In re: Case No.: Debtor. (If known) DECLARATION OF CURRENT/ POST-PETITION INCOME Complete this statement by providing the monthly income of the debtor and the debtor’s spouse at this time. The column labeled “Spouse” must be completed in all cases filed by joint debtors and by every married debtor, whether or not a joint petition was filed, unless the spouses are separated and a joint petition was not filed. Do not state the name of any minor child. Debtor’s Marital Status: DEPENDENTS OF DEBTOR AND SPOUSE RELATIONSHIP(S) Employment: AGE(S) DEBTOR SPOUSE Occupation Name of Employer How Long Employed Address of Employer INCOME: DEBTOR SPOUSE 1. Monthly gross wages, salary, and commissions (Prorate if not paid monthly) $ _____________ $ _____________ 2. Estimate monthly overtime $ _____________ $ _____________ 3. SUBTOTAL $ _____________ $ _____________ 4. LESS PAYROLL DEDUCTIONS a. Payroll taxes and social security $ _____________ $ _____________ b. Insurance $ _____________ $ _____________ c. Union dues $ _____________ $ _____________ d. Other (specify) ______________________________________________________ $ _____________ $ _____________ SUBTOTAL OF PAYROLL DEDUCTIONS $ _____________ $ _____________ 6. TOTAL NET MONTHLY TAKE HOME PAY $ _____________ $ _____________ 7. Regular income from operation of business or profession or farm (attach detailed statement) $ _____________ $ _____________ 8. Income from real property $ _____________ $ _____________ 9. Interest and dividends $ _____________ $ _____________ 10. Alimony, maintenance or support payments payable to the debtor for the debtor’s use or that of dependents listed above. $ _____________ $ _____________ 11. Social security or other government assistance (Specify) ___________________________________________________________________ $ _____________ $ _____________ 12. Pension or retirement income $ _____________ $ _____________ 13. Other monthly income (Specify) ___________________________________________________________________ $ _____________ $ _____________ 14. SUBTOTAL OF LINES 7 THROUGH 13 $ _____________ $ _____________ 15. MONTHLY INCOME: (Add amounts shown on lines 6 and 14) $ _____________ $ _____________ 5. 16. COMBINED MONTHLY INCOME (Combine column totals from line 15) $ _____________ 17. Describe any increase or decrease in income reasonably anticipated to occur within the year following the filing of this document: ___________________________________________________________________________________________________________________ I declare under penalty of perjury that the foregoing is true and correct. Dated: _________________________ __________________________________________________ Debtor Dated: _________________________ __________________________________________________ Joint Debtor This form has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.20 In re Case No.: Debtor. (If known) DECLARATION OF CURRENT/ POST-PETITION EXPENSES Complete this statement by providing the monthly expenses of the debtor and the debtor’s family at this time. Prorate any payments made bi-weekly, quarterly, semi-annually, or annually to show monthly rate. □ Check this box if this is a joint case and debtor’s spouse maintains a separate household. Complete a Declaration of current/PostPetition Expenses labeled “Spouse.” 1. Rent or home mortgage payment (include lot rented for mobile home) a. Are real estate taxes included? b. Is property insurance included? Yes ________ Yes ________ $_____________ No ________ No ________ 2. Utilities: a. b. c. d. Electricity and heating fuel Water and sewer Telephone Other ___________________________________________________________________ $_____________ $_____________ $_____________ $_____________ 3. 4. 5. 6. 7. 8. 9. 10. 11. Home maintenance (repairs and upkeep) Food Clothing Laundry and dry cleaning Medical and dental expenses Transportation (not including car payments) Recreation, clubs and entertainment, newspapers, magazines, etc. Charitable contributions Insurance (not deducted from wages or included in home mortgage payments) a. Homeowner’s or renter’s b. Life c. Health d. Auto e. Other ______________________________________________________________________ Taxes (not deducted from wages or included in home mortgage payments) (Specify) ___________________________________________________________________________ Installment payments: (In chapter 11, 12, and 13 cases, do not list payments to be included in the plan) a. Auto b. Other _____________________________________________________________________ c. Other _____________________________________________________________________ Alimony, maintenance, and support paid to others Payments for support of additional dependents not living at your home Regular expenses from operation of business, profession, or farm (attach detailed statement) Other $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ 12. 13. 14. 15. 16. 17. $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ 18. MONTHLY EXPENSES (Total lines 1-17) $___________ 19. Describe any increase or decrease in expenditures reasonably anticipated to occur within the year following the filing of this document: _____________________________________________________________________________________ _______________________________________________________________________________________________________ 20. STATEMENT OF MONTHLY NET INCOME a. Total monthly income from Line 15 of Declaration of Current/Post-Petition Income b. Total monthly expenses from Line 18 above c. Monthly net income (a. minus b.) $_____________ $_____________ $_____________ I declare under penalty of perjury that the foregoing is true and correct. Dated: _________________________ ________________________________________________ Debtor Dated: _________________________ ________________________________________________ Joint Debtor This form has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.20 In re Case No.: Debtor. (If known) NOTE: When using this form to indicate service of a proposed order, DO NOT list any person or entity in Category I. Proposed orders do not generate an NEF because only orders that have been entered are placed on a CM/ECF docket. PROOF OF SERVICE OF DOCUMENT I am over the age of 18 and not a party to this bankruptcy case or adversary proceeding. My business address is: A true and correct copy of the foregoing document described as _____________________________________________ ______________________________________________________________________________ will be served or was served (a) on the judge in chambers in the form and manner required by LBR 5005-2(d), and (b) in the manner indicated below: I. TO BE SERVED BY THE COURT VIA NOTICE OF ELECTRONIC FILING (“NEF”) - Pursuant to controlling General Order(s) and Local Bankruptcy Rule(s) (“LBR”), the foregoing document will be served by the court via NEF and hyperlink to the document. On ________________________ I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the following person(s) are on the Electronic Mail Notice List to receive NEF transmission at the email addressed indicated below: ☐ Service information continued on attached page II. SERVED BY U.S. MAIL OR OVERNIGHT MAIL (indicate method for each person or entity served): On _________________________ I served the following person(s) and/or entity(ies) at the last known address(es) in this bankruptcy case or adversary proceeding by placing a true and correct copy thereof in a sealed envelope in the United States Mail, first class, postage prepaid, and/or with an overnight mail service addressed as follow. Listing the judge here constitutes a declaration that mailing to the judge will be completed no later than 24 hours after the document is filed. ☐ Service information continued on attached page III. SERVED BY PERSONAL DELIVERY, FACSIMILE TRANSMISSION OR EMAIL (indicate method for each person or entity served): Pursuant to F.R.Civ.P. 5 and/or controlling LBR, on _______________________ I served the following person(s) and/or entity(ies) by personal delivery, or (for those who consented in writing to such service method) by facsimile transmission and/or email as follows. Listing the judge here constitutes a declaration that mailing to the judge will be completed no later than 24 hours after the document is filed. ☐ Service information continued on attached page I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. _________________________________________________________ Date Type Name _____________________________________ Signature This form has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.20 In re Case No.: Debtor. (If known) ADDITIONAL SERVICE INFORMATION (if needed): This form has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.20