1. Your family includes you, your spouse,and any dependents listed on ScheduleJ: (Official Form 6J) Check all that apply:[ ] You[ ] Your spouseHow manydependents: Total number ofpeople: [ ] Your dependents2.Include your spouse222s income ifyour spouse is living with you,even if your spouse is not filing.Do not include your spouse222sincome if you are separated andyour spouse is not filing with you.Add your income and yourspouse222s income. Include thevalue (if known) of any non-cash governmental assistancethat you receive, such as foodstamps (benefits under theSupplemental NutritionAssistance Program) orhousing subsidies.You . . . . . . . . . .That person222saverage monthlynet income (take-home pay)$ If you have already filled outSchedule I: Your Income, seeline 10 of that schedule.Your Spouse . . . +$ Subtotal . . . . . . .$ Subtract any non-casgovernmental assistance thatyou included above. (minus)$ Total . . . . . . . . . .$ American LegalNet, Inc. www.FormsWorkFlow.com 3.[ ] No[ ] Yes. DescribeType of Assistance:4.[ ] No[ ] Yes. Explain 5. If you have some additional circumstances thatcause you to not be able to pay your filing fee ininstallments, explain them. 6.Include amounts paid by any government assistance that you reported online 2.If you have already filled out Schedule J, Your Expenses, copy line 22 fromthat form.$ 7.[ ] No[ ] Yes. Identify who 8.If you have already filled outSchedule I: Your Income,copy the total from line 11.[ ] No[ ] Yes. How much do you regularly receiveas contributions?$ monthly American LegalNet, Inc. www.FormsWorkFlow.com 9.[ ] No[ ] Yes. Explain EITHER (1) attach completed cop of Schedule A: Property (Official Form 6A) OR (2) if you have not yet completedchedule, answer the following questions 10. Examples: Money you have in your wallet, in your home, and on hand whenyou file this application.Cash: $ 11.Examples: Checking,savings, money market, orother financial accounts;certificates of deposit;shares in banks, creditunions, brokerage houses,and other similar institutions.If you have more than oneaccount with the sameinstitution, list each. Do notinclude 401(k) or IRAaccounts.Institution name:Amount:Checking account:$ Savings account:$ Other financialaccounts:$ Other financialaccounts:$ 12.(if you own itoutright or are purchasing it)Examples: House,condominium, manufacturedhome, or mobile home Number StreetCurrentvalue:$ CityState ZIP CodeAmountyou oweonmortgageand liens:$ American LegalNet, Inc. www.FormsWorkFlow.com 13. Number StreetCurrentvalue:$ CityState ZIP CodeAmountyou oweonmortgageand liens:$ 14.Examples: Cars, vans,trucks, sports utility vehicles,motorcycles, tractors, boatsMake: Model: Year: Mileage: Current value:Amount you owe onliens:$ $ Make: Model: Year: Mileage: Current value:Amount you owe on liens:$ $ 15.Do not include householditems and clothing.Current value:$ Amount you owe onliens:$ 16.Examples: Tax refunds, pastdue or lump sum alimony,spousal support, childsupport, maintenance,divorce or propertysettlements, Social Securitybenefits, Workers222compensation, personalinjury recovery Enter thenames in the below boxes.Do you believe youwill likely receivepayment in the next180 days?$ [ ] No[ ] Yes. Explain in the box below$ American LegalNet, Inc. www.FormsWorkFlow.com 17.[ ] No [ ] YesCheck all that apply:[ ] An attorney[ ] A bankruptcy petition preparer, paralegal, or typing service[ ] Someone else: $ 18.[ ] No [ ] YesCheck all thatapply:[ ] An attorney[ ] A bankruptcy petition preparer, paralegal, or typing service[ ] Someone else: 19.[ ] No [ ] YesCheck all that apply:[ ] An attorney[ ] A bankruptcy petition preparer, paralegal, or typing service[ ] Someone else: Check allthat apply:[ ] Parent[ ] Brother or sister[ ] Friend[ ] Pastor or clergy[ ] Someone else: 20.[ ] No [ ] YesDistrict:When: MM/DD/YYYYCase Number: District:When: MM/DD/YYYYCase Number: District:When: MM/DD/YYYYCase Number: American LegalNet, Inc. www.FormsWorkFlow.com I (we) declare under penalty of perjury that I (we) cannot currently afford to pay the filing fee in full or in installmentsand that the foregoing information is true and correct.Dated:Signed: Signature of DebtorDated:Signed: Signature of Co-debtor If this document is prepared by a , the form 19, Bankruptcy Petition Preparer, must becompleted and submitted with this Application. American LegalNet, Inc. www.FormsWorkFlow.com