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Form B22A (Chapter 7) (10/05) In re ______________________________
Debtor(s)

According to the calculations required by this statement: The presumption arises. The presumption does not arise.
(Check the box as directed in Parts I, III, and VI of this statement.)

Case Number: __________________
(If known)

STATEMENT OF CURRENT MONTHLY INCOME AND MEANS TEST CALCULATION
FOR USE IN CHAPTER 7 ONLY
In addition to Schedule I and J, this statement must be completed by every individual Chapter 7 debtor, whether or not filing jointly, whose debts are primarily consumer debts. Joint debtors may complete one statement only.

Part I. EXCLUSION FOR DISABLED VETERANS
If you are a disabled veteran described in the Veteran's Declaration in this Part I, (1) check the box at the beginning of the Veteran's Declaration, (2) check the box for "The presumption does not arise" at the top of this statement, and (3) complete the verification in Part VIII. Do not complete any of the remaining parts of this statement. Veteran's Declaration. By checking this box, I declare under penalty of perjury that I am a disabled veteran (as defined in 38 U.S.C. § 3741(1)) whose indebtedness occurred primarily during a period in which I was on active duty (as defined in 10 U.S.C. § 101(d)(1)) or while I was performing a homeland defense activity (as defined in 32 U.S.C. §901(1)).

1

Part II. CALCULATION OF MONTHLY INCOME FOR § 707(b)(7) EXCLUSION
Marital/filing status. Check the box that applies and complete the balance of this part of this statement as directed. a. b. 2 c. d. Unmarried. Complete only Column A ("Debtor's Income") for Lines 3-11. Married, not filing jointly, with declaration of separate households. By checking this box, debtor declares under penalty of perjury: "My spouse and I are legally separated under applicable non-bankruptcy law or my spouse and I are living apart other than for the purpose of evading the requirements of § 707(b)(2)(A) of the Bankruptcy Code." Complete only Column A ("Debtor's Income") for Lines 3-11. Married, not filing jointly, without the declaration of separate households set out in Line 2.b above. Complete both Column A ("Debtor's Income") and Column B (Spouse's Income) for Lines 3-11. Married, filing jointly. Complete both Column A ("Debtor's Income") and Column B ("Spouse's Income") for Lines 3-11. Column A Debtor's Income $ $ Column B Spouse's Income

All figures must reflect average monthly income for the six calendar months prior to filing the bankruptcy case, ending on the last day of the month before the filing. If you received different amounts of income during these six months, you must total the amounts received during the six months, divide this total by six, and enter the result on the appropriate line. 3 Gross wages, salary, tips, bonuses, overtime, commissions. Income from the operation of a business, profession or farm. Subtract Line b from Line a and enter the difference on Line 4. Do not enter a number less than zero. Do not include any part of the business expenses entered on Line b as a deduction in Part V. 4 a. b. c. Gross receipts Ordinary and necessary business expenses Business income $ $ Subtract Line b from Line a $

$

Rent and other real property income. Subtract Line b from Line a and enter the difference on Line 5. Do not enter a number less than zero. Do not include any part of the operating expenses entered on Line b as a deduction in Part V. 5 a. b. c. 6 7 8 Gross receipts Ordinary and necessary operating expenses Rental income $ $ Subtract Line b from Line a $ $ $ $ $ $

Interest, dividends and royalties. Pension and retirement income. Regular contributions to the household expenses of the debtor or the debtor's dependents, including child or spousal support. Do not include contributions from the debtor's spouse if Column B is completed.

$

$

Form B 22A (Chapter 7) (10/05)
Unemployment compensation. Enter the amount in Column A and, if applicable, Column B. However, if you contend that unemployment compensation received by you or your spouse was a benefit under the Social Security Act, do not list the amount of such compensation in Column A or B, but instead state the amount in the space below: Unemployment compensation claimed to be a benefit under the Social Security Act Debtor $ ________ Spouse $ _________ $ $

2

9

10

Income from all other sources. If necessary, list additional sources on a separate page. Do not include any benefits received under the Social Security Act or payments received as a victim of a war crime, crime against humanity, or as a victim of international or domestic terrorism. Specify source and amount. a. b. Total and enter on Line 10 $ $ $ $

11

Subtotal of Current Monthly Income for § 707(b)(7). Add Lines 3 thru 10 in
Column A, and, if Column B is completed, add Lines 3 through 10 in Column B. Enter the total(s). $ $

12

Total Current Monthly Income for § 707(b)(7). If Column B has been completed,
add Line 11, Column A to Line 11, Column B, and enter the total. If Column B has not been completed, enter the amount from Line 11, Column A. $

Part III. APPLICATION OF § 707(b)(7) EXCLUSION
13

Annualized Current Monthly Income for § 707(b)(7). Multiply the amount from Line 12 by
the number 12 and enter the result. $

14

Applicable median family income. Enter the median family income for the applicable state and household size. (This information is available by family size at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.)
a. Enter debtor's state of residence: _______________ b. Enter debtor's household size: __________ $

Application of Section 707(b)(7). Check the applicable box and proceed as directed. The amount on Line 13 is less than or equal to the amount on Line 14. Check the box for "The pre15 sumption does not arise" at the top of page 1 of this statement, and complete Part VIII; do not complete Parts IV, V, VI or VII.

