Fill in this information to identify your case:
(Spouse, if filing)
United States Bankruptcy Court for the
Check if this is an
Application for Waiver of the Appellate Filing Fee in a
Chapter 7 Case
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
Tell the Court About Your Family and Your Family’s Income
What is the size of your family?
Check all that apply:
Your family includes you, your
spouse, and any dependents listed
on Schedule J: Your Expenses
(Official Form 106J).
How many dependents?
Total number of people
Fill in your family’s average
That person’s average
monthly net income
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
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
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.
Subtract any non-cash governmental assistance that you
Your family’s average monthly net income
Type of assistance
Do you receive non-cash
Yes. Describe. ...........
Do you expect your family’s
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
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.
This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central Distict of California.