R.I. Local Form 1006-1.1 UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND --------------------------------x In re: : : : : BK No. Chapter --------------------------------x SUPPLEMENTAL INCOME AND EXPENSE INFORMATION FOR FEE WAIVER APPLICATION In order for the Court to consider and act on an Application for Waiver of the Chapter 7 Filing Fee, the debtor(s) must also file Schedules I and J with the Application, in addition to this supplemental income and expense form. A. SOURCE OF INCOME OF INDIVIDUAL DEBTOR(S) 1. Source of income (i.e., wages, commissions, social security, unemployment, disability, pension). . 2. If the attorney, petition preparer or other person or entity was paid to represent the debtor(s) in this bankruptcy case, provide the source of the payment to the attorney (i.e., wages, social security, unemployment, borrowed funds - such as from a friend or relative). _ B. CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S) 1. Recreation, clubs and entertainment, newspapers, magazines, etc. List each specific recreation item separately and the monthly expense: $ $ $ $ DECLARATION CONCERNING DEBTOR'S SUPPLEMENTAL INCOME AND 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(we) have read the foregoing expense information and that it is true and correct to the best of my knowledge, information, and belief. . Date Signature Debtor Date Signature Joint Debtor, if any American LegalNet, Inc. www.FormsWorkFlow.com