Official Form 122c-1 - Chapter 13 Statement Of Your Current Monthly Income And Calculation Of Commitment Period Page 2
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1
2
3Debtor 1
_______________________________________________________
Case number
_____________________________________
(if known)
First Name
Middle Name
Last Name
Column A
Column B
Debtor 1
Debtor 2 or
non-filing spouse
$____________
$__________
Interest, dividends, and royalties
7.
$____________
$__________
Unemployment compensation
8.
Do not enter the amount if you contend that the amount received was a benefit under
the Social Security Act. Instead, list it here: ..................................
For you .......................................................................
$_____________
For your spouse .........................................................
$_____________
Pension or retirement income. Do not include any amount received that was a
9.
$____________
$__________
benefit under the Social Security Act.
Income from all other sources not listed above. Specify the source and amount.
10.
Do not include any benefits received under the Social Security Act or payments
received as a victim of a war crime, a crime against humanity, or international or
domestic terrorism. If necessary, list other sources on a separate page and put the
total on line 10c.
$_____________
$___________
10a. __________________________________________________________________
$_____________
$___________
10b. __________________________________________________________________
+
+
Total amounts from separate pages, if any.
10c.
$____________
$__________
Calculate your total average monthly income. Add lines 2 through 10 for each
11.
+
=
$____________
$___________
$________
column. Then add the total for Column A to the total for Column B.
Total average
monthly income
Part 2:
Determine How to Measure Your Deductions from Income
Copy your total average monthly income from line 11.
12.
..........................................................................................................................
$_____________
Calculate the marital adjustment. Check one:
13.
You are not married. Fill in 0 in line 13d.
You are married and your spouse is filing with you. Fill in 0 in line 13d.
You are married and your spouse is not filing with you.
Fill in the amount of the income listed in line 11, Column B, that was NOT regularly paid for the household expenses of you
or your dependents, such as payment of the spouse’s tax liability or the spouse’s support of someone other than you or
your dependents.
In lines 13a-c, specify the basis for excluding this income and the amount of income devoted to each purpose. If
.
necessary, list additional adjustments on a separate page
If this adjustment does not apply, enter 0 on line 13d.
13a. _______________________________________________________________________
$___________
$___________
13b. _______________________________________________________________________
+
13c. _______________________________________________________________________
$___________
─
Total .............................................................................................................
13d.
$___________
____________
.
13d
Copy here.
Your current monthly income. Subtract line 13d from line 12.
$ __________
14.
14.
Calculate your current monthly income for the year. Follow these steps:
15.
$ ____________
Copy line 14 here
.....................................................................................................................................................
15a.
15a.
x 12
Multiply line 15a by 12 (the number of months in a year).
The result is your current monthly income for the year for this part of the form.
15b.
15b.
$___________
Official Form 122C–1
Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period
page 2
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