Fill in this information to identify your case: Debtor 1 Debtor 2 __________________________________________________________________ First Name Middle Name Last Name (Spouse, if filing) First Name ________________________________________________________________ Middle Name Last Name ______________________ District of __________ United States Bankruptcy Court for the: ___________________________ District of ________ Case number _____________________________________________ (If known) Check if this is an amended filing Official Form 103A Application for Individuals to Pay the Filing Fee in Installments Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. Part 1: Select Your Chapter 12/15 Which chapter of the Bankruptcy Code are you choosing to file under? Chapter 7 Chapter 11 Chapter 12 Chapter 13 Part 2: Sign Below By signing here, you state that you are unable to pay the full filing fee at once, that you want to pay the fee in installments, and that you understand that: You must pay your entire filing fee before you make any more payments or transfer any more property to an attorney, bankruptcy petition preparer, or anyone else for services in connection with your bankruptcy case. If you do not pay the filing fee in full, then you will not receive a discharge or your debts when your bankruptcy case is closed. Your discharge, or confirmation of any plan, will be delayed until the filing fee is paid in full. If you do not make any payment when it is due, your bankruptcy case may be dismissed or closed without discharge, and your rights in other bankruptcy proceedings may be affected. The Clerk's Office will set the terms for payment of the filing fee, and the number of installments shall not exceed four (4). The final installment shall be payable not later than 120 days after filing the petition. _________________________________ ___________________________________ Signature of Debtor 1 Signature of Debtor 2 Date _________________ MM / DD / YYYY Date ________________ MM / DD / YYYY _______________________________________ Your attorney's name and signature, if you used one Date _________________ MM / DD / YYYY EDC 2-020 (Revised 12/15) Application for Individuals to Pay the Filing Fee in Installments American LegalNet, Inc. www.FormsWorkFlow.com