UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW HAMPSHIRE In re: _________________________________, Debtor Bk. No. ________-_________-_______ Chapter 13 Reporting Period__________________ MONTHLY OPERATING REPORT Complete and submit to the chapter 13 trustee within fourteen (14) days after the end of each month. Required Documents Monthly Reporting Questionnaire Schedule of Cash Receipts and Disbursements - Copies of debtor's bank reconciliations - Copies of debtor's bank statements Detailed Listing of Disbursements Schedule of Post-Petition Unpaid Taxes and Liabilities - Copies of IRS Form 6123 or payment receipt - Copies of tax returns filed during reporting period Summary of Accounts Receivable MOR-5 MOR-3 MOR-4 Form No. MOR-1 MOR-2 Document Attached Explanation Attached I declare under the penalty of perjury that this report and all attachments are true and correct to the best of my knowledge and belief. __________________________________________ Signature of Debtor __________________________________________ Signature of Debtor ____________________________ Date ____________________________ Date (Cover Page) LBF 2083-3 (Eff. 2/1/13) American LegalNet, Inc. www.FormsWorkFlow.com Debtor__________________________________ Bk. No. ______-_________-______ Chapter 13 Reporting Period________________ MONTHLY REPORTING QUESTIONNAIRE Must be completed each month. 1 Have any assets been sold or transferred outside the normal course of business during this reporting period? If yes, provide an explanation below. Yes No 2 Have any funds been disbursed from any account other than an account of which you have attached a copy during this reporting period? If yes, provide an explanation. 3 Have any payments been made on a prepetition debt, other than payments in the normal course, to secured creditors or lessors? If yes, attach listing, including date of payment, amount of payment and name of payee. Have any payments been made to professionals? If yes, attach listing, including date of payment, amount of payment and name of payee. If the answer to question 3 and/or 4 is yes, were all such payments approved by the court? Have any payments been made to officers, insiders, shareholders or relatives? If yes, attach listing, including date of payment, amount and reason for payment and name of payee. Have all post-petition tax returns been timely filed? If no, provide an explanation below. Is the estate current with payment of all post-petition taxes? Is the estate insured for the replacement cost of assets and for general liability? If no, provide an explanation below. 4 5 6 7 8 9 10 11 Is worker's compensation insurance in effect? Have all current insurance payments been made? Attach copies of all new and renewed insurance policies. 12 Was there any post-petition borrowing during this reporting period? (MOR-1) LBF 2083-3 (Eff. 2/1/13) -2- American LegalNet, Inc. www.FormsWorkFlow.com Debtor__________________________________ Bk. No. ______-_________-______ Chapter 13 Reporting Period_______________ SCHEDULE OF CASH RECEIPTS AND DISBURSEMENTS Amounts reported should be per debtor's books, not bank statement. The beginning cash should be the ending cash from the prior month or, if this is the first report, the amount should be the balance on the date the petition was filed. Attach copies of the bank statements and the cash disbursements journal. A bank reconciliation must be attached for each account. The total disbursements listed in the disbursements journal must equal the total disbursements reported on this page. Operational Cash - Beginning of Month Receipts Cash Sales Accounts Receivable Loans and Advances Sale of Assets Other (attach list) Transfers (from other accounts) Total Receipts Disbursements Net Payroll Payroll Taxes Sales, Use & Other Taxes Inventory Purchases Secured/Rental/Leases Insurance Administrative Selling Other (attach list) Owner Draw* Transfers (to other accounts) Total Disbursements Net Cash Flow (Receipts Less Disbursements) Cash - End of Month Payroll Tax Other Total (MOR-2) LBF 2083-3 (Eff. 2/1/13) American LegalNet, Inc. www.FormsWorkFlow.com -3- Debtor__________________________________ Bk. No. ______-_________-______ Chapter 13 Reporting Period_______________ DETAILED LISTING OF DISBURSEMENTS Date Check No. Paid to/In Payment of Amount TOTAL DISBURSEMENTS: _____________________ (MOR-3) LBF 2083-3 (Eff. 2/1/13) -4- American LegalNet, Inc. www.FormsWorkFlow.com Debtor__________________________________ Bk. No. ______-_________-______ Chapter 13 Reporting Period_______________ STATUS OF POST-PETITION TAXES The beginning tax liability should be the ending liability from the prior month or, if this is the first report, the amount should be zero. Attach photocopies of IRS Form 6123 and all applicable state and local forms and/or all federal, state and local payment receipts to verify payment of taxes. Attach photocopies of any tax returns filed during the reporting period. Beginning Amount Amount Tax Withheld or Paid Liability Accrued Date Paid Check No. or EFT Ending Tax Liability Federal Income Tax Withholding FICA ­ Employee FICA ­ Employer Unemployment Income Other Total Federal Taxes State and Local Income Tax Withholding Sales Excise Unemployment Real Property Other: Total State and Local Withholding for Employee Healthcare Premiums, Pensions & Other Benefits Total Taxes SUMMARY OF UNPAID POST-PETITION DEBTS Attach aged listing of accounts payable. Number of Days Past Due Current 31-60 61-90 Over 90 Accounts Payable Wages Payable Taxes Payable Rent/Leases - Equipment Secured Debt/Adequate Protection Payments Professional Fees Amounts Due to Insiders* Other: Other: Total Post-Petition Debts LBF 2083-3 (Eff. 2/1/13) Total Cont'd American LegalNet, Inc. www.FormsWorkFlow.com -5- Explain how and when the debtor intends to pay any past due post-petition debts: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ * "Insider" is def