Form 1006-1.1 - Supplemental Income And Expense Information For Fee Waiver Application

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R.I. Bankr. Form 1006-1.1
UNITED STATES BANKRUPTCY COURT
FOR THE DISTRICT OF RHODE ISLAND
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - x
In re:
:
BK No.
:
Chapter
:
:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - x
SUPPLEMENTAL INCOME AND EXPENSE INFORMATION
FOR FEE WAIVER APPLICATION
In order for the Court to consider and act on an Application for Waiver of the Chapter 7 Filing Fee, the debtor(s)
must also file Schedules I and J with the Application, in addition to this supplemental income and expense form.
A.
SOURCE OF INCOME OF INDIVIDUAL DEBTOR(S)
1. Source of income (i.e., wages, commissions, social security, unemployment, disability, pension).
.
2. If the attorney, petition preparer or other person or entity was paid to represent the debtor(s) in this
bankruptcy case, provide the source of the payment to the attorney (i.e., wages, social security,
unemployment, borrowed funds - such as from a friend or relative).
________________________________________________________________________ _
.
B.
CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S)
1. Recreation, clubs and entertainment, newspapers, magazines, etc.
List each specific recreation item separately and the monthly expense:
__________________________
$_________
__________________________
$_________
__________________________
$_________
__________________________
$_________
DECLARATION CONCERNING DEBTOR=S SUPPLEMENTAL INCOME AND EXPENSE ADDENDUM
DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR
I (we) declare under penalty of perjury that I (we) cannot currently afford to pay the filing fee in full or in installments and that
the foregoing information is true and correct. I (we) further declare under penalty of perjury that I(we) have read the foregoing
expense information and that it is true and correct to the best of my knowledge, information, and belief.
Date
Signature _________________________
Debtor
Date _____________________
Signature _________________________
Joint Debtor, if any

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