Official Form 103a - Application Form For Individuals To Pay The Filing Fee In Installments
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1
2Fill 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
__________
United States Bankruptcy Court for the:
District of ___________
___________________________ District of ________
Case number
___________________________________________
(If known)
Check if this is an
amended filing
B 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
Chapter 7
Which chapter of the Bankruptcy Code
1.
are you choosing to file under?
Chapter 11
Chapter 12
Chapter 13
You may apply to pay the filing fee in up to
2.
four installments. Fill in the amounts you
You propose to pay…
propose to pay and the dates you plan to
pay them. Be sure all dates are business
With the filing of the
days. Then add the payments you propose
$_____________
petition
______________
to pay.
On or before this date ........
MM
/ DD / YYYY
You must propose to pay the entire fee no
later than 120 days after you file this
$_____________
______________
bankruptcy case. If the court approves your
On or before this date ...........
MM
/ DD / YYYY
application, the court will set your final
payment timetable.
______________
$_____________
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
B 103A (Official Form 103A)
Application for Individuals to Pay the Filing Fee in Installments
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