Fill in this information to identify your case: Debtor 1 Debtor 2 __________________________________________________________________ First Name Middle Name Last Name _________________________________________________________________ Middle Name Last Name (Spouse, if filing) First Name United States Bankruptcy Court for the: __________ District of __________ Case number (If known) ___________________________________________ Check if this is an amended filing Official Form 122B Chapter 11 Statement of Your Current Monthly Income 12/15 You must file this form if you are an individual and are filing for bankruptcy under Chapter 11. If more space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any additional pages, write your name and case number (if known). Part 1: Calculate Your Current Monthly Income 1. What is your marital and filing status? Check one only. Not married. Fill out Column A, lines 2-11. Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11. Married and your spouse is NOT filing with you. Fill out Column A, lines 2-11. Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this bankruptcy case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through August 31. If the amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6. Fill in the result. Do not include any income amount more than once. For example, if both spouses own the same rental property, put the income from that property in one column only. If you have nothing to report for any line, write $0 in the space. Column A Debtor 1 Column B Debtor 2 2. Your gross wages, salary, tips, bonuses, overtime, and commissions (before all payroll deductions). 3. Alimony and maintenance payments. Do not include payments from a spouse if Column B is filled in. 4. All amounts from any source which are regularly paid for household expenses of you or your dependents, including child support. Include regular contributions from an unmarried partner, members of your household, your dependents, parents, and roommates. Include regular contributions from a spouse only if Column B is not filled in. Do not include payments you listed on line 3. 5. Net income from operating a business, profession, or farm Gross receipts (before all deductions) Ordinary and necessary operating expenses Net monthly income from a business, profession, or farm 6. Net income from rental and other real property Gross receipts (before all deductions) Ordinary and necessary operating expenses Net monthly income from rental or other real property $____________ $__________ $____________ $__________ $____________ $__________ Debtor 1 Debtor 2 $______ $______ ­ $______ $______ ­ $______ $______ Copy here $_________ $__________ Debtor 1 Debtor 2 $______ $______ ­ $______ $______ ­ $______ Copy $______ here $_________ $__________ Official Form 122B Chapter 11 Statement of Your Current Monthly Income American LegalNet, Inc. www.FormsWorkFlow.com page 1 Debtor 1 _______________________________________________________ First Name Middle Name Last Name Case number (if known)_____________________________________ Column A Debtor 1 Column B Debtor 2 7. Interest, dividends, and royalties $____________ $____________ $__________ $__________ 8. Unemployment compensation Do not enter the amount if you contend that the amount received was a benefit under the Social Security Act. Instead, list it here:................................ For you .......................................................................... For your spouse ............................................................ $_________ $_________ 9. Pension or retirement income. Do not include any amount received that was a benefit under the Social Security Act. 10. Income from all other sources not listed above. Specify the source and amount. Do not include any benefits received under the Social Security Act or payments received as a victim of a war crime, a crime against humanity, or international or domestic terrorism. If necessary, list other sources on a separate page and put the total below. ________________________________________ ________________________________________ Total amounts from separate pages, if any. $____________ $__________ $____________ $____________ $__________ $__________ + $____________ + $__________ 11. Calculate your total current monthly income. Add lines 2 through 10 for each column. Then add the total for Column A to the total for Column B. + $____________ $_________ = $__________ Total current monthly income Part 2: Sign Below By signing here, under penalty of perjury I declare that the information on this statement and in any attachments is true and correct. ______________________________________________ Signature of Debtor 1 Date _________________ MM / DD / YYYY ______________________________________ Signature of Debtor 2 Date_________________ MM / DD / YYYY Official Form 122B Chapter 11 Statement of Your Current Monthly Income American LegalNet, Inc. www.FormsWorkFlow.com page 2