) an

d 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: Hous

e, condominium,

manufactured h

ome, 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?

Exam

ples: Cars, vans, tr

ucks,

spor

ts utility vehicles, motorcyc

les,

tractors, boats

Make: _____________________

Model: _____________________

Year: ____________

Mileage _____________________

Current value:

Amount y

ou owe

on liens:

$_________________

Make: _____________________

Model: _____________________

Year: ____________

Mileage _____________________

Current value:

Amount y

ou owe

on liens:

$_________________

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 3

15. Other assets?

Do not include household items

and clothing.

Describe the other assets:

Current value:

Amount you owe

on liens:

$_________________

16. Money or property due you?

Examples: Tax re

funds, past due

or lump sum alimon

spousal

support, child support,

maintenance, divorce or p

roperty

settlements, Social Security

benefits, workers’

compensation,

personal injur

y recovery

Who owes you the money or property?

___________________________________________

How much is owed?

$_________________

Do you believe you will likely receive

payment in the next 180 days?

 No

 Yes. Explain:

Part 4: Answer These Additional Questions

17. Have you paid anyone for

services for this case, including

filling out this applicatio

n, the

bankr

uptcy filing package, or th

sched

ules?

 No

 Yes. Whom did you pay? Check all that apply:

 An attorney

 A bankruptcy petition preparer, paralegal, or typing service

 Someone else ________________________________________

How much did you pay?

$______________________

18. Have you promised to pay or do

you expect to pay someone fo

ser

vices for your bankruptcy

case?

 No

 Yes. Whom do you expect to pay? Check all that apply:

 An attorney

 A bankruptcy petition preparer, paralegal, or typing service

 Someone else _________________________________________

How much do you

expect to pay?

$_______________________

19. Has anyone paid someone on

your behalf for services for this

case?

 No

 Yes. Who was paid on your behalf?

Check all that apply:

 An attorney

 A bankruptcy petition preparer,

paralegal, or typing service

 Someone else _________________

Who paid?

Check all that apply:

 Parent

 Brother or sister

 Friend

 Pastor or clergy

 Someone else __________

How much did

someone else pay?

$______________________

20. 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

Part 5: Sign Below

By signing here under penalty of perjury, I declare that I cannot afford to pay the filing fee either in full or in installments. I also declare

that the information I provided in this application is true and correct.

_____________________________________________ _____________________________________________

Signature of Debtor 1 Signature of Debtor 2

Date __________________ Date __________________

MM / DD / YYYY MM / DD / YYYY

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 m

ust 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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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

benef

it under the Social Security Act. Also, except as stated in the next sentence,

not

include any compensation, pension, pay, annuity, or allowance paid by t

nited 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

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 Unit

tates 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

olumn. 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).

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.

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 3

Part 3: Sign Below

By signing here, I declare under penalty of perjury that the information on this statement and in any attachments is true and correct.

__________________________________________________________  ______________________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

If you checked line 14a, do NOT fill out or file Form 122A–2.

If you checked line 14b, fill out Form 122A–2 and file it with this form.

¯¯¯¯¯

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