Official Form 122b - Chapter 11 Statement Of Your Current Monthly Income
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1
2Fill in this information to identify your case:
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
_________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
______________________
__________
United States Bankruptcy Court for the:
District of
(State)
Case number
___________________________________________
(If known)
Check if this is an amended filing
Official Form 122B
Chapter 11 Statement of Your Current Monthly Income
12/15
You must file this form if you are an individual and are filing for bankruptcy under Chapter 11. 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).
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. Fill out Column A, lines 2-11.
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
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
Official Form 122B
Chapter 11 Statement of Your Current Monthly Income
page 1
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