B 3B (Official Form 3B) (12/07) -- Cont. UNITED STATES BANKRUPTCY COURT Eastern District of of __________ __________ District New York In re: ___________________ Case No. ___________________ Debtor(s) (if known) APPLICATION FOR WAIVER OF THE CHAPTER 7 FILING FEE FOR INDIVIDUALS WHO CANNOT PAY THE FILING FEE IN FULL OR IN INSTALLMENTS Part A. Family Size and Income 1. Including yourself, your spouse, and dependents you have listed or will list on Schedule I (Current Income of Individual Debtors(s)), how many people are in your family? (Do not include your spouse if you are separated AND are not filing a joint petition.) __________ 2. Restate the following information that you provided, or will provide, on Line 16 of Schedule I. Attach a completed copy of Schedule I, if it is available. Total Combined Monthly Income (Line 16 of Schedule I): 3. $____________________ State the monthly net income, if any, of dependents included in Question 1 above. Do not include any income already reported in Item 2. If none, enter $0. $____________________ 4. Add the “Total Combined Monthly Income” reported in Question 2 to your dependents’ monthly net income from Question 3. $____________________ 5. Do you expect the amount in Question 4 to increase or decrease by more than 10% during the next 6 months? Yes ___ No ___ If yes, explain. Part B. Monthly Expenses 6. EITHER (a) attach a completed copy of Schedule J (Schedule of Monthly Expenses), and state your total monthly expenses reported on Line 18 of that Schedule, OR (b) if you have not yet completed Schedule J, provide an estimate of your total monthly expenses. $____________________ 7. Do you expect the amount in Question 6 to increase or decrease by more than 10% during the next 6 months? Yes ___ No ___ If yes, explain. Part C. Real and Personal Property EITHER (1) attach completed copies of Schedule A (Real Property) and Schedule B (Personal Property), OR (2) if you have not yet completed those schedules, answer the following questions. $ ____________________ 8. State the amount of cash you have on hand. 9. State below any money you have in savings, checking, or other accounts in a bank or other financial institution. Bank or Other Financial Institution: Type of Account such as savings, checking, CD: Amount: _________________________ ___________________ $____________________ _________________________ ___________________ $____________________ American LegalNet, Inc. www.FormsWorkFlow.com B 3B (Official Form 3B) (12/07) -- Cont. 10. State below the assets owned by you. Do not list ordinary household furnishings and clothing. Address: Home ____________________________ Value: $ ____________________ Amount owed on mortgages and liens: $ ____________________ ____________________________ Address: Other real estate ____________________________ Value: $ ____________________ Amount owed on mortgages and liens: $ ____________________ _____________________________ Amount owed: $ ____________________ Model/Year: ___________________ Value: $ ____________________ Amount owed: $ ____________________ Description___________________ Value: $ ____________________ ___________________________ Other Value: $ ____________________ ____________________________ Motor vehicle Model/Year: ___________________ ____________________________ Motor vehicle Amount owed: $ ____________________ 11. State below any person, business, organization, or governmental unit that owes you money and the amount that is owed. Name of Person, Business, or Organization that Owes You Money Amount Owed __________________________________ $ ____________________ __________________________________ $ ____________________ Part D. Additional Information. 12. Have you paid an attorney any money for services in connection with this case, including the completion of this form, the bankruptcy petition, or schedules? Yes ___ No ___ If yes, how much have you paid? $ ____________________ 13. Have you promised to pay or do you anticipate paying an attorney in connection with your bankruptcy case? Yes ___ No ___ If yes, how much have you promised to pay or do you anticipate paying? $ ____________________ 14. Have you paid anyone other than an attorney (such as a bankruptcy petition preparer, paralegal, typing service, or another person) any money for services in connection with this case, including the completion of this form, the bankruptcy petition, or schedules? Yes ___ No ___ If yes, how much have you paid? $ ____________________ 15. Have you promised to pay or do you anticipate paying anyone other than an attorney (such as a bankruptcy petition preparer, paralegal, typing service, or another person) any money for services in connection with this case, including the completion of this form, the bankruptcy petition, or schedules? Yes ___ No ___ If yes, how much have you promised to pay or do you anticipate paying? $ ____________________ 16. Has anyone paid an attorney or other person or service in connection with this case, on your behalf? Yes ___ No ___ If yes, explain. American LegalNet, Inc. www.FormsWorkFlow.com B 3B (Official Form 3B) (12/07) -- Cont. 17. Have you previously filed for bankruptcy relief during the past eight years? Yes ___ No ___ Case Number (if known) ___________________ Year filed Location of filing Did you obtain a discharge? (if known) _______ ______________ Yes ____ No ____ Don't know ____ ___________________ _______ ______________ Yes ____ No ____ Don't know ____ 18. Please provide any other information that helps to explain why you are unable to pay the filing fee in installments. 19. I (we) declare under penalty of perjury that I (we) cannot currently afford to pay the filing fee in full or in installments and that the foregoing information is true and correct. Executed on: ___________________ Date ___________________ Date ________________________________ Signature of Debtor ________________________________ Signature of Codebtor -----------------------------------------------------------------------------------------------------------------------------------------------------DECLARATION AND SIGNATURE OF BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110) I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. §§ 110(b), 110(h), and 342(b); and (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required under that section. ___________________________________________________________ __________________________ Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer Social-Security No. (Required by 11 U.S.C. §110.) If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social-security number of the officer, principal, responsible person, or partner who signs the document. ________________________________ ________________________________ Address x__________________________________________________ Signature of Bankruptcy Petition Preparer _____________________ Date Names and Social-Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person. A bankruptcy petition preparer’s failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156. American LegalNet, Inc. www.FormsWorkFlow.com 150% of the HHS Poverty Guidelines for 2011* Monthly Basis Persons in family unit 48 Contiguous States (includes New York) 1 $1,361.25 2 $1,838.75 3 $2,316.25 4 $2,793.75 5 $3,271.25 6 $3,748.78 7 $4,226.25 8 $4,703.75 For each additional person add $477.50 * As required by section 673(2) of the Omnibus Budget Reconciliation Act of 1981 (Pub. L. 97-35 - reauthorized by Pub. L. 105-285, Section 201 (1988)). American LegalNet, Inc. www.FormsWorkFlow.com