Chapter 13 - Debtor'S Statement Under Penalty Of Perjury Form
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2MOID MODR MOCDR SSCARD INS PAYSTUB W2
MOID MODR MOCDR SSCARD INS PAYSTUB W2
CHAPTER 13
DEBTOR'S STATEMENT UNDER PENALTY OF PERJURY
REVISION DATE: 1-15
PLEASE READ AND ANSWER EVERY QUESTION CAREFULLY. CHECK THE APPROPRIATE ANSWER IF MULTIPLE CHOICE.
IF BLANK, PLEASE FILL IN EVERY BLANK. IF NOT APPLICABLE OR NONE, WRITE "NONE" OR "0" IN THE BLANK.
DEBTOR
SPOUSE OR JOINT DEBTOR
NAME: ______________________________
NAME: ______________________________
ADDRESS:______________________________
ADDRESS:______________________________
EMPLOYER_____________________________
EMPLOYER_____________________________
EMPLOYER ADDRESS:___________________________
EMPLOYER ADDRESS:___________________________
______________________
___________________
How long at this job?
How long at this job?
A
A
re you paid hourly, salary or in some other way? (Please check one)
re you paid hourly, salary or in some other way? (Please check one)
□
:
___________ $____________
□
:
___________ $____________
HOURLY
HOURLY
HOURS PER WEEK
HOURLY RATE
HOURS PER WEEK
HOURLY RATE
□
:
$___________________________
□
:
$_________________________
SALARY
SALARY
MONTHLY SALARY
MONTHLY SALARY
□
:
$___________________________
□
:
$_________________________
OTHER
OTHER
MONTHLY AMOUNT
MONTHLY AMOUNT
________________________________________________
________________________________________________
DESCRIBE
DESCRIBE
Do you have a second job or other income?
Do you have a second job or other income?
□
□
□
□
Yes
No
Yes
No
______________________________________
______________________________________
.
.
Describe source and amount
Describe source and amount
□ MARRIED ____ YEARS: □ Living with Spouse
OR □ Separated for _____ years.
□ OTHER: (
AND
)
CHECK ONE BOX IN FIRST COLUMN
ONE BOX IN SECOND COLUMN
□ SINGLE
□
SHARE EXPENSES WITH ANOTHER ADULT
□ DIVORCED FOR ________ YEARS
□ WIDOWED
□
LIVE ALONE OR ONLY WITH MINOR CHILDREN
CHILDREN (
)
LIST NUMBER OF CHILDREN IN EACH CATEGORY AND AGE OF EACH CHILD
(USE ONLY SECTION THAT MATCHES YOUR CURRENT MARITAL STATUS)
MARRIED DEBTOR(S):
CHILDREN OF THIS MARRIAGE LIVING WITH YOU:___________________________________________
HUSBAND'S CHILDREN LIVING WITH YOU __________________________________________________
WIFE'S CHILDREN LIVING WITH YOU ______________________________________________________
HUSBAND’S CHILDREN NOT LIVING WITH YOU _____________________________________________
WIFE’S CHILDREN NOT LIVING WITH YOU _________________________________________________
UNMARRIED DEBTOR:
CHILDREN LIVING WITH YOU _____________________________________________________________
CHILDREN NOT LIVING WITH YOU _________________________________________________________
CHILD SUPPORT PAID: $_____________ PER MONTH.
CURRENT WHEN PETITION FILED?______ IF NOT CURRENT, ARREARS DUE AT TIME PETITION
FILED $___________________
CHILD SUPPORT RECEIVED: $___________________ PER MONTH
I AM REQUIRED BY COURT OR ADMINISTRATIVE ORDER OR STATUTE TO PAY SUPPORT:
YES
NO
(CIRCLE ONE)
I HAVE MADE ALL SUPPORT PAYMENTS DUE AFTER THE DATE MY PETITION WAS FILED:
YES
NO
(CIRCLE ONE)
NAME/ADDRESS/PHONE NUMBER OF PERSON WHO RECEIVES SUPPORT:
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