APPENDIX A UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF MARYLAND IN RE: Debtor(s) : : : : F I N A N C I A L MONTHLY INCOME GROSS: Case No. Chapter Adversary proceeding No. S T A T E M E N T MONTHLY EXPENSES: $ Party Expenses Now Paid by Spouse Children Rent LESS DEDUCTIONS: House Payment Federal Tax Utilities: Heat Gas & Light State Tax Telephone FICA or Retirement Food All other deductions Medical, Dental Transportation NET INCOME: $ Insurance: Life Health Auto Other Income from property Income from any other sources Child Care Expense Tax Refund Recreation Monies from spouse Incidentals Periodic Pymts. (attach list) TOTAL MONIES RECEIVED: TOTAL EXPENSES: A S S E T S L I A B I L I T I E S $ TOTAL ASSETS: $ $ TOTAL LIABILITIES $ I HEREBY SWEAR OR AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE ABOVE FINANCIAL STATEMENT IS TRUE AND CORRECT. ________________________________________________________ (Party) (Date) Local Bankruptcy Form D 2002 © American LegalNet, Inc.