Official Form 103b - Application To Have The Chapter 7 Filing Fee Waived
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1
2
3
4Fill in this information to identify your case:
Debtor 1
________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
__________ District of __________
__________
United States Bankruptcy Court for the:
District of ___________
Case number
___________________________________________
Check if this is an
(If known)
amended filing
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
What is the size of your family?
Check all that apply:
1.
Your family includes you, your
You
spouse, and any dependents listed
on Schedule J: Your Expenses
Your spouse
(Official Form 106J).
_____________________
Your dependents
___________________
How many dependents?
Total number of people
Fill in your family’s average
2.
That person’s average
monthly income.
monthly net income
(take-home pay)
Include your spouse’s income if
your spouse is living with you, even
Add your income and your spouse’s income. Include the
if your spouse is not filing.
value (if known) of any non-cash governmental assistance
You ..................
$_________________
that you receive, such as food stamps (benefits under the
Do not include your spouse’s
Supplemental Nutrition Assistance Program) or housing
income if you are separated and
subsidies.
+
your spouse is not filing with you.
Your spouse ....
$_________________
If you have already filled out Schedule I: Your Income, see
line 10 of that schedule.
Subtotal .............
$_________________
Subtract any non-cash governmental assistance that you
–
$_________________
included above.
Total ..................
Your family’s average monthly net income
$_________________
Type of assistance
Do you receive non-cash
3.
No
governmental assistance?
Yes. Describe. ...........
Do you expect your family’s
4.
No
average monthly net income to
Yes. Explain. .............
increase or decrease by more than
10% during the next 6 months?
Tell the court why you are unable to pay the filing fee in
5.
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.
Official Form 103B
Application to Have the Chapter 7 Filing Fee Waived
page 1
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