Application for Waiver of Ch 7 Filing Fee (Official Form B3B)

Wavering the required chapter 7 filling fee requires the use of this application. Complete the application and submit it along with any required information.

Extracted Text for Proper Search

Official Form 103BApplication to Have the Chapter 7 Filing Fee Waived
page1 
  Official Form 
103B 	
Application to Have the Chapter 7 Filing Fee Waived 	12/15	
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct 
information.  If more space is needed, attach a separate sheet to  this form. On the top of any additional pages, write your name and case number 
(if known).  
Part 1:  Tell the Court About Your Family and Your Family’s Income 
1. 	What is the size of your family?
Your family includes y	
ou, your	spouse, and an

y 	
dependents listed	on 	Schedule J: Your Expenses	(Official Form 10

6J).  Check all that apply: 	
	You	
	Your	 spouse	
	Your dependents	___________________	 	How	
 many dependents?	 	
______	_______________  	
Total number of people	 	
2. 	Fill in your family’s average
monthly income	.	
Include 

your spou	
se’s income if	your spo

use is living with you, even
if y	
our spouse is not filing.	
Do not include 	your spouse’s	income if y

ou are separated an	
d	your spo

use is not filing with you.	That person’s average monthly net income  (take-home pay)	
Add your income and your spouse’s income. Include the 
value (if known) of any non-cash governmental assistance 
that you receive, such as food stamps (benefits under the 
Supplemental Nutrition Assistance Program) or housing 
subsidies. 
If you have already filled out Schedule I:  Your Income,  see 
line 10 of that schedule.  	
You  ..................  $_________________ 
Your spouse  ....	+ $_________________	
 Subtotal .............  $_________________ 	
Subtract any non-cash governmental assistance that you 
included above.	 	–	$_________________	
Your family’s average monthly net income  Total ..................
 $_________________	 	
3. 	Do you receive non-cas	h	go
vernmental assistan	ce?		No	
	Yes. Describe. ........... Type of assistance 	
4. 	Do you expect your family	’s	a
verage monthly net income to
increase or decrease by more th	
an	10

% during the next 6 mont	
hs?	
	No	
	Yes. Explain. .............	
5. 	Tell the court why you are unable to pay the filing fe	e in	install ments within 120 days.  If you have some a	dditional	circumstances th

at cause you to not be able to pay 	
your filing	fee in installment

s, explain them.
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: 	
 	Check if this is an
amended filing

Debtor 1  _______________________________________________________ Case number 	(if known ) 	_____________________________________  	First Name  Middle Name  Last Name	  Official Form 103B
 	
Application to Have the Chapter 7 Filing Fee Waivedpage2 	
Part 2:   Tell the Court About Your Monthly Expenses 
6. 	Estimate your average monthly expenses.
Include amounts paid by any government assistance that yo	
u	reporte

d on line 	
2.	
If 

you have already filled out  Schedule J, Your Expenses, 	
copy	line 22 from that 

form. $___________________ 	
7. 	Do these expenses cover anyo	ne	w
ho is not included in your family
as reported in line 1?		No	
	Yes. Identify who 	........	
8. 	Does anyone other than yo	u	regularl y pay any of th	ese	expens	es?	
If 

you have already	
 filled out	Schedule I: Your 

Income, copy the
total from line 11.		No	
	Yes. How much do you regularly receive as contributions?  $_________ monthl	y	
9. 	Do you expect your averag	e	mon
thly expenses to increase or
decrease by more than 10% dur	
ing	the n

ext 6 months?		No	
	Yes. Explain ................	
Part 3:  Tell the Court About Your Property  
If you have already filled out Schedule A/B: Property (Official Form 106A/B)  attach copies to this application and go to Part 4. 
10. 	How much cash	 do you have?
Examples: Money 
you have in	your 	

wallet, in your home, an	
d on	hand 	

when you file this application	
Cash:  	$_________________ 	
11. 	Bank accounts and other depos	its	of m oney?
Examples:  Chec	
king, savings,	mone

y market, or	
 other financial
accounts; certificates of deposit;
shares in banks, credit unions,	
brokerage 

houses	
, and other	similar inst

itutions. If y	
ou have	more than o

ne account wi	
th the	same institution, 	list each. Do not	include 401(k) an

d IRA accounts.	Institution name: 	
Checking account:	   __________________________________________________ 	
Savings account:	   __________________________________________________ 	
Other financial accounts:	   __________________________________________________ 	
Other financial accounts:	   __________________________________________________ 	
Amount: 
$__________________ 
$__________________ 
$__________________ 
$__________________ 	
12. 	Your home? (if you own it outrigh	t or	are purchasing it)
Examples: Hous	
e, condominium,	manufactured h

ome, or mobile home	_______________________________________________________ 
Number Street 
_______________________________________________________	
 	City State  ZIP Code	 	
Current value: 
Amount you owe 
on mortgage and 
liens:  	$_________________  
$_________________  	
13. 	Other real estate?	_______________________________________________________ 
Number Street 
_______________________________________________________	
 	City State  ZIP Code	 	
Current value: 
Amount you owe 
on mortgage and 
liens:  	$_________________  
$_________________  	
14. 	The vehicles you ow	n?	
Exam

ples: Cars, vans, tr	
ucks,	spor

ts utility vehicles, motorcyc	
les,	tractors, boats	
Make:	   _____________________ 	
Model:	  	_____________________ 	
Year:	   ____________ 	
Mileage	 _____________________ Current value: 
Amount y	

ou owe 
on liens:  	$_________________  
$_________________  	
Make:	   _____________________ 	
Model:	  	_____________________ 	
Year:   ____________ 
Mileage _____________________ Current value: 
Amount y	

ou owe 
on liens:  	$_________________ 
$_________________

Debtor 1  _______________________________________________________ Case number 	(if known ) 	_____________________________________  	First Name  Middle Name  Last Name	  Official Form 103B
 	
