Official Form 122b - Chapter 11 Statement Of Your Current Monthly Income Page 2
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1
2_______________________________________________________
Case number
_____________________________________
Debtor 1
(if known)
First Name
Middle Name
Last Name
Column A
Column B
Debtor 1
Debtor 2
7. Interest, dividends, and royalties
$____________
$__________
8. Unemployment compensation
$____________
$__________
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...........................................................
$_________
9. Pension or retirement income. Do not include any amount received that was a
benefit under the Social Security Act.
$__________
$____________
10. Income from all other sources not listed above. Specify the source and amount.
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 below.
$__________
________________________________________
$____________
$__________
________________________________________
$____________
+
+
Total amounts from separate pages, if any.
$____________
$__________
11. Calculate your total current monthly income.
+
=
Add lines 2 through 10 for each column.
Then add the total for Column A to the total for Column B.
$_______
$____________
$_________
Total current
monthly income
Part 2:
Sign Below
By signing here, under penalty of perjury I declare that the information on this statement and in any attachments is true and correct.
______________________________________
______________________________________________
Signature of Debtor 1
Signature of Debtor 2
_________________
_________________
Date
Date
MM / DD
/ YYYY
MM / DD
/ YYYY
Official Form 122B
Chapter 11 Statement of Your Current Monthly Income
page 2
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