Official Form 122B Chapter 11 Statement of Your Current Monthly Income

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Official Form 122BChapter 11 Statement of Your Current Monthly Income
page1  Official Form 122B 	
Chapter 11 Statement of Your Current Monthly Income 	12/15	
You must file this form if you are an individual and are filing 
for bankruptcy under Chapter 11. If more space is needed, attac h a separate sheet 
to this form. Include the line number to which the additional information applies. On the top of any additional pages, write yo ur name and case 
number (if known). 
Part 1: 	 	Calculate Your Current Monthly Income	 	
1.	W	hat is your marital and filing status?	 Check one only.	
	Not 	married.  F	 ill 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. Fill out Column A, lines 2-11.	
Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this ba nkruptcy 
case. 11 U.S.C. § 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	 	
2.	Your gr	oss wages, salary, tips, bonuses, overtime, and commissions  (before al	l	pa	
yr	oll deductions).	$________	 ____ $__________ 
3.	A	limony and maintenance payments. Do not include payments fr	om a spouse if	Column B is fille	
d in.  $____________  $__________ 
4.	A	ll amounts from any source which are regularly paid for household expenses	 of	
y	

ou or your dependents, including child support.  Include regular contributions from
an unmarried partner, members of your household, your depende	
nts, parents, and	
roommates. Inclu	

de regular contributions from  a spouse only if Column B is not filled 	
in.	
Do not include p	

ayments you listed on line 3.  $____________  $__________ 
5.	Net in	come from operating a business, profes	sion,
or farm	Debtor 1	 	Debtor 2	 	
Gross receipts (b	efore all deductions)	$______ $______	
Ordinary and necessary operating expenses	–$______	– $______	
Net monthly income from a business, profession, or farm  
$______ $______ 	Copy 
here		 $_________ $__________ 	
6.	Net in	come from rental and other real propert	y	Debtor 1	Debtor 2	
Gross receipts (b	efore all deductions)	$______ $______	
Ordinary and necessary operating expenses	–$______	– $______	
Net monthly income from rental or other real propert	y	$______ $______	Copy 
here		 $_________ 
$__________ 	
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 122B	
Chapter 11 Statement of Your Current Monthly Income
page2 	
Column A Debtor 1	 	Column B Debtor 2 	 	
7.	Interes	t, dividends, and royaltie	s	 $________	
____  $__________ 
8.	Unem	ployment compensation $____________  $__________ 	
Do not enter the amount if you contend that the amount received was a b	enefit	
under the S

ocial Security Act. Instead, list it here:  ................................ 	
 	
For you ........................................................................\
..   $_________ 
For your spouse ............................................................  $_________ 	
9.	Pensio	n or retirement income.  Do not include any amount received that wa	s a	benefit under t	
he Social Security Act. $____________ $__________ 
10.	Inco	me from all other sources not listed above. 
Specify the source	 and amount.	
Do not include a	

ny benefits received under  the Social Security Act or pa	
yments	
received as a victim of a war crim	

e, a crime against humanity, or inte	
rnational or
domestic terrorism.	
If necessar	

y, list other sources on a separate page and put the total below.	
 ________________________________________  $____________ $________	 __ 	
 ________________________________________ 
$____________ $________	 __ 	
Total amounts from separate pages, if any. 	  	+ 
$____________ 	+ $__________	
11.	Calcula	 te your total current monthly income.
Add lines 2 through 10 for ea	ch column.	Then add t	

he total for Column A to the total for 	
Column B.	 $________	

____ 	
+ 	$_________ 	=	$__________
Total current monthly income  	
Part 2: 	 	Sign Below	
By signing here, under penalty of perjury I declare that the information on this statement and in any attachments is true and c orrect. 
	______________________________________________ 		______________________________________	
Signature of Debtor 1 Signature of Debtor 2  
Date 	_________________	Date	_________________ 	MM  / DD     / YYYY 	 	MM  / DD     / YYYY