Official Form 122a1 - Chapter 7 Statement Of Your Current Monthly Income
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1
2Fill in this information to identify your case:
Check one box only as directed in this form and in
Form 122A-1Supp:
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
1. There is no presumption of abuse.
Debtor 2
________________________________________________________________
(Spouse, if filing)
2. The calculation to determine if a presumption of
First Name
Middle Name
Last Name
abuse applies will be made under Chapter 7
__________ District of __________
__________
United States Bankruptcy Court for the:
District of __________
Means Test Calculation (Official Form 122A–2).
3. The Means Test does not apply now because of
Case number
___________________________________________
(If known)
qualified military service but it could apply later.
Check if this is an amended filing
Official Form 122A─1
Chapter 7 Statement of Your Current Monthly Income
12/15
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more
space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any
additional pages, write your name and case number (if known). If you believe that you are exempted from a presumption of abuse because you
do not have primarily consumer debts or because of qualifying military service, complete and file Statement of Exemption from Presumption of
Abuse Under § 707(b)(2) (Official Form 122A-1Supp) with this form.
Part 1:
Calculate Your Current Monthly Income
1. What is your marital and filing status? Check one only.
Not married. Fill out Column A, lines 2-11.
Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11.
Married and your spouse is NOT filing with you. You and your spouse are:
Living in the same household and are not legally separated. Fill out both Columns A and B, lines 2-11.
Living separately or are legally separated. Fill out Column A, lines 2-11; do not fill out Column B. By checking this box, you declare
under penalty of perjury that you and your spouse are legally separated under nonbankruptcy law that applies or that you and your
spouse are living apart for reasons that do not include evading the Means Test requirements. 11 U.S.C. § 707(b)(7)(B).
Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this
bankruptcy case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through
August 31. If the amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6.
Fill in the result. Do not include any income amount more than once. For example, if both spouses own the same rental property, put the
income from that property in one column only. If you have nothing to report for any line, write $0 in the space.
Column A
Column B
Debtor 1
Debtor 2 or
non-filing spouse
2. Your gross wages, salary, tips, bonuses, overtime, and commissions
$_________
$__________
(before all payroll deductions).
3. Alimony and maintenance payments. Do not include payments from a spouse if
$_________
$__________
Column B is filled in.
4. All amounts from any source which are regularly paid for household expenses
of you or your dependents, including child support. Include regular contributions
from an unmarried partner, members of your household, your dependents, parents,
and roommates. Include regular contributions from a spouse only if Column B is not
$_________
$__________
filled in. Do not include payments you listed on line 3.
5. Net income from operating a business, profession,
Debtor 1
Debtor 2
or farm
$______
$______
Gross receipts (before all deductions)
–
–
Ordinary and necessary operating expenses
$______
$______
Copy
Net monthly income from a business, profession, or farm
$__________
$______
$______
$_________
here
6. Net income from rental and other real property
Debtor 1
Debtor 2
$______
$______
Gross receipts (before all deductions)
–
–
Ordinary and necessary operating expenses
$______
$______
Copy
Net monthly income from rental or other real property
$__________
$_________
$______
$______
here
7. Interest, dividends, and royalties
$__________
$_________
Official Form 122A-1
Chapter 7 Statement of Your Current Monthly Income
page 1
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