Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Incomepage1 122A1 Chapter 7 Statement of Your Current Monthly Income 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). If you believe that you are exempted from a presumption of abuse because you do not have primarily consumer debts or because of qualifying military service, complete and file Statement of Exemption from Presumption of Abuse Under 247 707(b)(2) (Official Form 122A-1Supp) with this form. 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. You and your spouse are: Living in the same household and are not legally separated. Fill out both Columns A and B, lines 2-11. Living separately or are legally separated. Fill out Column A, lines 2-11; do not fill out Column B. By checking this box, you declareunder penalty of perjury that you and your spouse are legally separated under nonbankruptcy law that applies or that you and yourspouse are living apart for reasons that do not include evading the Means Test requirements. 11 U.S.C. 247 707(b)(7)(B). 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. 247 101(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 or non-filing spouse 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 ifColumn B is filled in. $ $ 4.All amounts from any source which are regularly paid for household expensesof you or your dependents, including child support. Include regular contributionsfrom an unmarried partner, members of your household, your dependents, parents,and roommates. Include regular contributions from a spouse only if Column B is notfilled in. Do not include payments you listed on line 3. $ $ 5.Net income from operating a business, profession,or farm Debtor 1 Debtor 2 Gross receipts (before all deductions)$$ Ordinary and necessary operating expenses226$ 226 $ Net monthly income from a business, profession, or farm $$Copy here $ $ 6.Net income from rental and other real property Debtor 1 Debtor 2 Gross receipts (before all deductions)$$ Ordinary and necessary operating expenses226$ 226 $ Net monthly income from rental or other real property$$Copy here $ $ 7.Interest, dividends, and royalties $ $ Check if this is an amended filing 1. There is no presumption of abuse. 2. The calculation to determine if a presumption of abuse applies will be made under Chapter 7 Means Test Calculation (Official Form 122A2262). 3. The Means Test does not apply now because of qualified military service but it could apply later. Check one box only as directed in this form and in Form 122A-1Supp: Debtor 1 First Name Middle Name Last Name Debtor 2 (Spouse, if filing) First Name Middle Name Last Name United States Bankruptcy Court for the: District of Case number (If known) Fill in this information to identify your case: American LegalNet, Inc. www.FormsWorkFlow.com Debtor 1 Case number (if known) First Name Middle Name Last Name Chapter 7 Statement of Your Current Monthly Incomepage2 Column A Debtor 1 Column B Debtor 2 or non-filing spouse 8.Unemployment compensation $ $ Do not enter the amount if you contend that the amount received was a benefitunder 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 abenefit 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 receivedas a victim of a war crime, a crime against humanity, or international or domesticterrorism. 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 eachcolumn. Then add the total for Column A to the total for Column B.$ + $ =$ Total current monthly income Part 2: Determine Whether the Means Test Applies to You 12. Calculate your current monthly income for the year. Follow these steps: 12a. Copy your total current monthly income from line 11. .................................................................................. Copy line 11 here $ Multiply by 12 (the number of months in a year). x 12 12b. The result is your annual income for this part of the form.12b.$ 13.Calculate the median family income that applies to you. Follow these steps: Fill in the state in which you live. Fill in the number of people in your household. Fill in the median family income for your state and size of household. ............................................................................................. 13. To find a list of applicable median income amounts, go online using the link specified in the separate instructions for this form. This list may also be available at the bankruptcy clerk222s office.$ 14.How do the lines compare? 14a. Line 12b is less than or equal to line 13. On the top of page 1, check box 1, There is no presumption of abuse.Go to Part 3. 14b. Line 12b is more than line 13. On the top of page 1, check box 2, The presumption of abuse is determined by Form 122A-2. Go to Part 3 and fill out Form 122A2262. Part 3: Sign Below By signing here, I declare under penalty of perjury that the information on this statement and in any attachments is true and correct. Signature of Debtor 1 Signature of Debtor 2 Date Date MM / DD / YYYY MM / DD / YYYY If you checked line 14a, do NOT fill out or file Form 122A2262. If you checked line 14b, fill out Form 122A2262 and file it with this form. 257 American LegalNet, Inc. www.FormsWorkFlow.com