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Debtor 1

_______________________________________________________

Case number

_____________________________________

(if known)

First Name

Middle Name

Last Name

Column A

Column B

Debtor 1

Debtor 2 or

non-filing spouse

Interest, dividends, and royalties

$____________

$__________

$____________

$__________

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 ...........................................................

$_____________

Pension or retirement income. Do not include any amount received that was a

$____________

$__________

benefit under the Social Security Act.

Income from all other sources not listed above. Specify the source and amount.

10.

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 on line 10c.

$_____________

$___________

10a. __________________________________________________________________

$_____________

$___________

10b. __________________________________________________________________

Total amounts from separate pages, if any.

10c.

$____________

$__________

Calculate your total average monthly income. Add lines 2 through 10 for each

11.

$____________

$___________

$________

column. Then add the total for Column A to the total for Column B.

Total average

monthly income

Part 2:

Determine How to Measure Your Deductions from Income

Copy your total average monthly income from line 11.

12.

......................................................................................................................

$_____________

Calculate the marital adjustment. Check one:

13.





You are not married. Fill in 0 in line 13d.





You are married and your spouse is filing with you.

Fill in 0 in line 13d.



You are married and your spouse is not filing with you.

Fill in the amount of the income listed in line 11, Column B, that was NOT regularly paid for the household expenses of you

or your dependents,

such as payment of the spouse’s tax liability or the spouse’s support of someone other than you or



your dependents.

In lines 13a-c, specify the basis for excluding this income and the amount of income devoted to each purpose. If

necessary, list additional adjustments on a separate page



If this adjustment does not apply, enter 0 on line 13d.

13a. _______________________________________________________________________

$___________

13b. _______________________________________________________________________

13c. _______________________________________________________________________

$___________

─

Total .................................................................................................................



13d.

$___________

____________

Copy here.

13d

Your current monthly income. Subtract line 13d from line 12.

$ __________

14.

Calculate your current monthly income for the year. Follow these steps:

15.



$ ____________

Copy line 14 here

.........................................................................................................................................................

15a.

x 12

Multiply line 15a by 12 (the number of months in a year).

The result is your current monthly income for the year for this part of the form.

15b.

$___________

Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period

page 2

Official Form B 22C1

Official Form B 22c1 - Chapter 13 Statement Of Your Current Monthly Income And Calculation Of Commitment Period Page 3

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