Application he Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Part 1: Tell the Court About Your Family and Your Family222s Income 1. What is the size of your family?Your family includes you, yourspouse, and any dependents listedon Schedule J: Your Expenses(Official Form 106J). Check all that apply: You Your spouse Your dependents How many dependents? Total number of people 2. Fill in your family222s averagemonthly income.Include your spouse222s income ifyour spouse is living with you, evenif your spouse is not filing.Do not include your spouse222sincome if you are separated andyour spouse is not filing with you. That person222s average monthly net income (take-home pay) Add your income and your spouse222s income. Include the value (if known) of any non-cash governmental assistance that you receive, such as food stamps (benefits under the Supplemental Nutrition Assistance Program) or housing subsidies. If you have already filled out Schedule I: Your Income, see line 10 of that schedule. You .................. $ Your spouse ....+ $ Subtotal ............. $ Subtract any non-cash governmental assistance that you included above. 226$ Your family222s average monthly net income Total .................. $ 3. Do you receive non-cashgovernmental assistance?NoYes. Describe. ...........Type of assistance 4. Do you expect your family222saverage monthly net income toincrease or decrease by more than10% during the next 6 months?NoYes. Explain. ............. 5. Tell the court why you are unable to pay the filing fee ininstallments within 120 days. If you have some additionalcircumstances that cause you to not be able to pay your filingfee in installments, explain them. 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 Case number (If known) Fill in this information to identify your case: Check if this is anamended filing Debtor 1 Case number (if known) First Name Middle Name Last Name Part 2: Tell the Court About Your Monthly Expenses 6. Estimate your average monthly expenses.Include amounts paid by any government assistance that youreported on line 2.If you have already filled out Schedule J, Your Expenses, copyline 22 from that form.$ 7. Do these expenses cover anyonewho is not included in your familyas reported in line 1? No Yes. Identify who ........ 8. Does anyone other than youregularly pay any of theseexpenses?If you have already filled outSchedule I: Your Income, copy thetotal from line 11.No Yes. How much do you regularly receive as contributions? $ monthly 9. Do you expect your averagemonthly expenses to increase ordecrease by more than 10% duringthe next 6 months? No Yes. Explain ................ Part 3: Tell the Court About Your Property If you have already filled out Schedule A/B: Property (Official Form 106A/B) attach copies to this application and go to Part 4. 10. How much cash do you have?Examples: Money you have inyour wallet, in your home, and onhand when you file this application Cash: $ 11. Bank accounts and other depositsof money?Examples: Checking, savings,money market, or other financialaccounts; certificates of deposit;shares in banks, credit unions,brokerage houses, and othersimilar institutions. If you havemore than one account with thesame institution, list each. Do notinclude 401(k) and IRA accounts. Institution name: Checking account: Savings account: Other financial accounts: Other financial accounts: Amount: $ $ $ $ 12. Your home? (if you own it outright orare purchasing it)Examples: House, condominium,manufactured home, or mobile home Number Street City State ZIP Code Current value: Amount you owe on mortgage and liens: $ $ 13. Other real estate? Number Street City State ZIP Code Current value: Amount you owe on mortgage and liens: $ $ 14. The vehicles you own?Examples: Cars, vans, trucks,sports utility vehicles, motorcycles,tractors, boats Make: Model: Year: Mileage Current value: Amount you owe on liens: $ $ Make: Model: Year: Mileage Current value: Amount you owe on liens: $ $ Debtor 1 Case number (if known) First Name Middle Name Last Name 15. Other assets?Do not include household itemsand clothing. Describe the other assets: Current value: Amount you owe on liens: $ $ 16. Money or property due you?Examples: Tax refunds, past dueor lump sum alimony, spousalsupport, child support,maintenance, divorce or propertysettlements, Social Securitybenefits, workers222 compensation,personal injury recovery Who owes you the money or property? How much is owed? $ $ Do you believe you will likely receive payment in the next 180 days? No Yes. Explain: Part 4: Answer These Additional Questions 17. Have you paid anyone forservices for this case, includingfilling out this application, thebankruptcy filing package, or theschedules? No Yes. Whom did you pay? Check all that apply: An attorney A bankruptcy petition preparer, paralegal, or typing service Someone else How much did you pay? $ 18. Have you promised to pay or doyou expect to pay someone forservices for your bankruptcycase? No Yes. Whom do you expect to pay? Check all that apply: An attorney A bankruptcy petition preparer, paralegal, or typing service Someone else How much do you expect to pay? $ 19. Has anyone paid someone onyour behalf for services for thiscase? No Yes. Who was paid on your behalf? Check all that apply: An attorney A bankruptcy petition preparer, paralegal, or typing service Someone else Who paid? Check all that apply: Parent Brother or sister Friend Pastor or clergy Someone else How much did someone else pay? $ 20. Have you filed for bankruptcywithin the last 8 years? No Yes. District When Case number MM/ DD/ YYYY District When Case number MM/ DD/ YYYY District When Case number MM/ DD/ YYYY Part 5: Sign Below By signing here under penalty of perjury, I declare that I cannot afford to pay the filing fee either in full or in installments. I also declare that the information I provided in this application is true and correct. Signature of Debtor 1 Signature of Debtor 2 Date Date MM / DD / YYYY MM / DD / YYYY