FLNB Local Form 27 (11/09) Case Number: Debtor Name(s): SUPPLEMENTAL DISCLOSURE TO SCHEDULES I AND/OR J REGARDING LISTED EXPENSES Check the applicable boxes and provide details as needed: Child Care: Disclose the category of the child's/children's age(s), if not indicated on the petition, and the type of child care received (e.g., infant to preschool, after school care, summer care and after school care). Life Insurance: Term Whole Life Home Maintenance Ͳ Describe debtor(s)' home and/or home maintenance needs (e.g., debtor has 25 year old roof with shingle problems; house is 50 years old with original appliances, etc.) Medical & Dental: Disclose extenuating circumstances such as "Debtor has medical problems including diabetes and their maximum out of pocket expense per their policy is $xxx.xx." or "Policy does not include payment of prescriptions." American LegalNet, Inc. www.FormsWorkFlow.com Transportation: � Age(s) of debtor's vehicle(s): � Warranty details: � Other: 401(k) Loan: The debtor(s) has had a 401(k) loan since not payout during the life of the plan. The 401(k) loan will pay out to the plan. Alimony: Per Case Number pay alimony and/or child support. and the loan does and the funds are dedicated , the debtor is required to These payments will continue during the life of the plan. These payments will end increase is included in the plan payments. and the plan and the American LegalNet, Inc. www.FormsWorkFlow.com Adult Dependents: The debtor(s) has claimed an adult dependent who is age living at home. and who is The adult is a dependent of the debtor due to: Medical issues Attendance at a postͲsecondary school � Anticipated graduation: � Adult dependent is employed. Other reason: This dependant will remain a dependant for the life of the plan; or Debtor will dedicate the additional income during the life of the plan. Business & Operating Reports: The debtor is operating a business with gross receipts of $ Income Discrepancy & Overtime or OneͲtime Income: Indicate how the debtor(s) intends to alleviate the need to object to facially apparent income discrepancies (e.g., The debtor agrees to dedicate and pay any additional income above 8%.) American LegalNet, Inc. www.FormsWorkFlow.com NonͲFiling CoͲDebtor: The income and expenses have been divided on a proͲrate share of each spouse's income. Each spouse's income has been divided by the total income to determine a proͲ rata share. The total income will be reduced by the total joint expenses (Form B22C, if applicable). The remaining sum will be divided by each spouse's proͲrate share to determine the amount due to the chapter 13 plan. Other: American LegalNet, Inc. www.FormsWorkFlow.com