Filing Fee Updated 11/1/11 Local Form 6 UNITED STATES BANKRUPTCY COURT Western District of North Carolina Instructions for Filing an Application for Waiver of the Chapter 7 Filing Fee for Individuals Who Cannot Pay the Filing Fee in Full or in Installments The fee for filing a case under chapter 7 of the Bankruptcy Code is $306. If you cannot afford to pay the fee either in full at the time of filing or in installments, then you may request a waiver of the filing fee by completing this application (NCWD Local Form 6) and filing it with the Clerk of Court. A judge will decide whether you have to pay the fee. By law, the judge may waive the fee only if your income is less than 150 percent of the official poverty line applicable to your family size and you are unable to pay the fee in installments. The poverty guidelines are attached. You may obtain additional information about the poverty guidelines at the United States Department of Health and Human Services website at http://aspe.hhs.gov/poverty. Required information. All items in the application and attached requested schedules must be answered in order for a proper determination to be made regarding allowance of your waiver of fee. If the question does not apply; write in not applicable or n/a. If the amount is zero or none use: zero, -0-, none. Sign the application on the last page. If you and your spouse are filing a joint bankruptcy petition, each of you must provide information as requested and sign the application. Your failure to timely comply with these requirements may result in the application being denied. If your application is denied, an order will be entered directing the payment of the filing fee in installments. American LegalNet, Inc. www.FormsWorkFlow.com 2011 HHS Poverty Guidelines Persons in Family 48 Contiguous States and D.C. Alaska Hawaii 1 $10,890 $13,600 $12,540 2 14,710 18,380 16,930 3 18,530 23,160 21,320 4 22,350 27,940 25,710 5 26,170 32,720 30,100 6 29,990 37,500 34,490 7 33,810 42,280 38,880 8 37,630 47,060 43,270 For each additional 3,820 4,780 4,390 person, add SOURCE: Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638 2 American LegalNet, Inc. www.FormsWorkFlow.com Local Form 6 Feb. 2006 UNITED STATES BANKRUPTCY COURT Western District of North Carolina In re: Chapter 7 Debtor(s). Case No.______________ 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, how many people are in your family? (Do not include your spouse if you are separated AND are not filing a joint petition.) Number of people in family: 2. ______________ Restate the following information that you provided, or will provide, on Line 16 of Schedule I, Current Income of Individual Debtor. 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 income already reported in Question 2. If none, enter $0. Monthly net income of dependants: 4. $_______________ Add the “Total Combined Monthly Income” reported in Question 2 to your dependents’ monthly net income from Question 3. Total of amounts in question 2 and 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: _____________________________________ _________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com 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. Total monthly expenses from Schedule J or estimate: 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. Name of Financial Institution Type of Account Amount __________________________ ____________________ $_________________ __________________________ ____________________ $_________________ 10. State below the assets owned by you. Do not list ordinary furnishings and clothing. Home Address: ____________________________________________ Value: ____________________ $__________________ Amount owed on mortgages and liens: $__________________ Other real estate address: ____________________________________________ Value: ____________________ $__________________ Amount owed on mortgages and liens: $__________________ Motor Vehicle Model/year: _______________________ Value: Amount Owed: Motor Vehicle Model/year: _______________________ Value: Amount Owed: $__________________ $__________________ $__________________ $__________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com Other (Describe):_______________________________ Value: $__________________ ___________________________________ $__________________ 11. Amount Owed: 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 connections 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 bankruptcy petition preparer, paralegal, typing service, or other person) any money for services in connection with this case, including the competition of this form, the bankruptcy petition, or schedules? Yes _____ No _____ If yes, how much have you paid? 15. $________________ Have you promised to pay anyone other than an attorney (such as bankruptcy petition preparer, paralegal, typing service, or other person) any money for services in connection with this case, including the competition 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: ___________________________________________________ _______________________________________________________________ 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 full or 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 ___________________________________ Signature of Debtor ____________________ Date ___________________________________ Signature of Debtor 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; U.S.C. § 156 6 American LegalNet, Inc. www.FormsWorkFlow.com