Fill in this information to identify your case: Debtor 1 Debtor 2 __________________________________________________________________ First Name Middle Name Last Name Check as directed in lines 17 and 21: According to the calculations required by this Statement: (Spouse, if filing) First Name ________________________________________________________________ Middle Name Last Name 1. Disposable income is not determined under 11 U.S.C. § 1325(b)(3). 2. Disposable income is determined under 11 U.S.C. § 1325(b)(3). 3. The commitment period is 3 years. 4. The commitment period is 5 years. United States Bankruptcy Court for the: ______________________ District of __________ (State) Case number (If known) ___________________________________________ Check if this is an amended filing Official Form 122C­1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period 12/15 Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. 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 Average Monthly Income 1. What is your marital and filing status? Check one only. Not married. Fill out Column A, lines 2-11. Married. Fill out both Columns A and B, 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 Column B Debtor 1 2. Your gross wages, salary, tips, bonuses, overtime, and commissions (before all Debtor 2 or non-filing spouse payroll deductions). $__________ $__________ $__________ $__________ 3. Alimony and maintenance payments. Do not include payments from a spouse. 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. Do not include payments from a spouse. Do not include payments you listed on line 3. farm Debtor 1 Debtor 2 $_________ $__________ 5. Net income from operating a business, profession, or 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 $______ $______ ­ $______ ­ $______ $______ Debtor 1 $______ here Debtor 2 Copy $_________ $__________ Gross receipts (before all deductions) Ordinary and necessary operating expenses Net monthly income from rental or other real property $______ $______ ­ $______ ­ $______ $______ $______ here Copy $_________ $__________ page 1 Official Form 122C­1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period American LegalNet, Inc. www.FormsWorkFlow.com Debtor 1 First Name _______________________________________________________ Middle Name Last Name Case number (if known)_____________________________________ Column A Debtor 1 Column B Debtor 2 or non-filing spouse 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 ..................................................................... benefit under the Social Security Act. $_____________ $_____________ $____________ $__________ 9. Pension or retirement income. Do not include any amount received that was a 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 average monthly income. Add lines 2 through 10 for each + $____________ $____________ + $__________ + $___________ column. Then add the total for Column A to the total for Column B. = $________ Total average monthly income Part 2: Determine How to Measure Your Deductions from Income $_____________ 12. Copy your total average monthly income from line 11. .......................................................................................................................... 13. Calculate the marital adjustment. Check one: You are not married. Fill in 0 below. You are married and your spouse is filing with you. Fill in 0 below. You are married and your spouse is not filing with you. Fill in the amount of the income listed in line 11, Column B, that was NOT regularly paid for the household expenses of you or your dependents, such as payment of the spouse's tax liability or the spouse's support of someone other than you or your dependents. Below, specify the basis for excluding this income and the amount of income devoted to each purpose. If necessary, list additional adjustments on a separate page. If this adjustment does not apply, enter 0 below. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ $___________ $___________ + $___________ $___________ Copy here Total ...............................................................................................