CURRENT INCOME: PART 1
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1 CURRENT INCOME: PART 1 This section deals with your household income. If you are married, information MUST be provided for both spouses, even if only one person is filing. Please provide the husband s information first. What is your marital status?: [ ] Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed Employment Information: 3 Very IMPORTANT Notes: Note #1: The amounts you list must be the monthly amounts unless otherwise stated below. Do the necessary math to ensure you are giving us monthly amounts. Note #2: You must provide us with ALL of your paystubs (or profit and loss statements) for the last seven months. Including any part time jobs. Note #3: Take your last pay stub and write out what each deduction is for. We must know what every line on your pay stub is for so help us out and include that information on your last pay stub. 1. What is the gross amount of your paychecks per month, before deductions? $ 2. Do you have any retirement loans deducted from your paycheck? [ ] Yes [ ] No If yes, provide the following information for EACH retirement loan you have: a) Amount Deducted Per Pay Check: b) Months Remaining on Loan: c) Amount Currently Owed on Loan: 3. Do you have a part-time job? [ ] Yes [ ] No 4. If you do have a part-time job, what is your gross monthly income? $ 37
2 5. Other Monthly Income List other monthly income including: a. Interest, dividends, or royalties [ ] Yes [ ] No If Yes, how much? $ b. Support from family members [ ] Yes [ ] No If Yes, how much? $ c. Alimony or child support [ ] Yes [ ] No If Yes, how much? $ d. Unemployment benefits [ ] Yes [ ] No If Yes, how much? $ e. Social Security benefits [ ] Yes [ ] No If Yes, how much? $ f. Government assistance [ ] Yes [ ] No If Yes, how much? $ What source, e.g. Food Stamp, Housing Subsidies, etc.? g. Retirement or pension [ ] Yes [ ] No If Yes, how much? $ h. Other income not listed above [ ] Yes [ ] No If Yes, how much? $ What source? i. Other contributions to your monthly expenses including contributions $ from an unmarried partner, members of your household, your dependents, your roommates, and other friends or family living with you/you and your spouse? Who is source? 6. Do you expect an increase or decrease in any source of income within the year after filing the bankruptcy? [ ] No [ ] Yes, Explain: Continue to Next Page 38
3 CURRENT INCOME: PART 2 This section is for the Debtor s Spouse, or Co-Debtor Spouse (even if the spouse is not filing) Employment Information for Spouse: 3 Very IMPORTANT Notes: Note #1: The amounts you list must be the monthly amounts unless otherwise stated below. Do the necessary math to ensure you are giving us monthly amounts. Note #2: You must provide us with ALL of your paystubs (or profit and loss statements) for the last seven months. Including any part time jobs. Note #3: Take your last pay stub and write out what each deduction is for. We must know what every line on your pay stub is for so help us out and include that information on your last pay stub. 1. What is the gross amount of your paychecks per month, before deductions? $ 2. Do you have any retirement loans deducted from your paycheck? [ ] Yes [ ] No If yes, provide the following information for EACH retirement loan you have: a) Amount Deducted Per Pay Check: b) Months Remaining on Loan: c) Amount Currently Owed on Loan: 3. Do you have a part-time job? [ ] Yes [ ] No 4. If you do have a part-time job, what is your gross monthly income? $ 39
4 5. Other Monthly Income List other monthly income including: a. Interest, dividends, or royalties [ ] Yes [ ] No If Yes, how much? $ b. Support from family members [ ] Yes [ ] No If Yes, how much? $ c. Alimony or child support [ ] Yes [ ] No If Yes, how much? $ d. Unemployment benefits [ ] Yes [ ] No If Yes, how much? $ e. Social Security benefits [ ] Yes [ ] No If Yes, how much? $ f. Government assistance [ ] Yes [ ] No If Yes, how much? $ What source, e.g. Food Stamp, Housing Subsidies, etc.? g. Retirement or pension [ ] Yes [ ] No If Yes, how much? $ h. Other income not listed above [ ] Yes [ ] No If Yes, how much? $ What source? i. Other contributions to your monthly expenses including contributions $ from an unmarried partner, members of your household, your dependents, your roommates, and other friends or family living with you/you and your spouse? Who is source? 6. Do you expect an increase or decrease in any source of income within the year after filing the bankruptcy? [ ] No [ ] Yes, Explain: Anything else we need to know about your spouse s employment: Continue to Next Page 40
