Official Form 106i - Schedule I: Your Income Page 2
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1
2Debtor 1
_______________________________________________________
Case number
_____________________________________
(if known)
First Name
Middle Name
Last Name
For Debtor 1
For Debtor 2 or
non-filing spouse
Copy line 4 here ...............................................................................................
4.
$___________
$_____________
List all payroll deductions:
5.
5a. Tax, Medicare, and Social Security deductions
5a.
$_____________
$____________
5b. Mandatory contributions for retirement plans
5b.
$____________
$_____________
5c. Voluntary contributions for retirement plans
5c.
$____________
$_____________
5d. Required repayments of retirement fund loans
5d.
$____________
$_____________
5e. Insurance
5e.
$____________
$_____________
5f. Domestic support obligations
5f.
$____________
$_____________
$____________
$_____________
5g. Union dues
5g.
+
+
5h. Other deductions. Specify: __________________________________
5h.
$____________
$_____________
Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h.
6.
6.
$____________
$_____________
Calculate total monthly take-home pay. Subtract line 6 from line 4.
7.
$____________
$_____________
7.
List all other income regularly received:
8.
8a. Net income from rental property and from operating a business,
profession, or farm
Attach a statement for each property and business showing gross
receipts, ordinary and necessary business expenses, and the total
$____________
$_____________
monthly net income.
8a.
8b. Interest and dividends
8b.
$_____________
$____________
8c. Family support payments that you, a non-filing spouse, or a dependent
regularly receive
Include alimony, spousal support, child support, maintenance, divorce
$____________
$_____________
settlement, and property settlement.
8c.
$____________
$_____________
8d. Unemployment compensation
8d.
8e. Social Security
8e.
$____________
$_____________
8f. Other government assistance that you regularly receive
Include cash assistance and the value (if known) of any non-cash assistance
that you receive, such as food stamps (benefits under the Supplemental
Nutrition Assistance Program) or housing subsidies.
$____________
$_____________
Specify: ___________________________________________________
8f.
8g. Pension or retirement income
8g.
$____________
$_____________
+
+
8h. Other monthly income. Specify: _______________________________
8h.
$____________
$_____________
Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h.
9.
$_____________
9.
$____________
Calculate monthly income. Add line 7 + line 9.
10.
+
=
$_____________
$___________
$_____________
Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse.
10
.
State all other regular contributions to the expenses that you list in Schedule J.
11.
Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and other
friends or relatives.
Do not include any amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J.
+
Specify: _______________________________________________________________________________
11.
$_____________
Add the amount in the last column of line 10 to the amount in line 11. The result is the combined monthly income.
12.
$_____________
Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies
12.
Combined
monthly income
Do you expect an increase or decrease within the year after you file this form?
13.
No.
Yes. Explain:
Official Form 106I
Schedule I: Your Income
page 2
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