Annual Statement Pursuant To 11 U.s.c. 521(F) And (G)
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2Annual Statement Pursuant to 11 U.S.C. § 521(f) and (g)
th
This form should be completed by April 15
each year and submitted to:
RICK A. YARNALL
CHAPTER 13 BANKRUPTCY TRUSTEE
701 Bridger Ave., Suite 820
Las Vegas, Nevada 89101
Phone (702) 853-4500 Fax (702) 853-4513
Debtor Name(s): ______________________________________
Case No.: __________________
Date: ____________
A. Does anyone else share responsibility for the support of your dependents?
Yes. [On a separate page, identify the individual and their support responsibilities.]
No.
B.
Does anyone else contribute financially to your household?
Yes. [On a separate page, identify the individual, your relationship with the individual, and describe the amount and type of support
provided.]
No.
C. Current monthly income: The column labeled “Spouse” must be completed in all cases filed by joint debtors and by every married debtor,
whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed. Do not state the name of any minor child.
Debtor’s Marital
DEPENDENTS OF DEBTOR AND SPOUSE
Status:
RELATIONSHIP(S):
AGE(S):
Employment
DEBTOR
SPOUSE
Name of Employer(s)
How long employed
Address of Employer
INCOME: (Estimate of average monthly income at the time this statement is submitted)
DEBTOR
SPOUSE
1.
Monthly gross wages, salary, tips, and commissions
$__________________
$__________________
(Prorate if not paid monthly)
2.
Estimate monthly overtime
$__________________
$__________________
3.
SUBTOTAL
$__________________
$__________________
4.
LESS PAYROLL DEDUCTIONS
a.
Payroll taxes and social security
$__________________
$__________________
b.
Insurance
$__________________
$__________________
c.
Union dues
$__________________
$__________________
d.
Other (Specify): ________________________________________
$__________________
$__________________
5.
SUBTOTAL OF PAYROLL DEDUCTIONS
$__________________
$__________________
6.
TOTAL NET MONTHLY TAKE HOME PAY
$__________________
$__________________
7.
Regular income from operation of business or profession or farm
$__________________
$__________________
(Attach detailed statement)
8.
Income from real property
$__________________
$__________________
9.
Interest and dividends
$__________________
$__________________
10.
Alimony, maintenance or support payments payable to the debtor for
the debtor’s use or that of dependents listed above
$__________________
$__________________
11.
Social security or government assistance
(Specify): ___________________________________________
$__________________
$__________________
12.
Pension or retirement income
$__________________
$__________________
13.
Other monthly income
(Specify): _____________________________________________
$__________________
$__________________
14.
SUBTOTAL OF LINES 7 THROUGH 13
$__________________
$__________________
15.
AVERAGE MONTHLY INCOME (Add amounts on lines 6 and 14)
$__________________
$__________________
16.
COMBINED AVERAGE MONTHLY INCOME:
$__________________
(Combine column totals from line 15)
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