5 CURRENT MONTHLY EXPENSES Below, list the average monthly expenses for your household. If you are married, and you and your spouse have separate households, add your spouse s expenses to the right of your expenses. Just draw a vertical line between your expenses and their expenses. Label your expenses and their expenses. If you and your spouse live together, just total your expenses and list them together. To get an idea of the typical expenses for different household sizes go to this website: Dependents, such as children: NAME (Will not be included in the filing.) AGE RELATIONSHIP DO THEY LIVE WITH YOU? [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No 1. Your rent or 1 st home mortgages payment on your primary residence $ 2. Does your payment include real estate property taxes [ ] Yes [ ] No If NO, how much do you pay for them each month 3. Does your payment include homeowners or renters insurance [ ] Yes [ ] No If NO, how much do you pay for them each month $ $ 4. Home maintenance, repairs and upkeep expense $ 5. Homeowner s association and condominium association dues $ 6. Additional mortgage payments on your residence (2 nd,3 rd, home equity line) $ 7. Utilities: a. Electricity, heating, natural gas $ b. Water, sewage, garbage collection $ c. Telephone, cell phone, Internet, satellite and cable services $ d. Other utility bills (Specify the utility: ) $ 8. Food and housekeeping supplies $ 9. Childcare/daycare and children s education costs $ 41
6 CURRENT MONTHLY EXPENSES CONTINUED 10. Clothing, laundry, and dry cleaning $ 11. Personal care products and services $ 12. Medical and dental expenses, do not include insurance $ 13. Transportation including gas, maintenance, bus, train. Do not include car payment. $ 14. Entertainment, clubs, recreation, newspaper, magazines and books $ 15. Charitable contributions or religious donations $ 16. Insurance not deducted from your paycheck (List each one individually): a. Life insurance $ b. Health insurance $ c. Auto insurance $ d. Other insurance, Specify: $ 17. Taxes not deducted from your paycheck a) How much do you pay each year for vehicle taxes? $ b) IRS back taxes $ c) State back taxes $ d) Other, Specify: $ 18. Installment OR lease payments a) Auto payment or lease for Vehicle One $ b) Auto payment or lease for Vehicle Two $ c) Other, e.g. furniture, computer, etc. Specify $ d) Other, e.g. furniture, computer, etc. Specify $ 19. Alimony and support for others, not including children, not deducted from check $ 20. Child support payments (for a child not permanently living with you) $ IMPORTANT: If you are behind on your child support payments, it MUST be listed on page 30. This is required to be included in your bankruptcy. You must also stay current on all future child support payments or risk having your bankruptcy dismissed. 21. Other real property expenses not included in your primary expenses on line 1-6, e.g. rental properties a) Mortgages on other property $ b) Real estate taxes $ c) Property, homeowner s or renter s insurance $ d) Maintenance, repair and upkeep expenses $ e) Homeowner s association and condominium dues $ 22. Other expenses not listed above, e.g., pet expenses, student loans, etc. (not business expenses) a) Other, Specify $ 42
7 b) Other, Specify $ c) Other, Specify $ 23. Do your expenses include expenses of people other than yourself and your dependents? [ ] Yes [ ] No If Yes, Explain 24. Do you expect an out of the ordinary increase or decrease in your expenses within the year after you file your bankruptcy? [ ] No [ ] Yes, Explain For example, will you pay your car off or is your mortgage expected to increase or decrease due to a modification of the mortgage loan. 25. IMPORTANT Below, list any and all other regular monthly expenses that you or your spouse (EVEN IF NOT FILING TOGETHER) have. It is important to provide these monthly expenses to accurately reflect your monthly budget. ***IMPORTANT*** The information on the following pages (Statement of Financial Affairs) is extremely important. You are required by federal law to provide this information. If something does not apply simply put a N/A in the box. However, we need all of the requested information. This will be one of the first places we look when you turn in the paperwork to ensure it has been fully and completely filled out. 43
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