R.I. Bankr. Form D See R. I. LBR 1006-1(e) New 6-1-2006 UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND --------------------------------x In re: : : : : --------------------------------x BK No. Chapter EXPENSE INFORMATION FOR FEE WAIVER APPLICATION This section must be completed if you have not filed Schedule J . CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S) Complete this document by estimating the average monthly expenses of the debtor and the debtor’s family. Pro rate any payments made bi-weekly, quarterly, semi-annually, or annually to show monthly rate. 1. Rent or home mortgage payment (include lot rented for mobile home) a. Are real estate taxes included? Yes No b. Is property insurance included? Yes No 2. Utilities: a. Electricity and heating fuel b. Water and sewer c. Telephone d. Other 3. Home maintenance (repair and upkeep) 4. Food 5. Clothing 6. Laundry and dry cleaning 7. Medical and dental expenses 8. Transportation (not including car payments) 9. Recreation, clubs and entertainment. newspaper, magazines. etc. 10.Charitable contributions 11.Insurance (not deducted from wages or included in home mortgage payments) a. Homeowner's or renter's b. Life c. Health d. Auto e. Other 12.Taxes (not deducted from wages or included in home mortgage payments) (Specify) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 13. Installment payments: a. Auto b. Other c. Other 14. Alimony, maintenance, and support paid to others 15. Payments for support of additional dependents not living at your home 16. Regular expenses from operation of business, profession, or farm (attach detailed statement) $ $ $ $ $ $ $ 17. Other 18. TOTAL MONTHLY EXPENSES $ 19. Describe any increase or decrease in expenditures reasonably anticipated to occur within the year following the filing of this document: DECLARATION CONCERNING DEBTOR’S EXPENSE ADDENDUM DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR 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. I (we) further declare under penalty of perjury that I have read the foregoing expense information and that it is true and correct to the best of my knowledge, information, and belief. Date Signature Date Signature Debtor (Joint Debtor, if any) --------------------------------------------------------------------------------------------------------------------------------------------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 (2) 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 Last four digits of 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.