Annual Statement Pursuant To 11 U.s.c. 521(F) And (G) (Page 2 of 2) in pdf

D. Current Monthly Expenses: Complete this schedule by estimating the average monthly expenses of the debtor and the debtor’s family at the

time this statement is submitted. Prorate any payments made bi- weekly, quarterly, semi-annually, or annually to show monthly rate.

Check this box if a joint petition is filed and debtor’s spouse maintains a separate household. Complete a separate schedule of expenditures labeled “Spouse.”

Rent or home mortgage payment (include lot rented for mobile home)

$_____________

Are real estate taxes included?

Yes _____ No _____

Is property insurance included?

Yes _____ No _____

Utilities: a. Electricity and heating fuel

$_____________

Water and sewer

$_____________

Telephone

$_____________

Other

$_____________

Home maintenance (repairs and upkeep)

$_____________

Food

$_____________

Clothing

$_____________

Laundry and dry cleaning

$_____________

Medical and dental expenses

$_____________

Transportation (not including car payments)

$_____________

Recreation, clubs and entertainment, newspapers, magazines, etc.

$_____________

10.

Charitable contributions

$_____________

11.

Insurance (not deducted from wages or included in home mortgage payments)

a. Homeowner’s or renter’s

$_____________

b. Life

$_____________

c. Health

$_____________

d. Auto

$_____________

e. Other: ____________________________________________________

$_____________

12.

Taxes (not deducted from wages or included in home mortgage payments)

$_____________

(Specify) _____________________________________________________________

13.

Installment payments: (do not list payments to be included in the plan)

Auto

$_____________

Other: ________________________________________________

$_____________

Other: ________________________________________________

$_____________

14.

Alimony, maintenance, and support paid to others

$_____________

15.

Payments for support of additional dependents not living at your home

$_____________

16.

Regular expenses from operation of business, profession, or farm (attach detailed statement)

$_____________

17.

Other: ____________________________________________________

$_____________

18.

AVERAGE MONTHLY EXPENSES (Total lines 1-17)

$_____________

19.

Describe any increase or decrease in income and/or expenditures reasonably anticipated to occur within the year following the completion of this document:

20.

STATEMENT OF MONTHLY NET INCOME

Average monthly income from section C line 15.

$_____________

Average monthly expenses from section D line 18.

$_____________

Monthly net income (a. minus b.)

$_____________

Declaration Under Penalty of Perjury by Debtor(s)

By signing below, I/we declare under penalty of perjury that the information provided is true and correct to the best

of my/our knowledge and belief.

Debtor 1: