Official Form 106c - Schedule C: The Property You Claim As Exempt - 2016
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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
___________________________________________
Check if this is an
(If known)
amended filing
Official Form 106C
Schedule C: The Property You Claim as Exempt
04/16
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information.
Using the property you listed on Schedule A/B: Property (Official Form 106A/B) as your source, list the property that you claim as exempt. If more
space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On the top of any additional pages, write
your name and case number (if known).
For each item of property you claim as exempt, you must specify the amount of the exemption you claim. One way of doing so is to state a
specific dollar amount as exempt. Alternatively, you may claim the full fair market value of the property being exempted up to the amount
of any applicable statutory limit. Some exemptions—such as those for health aids, rights to receive certain benefits, and tax-exempt
retirement funds—may be unlimited in dollar amount. However, if you claim an exemption of 100% of fair market value under a law that
limits the exemption to a particular dollar amount and the value of the property is determined to exceed that amount, your exemption
would be limited to the applicable statutory amount.
Part 1:
Identify the Property You Claim as Exempt
1. Which set of exemptions are you claiming? Check one only, even if your spouse is filing with you.
You are claiming state and federal nonbankruptcy exemptions. 11 U.S.C. § 522(b)(3)
You are claiming federal exemptions. 11 U.S.C. § 522(b)(2)
2. For any property you list on Schedule A/B that you claim as exempt, fill in the information below.
Brief description of the property and line on
Current value of the
Amount of the exemption you claim
Specific laws that allow exemption
Schedule A/B that lists this property
portion you own
Check only one box for each exemption.
Copy the value from
Schedule A/B
Brief
____________________________
_________________________
$________________
$ ____________
description:
____________________________
100% of fair market value, up to
____________________________
Line from
____________________________
any applicable statutory limit
______
Schedule A/B:
Brief
____________________________
_________________________
$________________
$ ____________
description:
____________________________
____________________________
100% of fair market value, up to
Line from
______
____________________________
any applicable statutory limit
Schedule A/B:
Brief
____________________________
_________________________
$________________
$ ____________
description:
____________________________
____________________________
100% of fair market value, up to
Line from
____________________________
any applicable statutory limit
Schedule A/B: ______
3. Are you claiming a homestead exemption of more than $160,375?
(Subject to adjustment on 4/01/19 and every 3 years after that for cases filed on or after the date of adjustment.)
No
Yes. Did you acquire the property covered by the exemption within 1,215 days before you filed this case?
No
Yes
Official Form 106C
Schedule C: The Property You Claim as Exempt
page 1 of __
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