Official Form 22c - Statement Of Current Monthly Income And Calculation Of Commitment Period And Disposable Income Page 6
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8B 22C (Official Form 22C) (Chapter 13) (12/10)
6
Health Insurance, Disability Insurance, and Health Savings Account Expenses. List the monthly
expenses in the categories set out in lines a-c below that are reasonably necessary for yourself, your spouse, or
your dependents.
a.
Health Insurance
$
39
b.
Disability Insurance
$
c.
Health Savings Account
$
Total and enter on Line 39
$
If you do not actually expend this total amount, state your actual total average monthly expenditures in the
space below:
$ ____________
Continued contributions to the care of household or family members. Enter the total average actual
monthly expenses that you will continue to pay for the reasonable and necessary care and support of an
40
elderly, chronically ill, or disabled member of your household or member of your immediate family who is
unable to pay for such expenses. Do not include payments listed in Line 34.
$
Protection against family violence. Enter the total average reasonably necessary monthly expenses that you
41
actually incur to maintain the safety of your family under the Family Violence Prevention and Services Act or
other applicable federal law. The nature of these expenses is required to be kept confidential by the court.
$
Home energy costs. Enter the total average monthly amount, in excess of the allowance specified by IRS
Local Standards for Housing and Utilities that you actually expend for home energy costs. You must provide
42
your case trustee with documentation of your actual expenses, and you must demonstrate that the
$
additional amount claimed is reasonable and necessary.
Education expenses for dependent children under 18. Enter the total average monthly expenses that you
actually incur, not to exceed $147.92 per child, for attendance at a private or public elementary or secondary
43
school by your dependent children less than 18 years of age. You must provide your case trustee with
documentation of your actual expenses, and you must explain why the amount claimed is reasonable
$
and necessary and not already accounted for in the IRS Standards.
Additional food and clothing expense. Enter the total average monthly amount by which your food and
clothing expenses exceed the combined allowances for food and clothing (apparel and services) in the IRS
44
National Standards, not to exceed 5% of those combined allowances. (This information is available at
or from the clerk of the bankruptcy court.) You must demonstrate that the additional
$
amount claimed is reasonable and necessary.
Charitable contributions. Enter the amount reasonably necessary for you to expend each month on
45
charitable contributions in the form of cash or financial instruments to a charitable organization as defined in
26 U.S.C. § 170(c)(1)-(2). Do not include any amount in excess of 15% of your gross monthly income.
$
46
Total Additional Expense Deductions under § 707(b). Enter the total of Lines 39 through 45.
$
Subpart C: Deductions for Debt Payment
Future payments on secured claims. For each of your debts that is secured by an interest in property that
you own, list the name of the creditor, identify the property securing the debt, state the Average Monthly
Payment, and check whether the payment includes taxes or insurance. The Average Monthly Payment is the
total of all amounts scheduled as contractually due to each Secured Creditor in the 60 months following the
filing of the bankruptcy case, divided by 60. If necessary, list additional entries on a separate page. Enter the
total of the Average Monthly Payments on Line 47.
Name of Creditor
Property Securing the Debt
Average
Does payment
47
Monthly
include taxes
Payment
or insurance?
a.
$
yes
no
b.
$
yes
no
c.
$
yes
no
Total: Add
$
Lines a, b, and c
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