Application to Have the Chapter 7 Filing Fee Waivedpage3 	
15. 	Other assets?
Do not include household items
and clothing.	Describe the other assets:	 
Current value: 
Amount you owe 
on liens:   $_________________ 
$_________________ 	
16. 	Money or property due you?
Examples : Tax re	
funds, past due	or lump sum alimon

y,	
 spousal
support, child support,	
maintenance, divorce or p

roperty
settlements, Social Security
benefits, workers’	
 compensation,	personal injur

y recovery	Who owes you the money or property? 
___________________________________________ 
___________________________________________ 	
How much is owed? 
$_________________  
$_________________ 	
Do you believe you will likely receive 
payment in the next 180 days? 
 No	
 Yes. Explain:	
Part 4:  Answer These Additional Questions  
17. 	Have you paid anyone for
services for this case, including
filling out this applicatio	
n, the	bankr

uptcy filing package, or th	
e	sched

ules?		No	
	Yes. Whom did you pay?	 Check all that apply:	
	An attorney	
	A bankruptcy petition preparer, paralegal, or typing service	
	Someone else 	________________________________________	
How much did you pay? 
$______________________  	
18. 	Have you promised to pay or do
you expect to pay someone fo	r	ser

vices for your bankruptcy
case?		No	
	Yes.  Whom do you expect to pay?	 Check all that apply:	
	An attorney	
	A bankruptcy petition preparer, paralegal, or typing service	
	Someone else 	_________________________________________	
How much do you expect to pay? 
$_______________________ 	
19. 	Has anyone paid someone on
your behalf for services for this
case?		No	
	Yes.  Who was paid on your behalf?	Check all that apply:  
	An attorney	
	A bankruptcy petition preparer	,	paralegal, or typi	ng service	
	Someone else 	_________________	
Who paid?  Check all that apply:  
	Parent	
	Brother or	 sister	
	Friend	
	Pastor or clergy	
	Someone else 	__________	
How much did someone else pay? 
$______________________ 	
20. 	Have you filed for bankruptcy
within the last 8 years?		No	
	Yes.   	District   _____________________________  When   _____________  Case number  _____________________	MM/ DD/ YYYY	
District   _____________________________  When   _____________  Case number  _____________________ 	MM/ DD/ YYYY	
District  _____________________________  When   _____________  Case number  _____________________  	MM/ DD/ YYYY	 	
Part 5: Sign Below 
By signing here under penalty of perjury, I declare that I cannot  afford to pay the filing fee either in full or in installments. I also declare 
that the information I provided in this application is true and correct. 
_____________________________________________	 _____________________________________________	
      Signature of Debtor 1	  	Signature of Debtor 2 	
Date __________________  Date __________________ 	MM   /   DD  / YYYY   MM  /   DD  / YYYY

Order on the Application to Have the Chapter 7 Filing Fee Waived 
After considering the debtor’s Application to Have the Chapter 7 Filing Fee Waived  (Official Form 103B), the court 
orders that the application is: 
[ ] Granted.   However, the court may order the debtor to pay  the fee in the future if developments in 
administering the bankruptcy case sh ow that the waiver was unwarranted. 
[ ] Denied	
.   The debtor must pay the filing fee  according to the following terms: 	
You m
ust pay… 	On or before this date… 	
$_____________ 	_____________ Month / day / year  	
$_____________ 	_____________ Month / day / year	
$_____________ 	_____________ Month / day / year	
+ $_____________	_____________  Month / day / year	
Total 
If the debtor would like to propose a different  payment timetable, the debtor must file a 
motion promptly with a payment proposal. The debtor may use  Application for Individuals to 
Pay the Filing Fee in Installments  (Official Form 103A) for this purpose. The court will 
consider it. 
The debtor must pay the entire filing fee befor e making any more payments or transferring any 
more property to an attorney, bankruptcy petition  preparer, or anyone else in connection with the 
bankruptcy case. The debtor must also pay the  entire filing fee to receive a discharge. If the 
debtor does not make any payment when it is  due, the bankruptcy case may be dismissed and 
the debtor’s rights in future bankruptcy cases may be affected.  
[ ] Scheduled for hearing. 
A hearing to consider the debtor’s application will be held 
 on	  _____________  	at _________ 	AM 	/ PM 	at  _________________________________________.	 	
Month / day / year	  Address of courthouse 	
If the debtor does not appear at this hear ing, the court may deny the application. 
_____________ 	By the court:	 _____________________________________ 	
Month / day / year	     United States Bankruptcy Judge  	
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 the case: