1/06 Local Form #10 Mon th of CHAPTER 12 CASE NAME OF DEB TOR: MONTHLY CASH RECEIPTS AND DISBURSEMENTS (Report on a cash basis, unless you keep financial records on an accrual basis) I. Cash Received During Month (Itemize): Item & Quantity Sold $ Amount , 20 New loan r eceiv ed thi s mon th (if an y) Wages earned from o utside work Other receipts: TOTAL CASH RECEIPTS II. Expenses Paid : Total amount paid for household or living expense Item $ Amount $ $ American LegalNet, Inc. www.USCourtForms.com Plan payments made to Chapter 12 Trustee TOTAL EXPENSES PAID DURING MONTH Losses due to crop failure o r damage Losses due to death or disease of livestock or poultry PROFIT (OR LOSS) FOR MONTH III. Cash Reconciliation: Cash and Bank Accoun ts Balance at beginning of Month: Income (or Loss) During M onth Cash and Ba nk Accoun t Balance at End of M onth IV. $ $ $ $ $ $ $ $ Expenses Charged But Not Paid During Month (Itemize) Item $ Amount I CERTIFY UNDER PENALTY OF PERJURY THAT I HAVE READ THE FOREGOING STATEMENT, AND IT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDG E, INFORMATION, AND BELIEF. Date Debtor/Officer of Debtor American LegalNet, Inc. www.USCourtForms.com