The amount on Line 13 is more than the amount on Line 14. Complete the remaining parts of this statement.

Complete Parts IV, V, VI, and VII of this statement only if required. (See Line 15.)

Part IV. CALCULATION OF CURRENT MONTHLY INCOME FOR § 707(b)(2)
16 17 18

Enter the amount from Line 12. Marital adjustment. If you checked the box at Line 2.c, enter the amount of the income listed in Line
11, Column B that was NOT regularly contributed to the household expenses of the debtor or the debtor's dependents. If you did not check box at Line 2.c, enter zero.

$

$ $

Current monthly income for § 707(b)(2). Subtract Line 17 from Line 16 and enter the result.

Part V. CALCULATION OF DEDUCTIONS ALLOWED UNDER § 707(b)(2)
Subpart A: Deductions under Standards of the Internal Revenue Service (IRS)
19

National Standards: food, clothing, household supplies, personal care, and miscellaneous. Enter "Total" amount from IRS National Standards for Allowable Living Expenses for the applicable family size and income level. (This information is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) $ $

20A

Local Standards: housing and utilities; non-mortgage expenses. Enter the amount of the
IRS Housing and Utilities Standards; non-mortgage expenses for the applicable county and family size.

Form B 22A (Chapter 7) (10/05)
(This information is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court).

3

Local Standards: housing and utilities; mortgage/rent expense. Enter, in Line a below, the

20B

amount of the IRS Housing and Utilities Standards; mortgage/rent expense for your county and family size (this information is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court); enter on Line b the total of the Average Monthly Payments for any debts secured by your home, as stated in Line 42; subtract Line b from Line a and enter the result in Line 20B. Do not enter an amount less than zero. a. b. c. IRS Housing and Utilities Standards; mortgage/rental expense Average Monthly Payment for any debts secured by your home, if any, as stated in Line 42 Net mortgage/rental expense $ $ Subtract Line b from Line a. $

Local Standards: housing and utilities; adjustment. if you contend that the process set out in
21 Lines 20A and 20B does not accurately compute the allowance to which you are entitled under the IRS Housing and Utilities Standards, enter any additional amount to which you contend you are entitled, and state the basis for your contention in the space below:

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Local Standards: transportation; vehicle operation/public transportation expense.
You are entitled to an expense allowance in this category regardless of whether you pay the expenses of operating a vehicle and regardless of whether you use public transportation. 22 Check the number of vehicles for which you pay the operating expenses or for which the operating expenses are included as a contribution to your household expenses in Line 8. 0 1 2 or more. Enter the amount from IRS Transportation Standards, Operating Costs & Public Transportation Costs for the applicable number of vehicles in the applicable Metropolitan Statistical Area or Census Region. (This information is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.)

$

$

Local Standards: transportation ownership/lease expense; Vehicle 1. Check the number
of vehicles for which you claim an ownership/lease expense. (You may not claim an ownership/lease expense for more than two vehicles.) 1 2 or more.

23

Enter, in Line a below, the amount of the IRS Transportation Standards, Ownership Costs, First Car (available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court); enter in Line b the total of the Average Monthly Payments for any debts secured by Vehicle 1, as stated in Line 42; subtract Line b from Line a and enter the result in Line 23. Do not enter an amount less than zero. a. b. c. IRS Transportation Standards, Ownership Costs, First Car Average Monthly Payment for any debts secured by Vehicle 1, as stated in Line 42 Net ownership/lease expense for Vehicle 1 $ $ Subtract Line b from Line a. $

Local Standards: transportation ownership/lease expense; Vehicle 2. Complete this Line
only if you checked the "2 or more" Box in Line 23. Enter, in Line a below, the amount of the IRS Transportation Standards, Ownership Costs, Second Car (available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court); enter in Line b the total of the Average Monthly Payments for any debts secured by Vehicle 2, as stated in Line 42; subtract Line b from Line a and enter the result in Line 24. Do not enter an amount less than zero. a. b. c. IRS Transportation Standards, Ownership Costs, Second Car Average Monthly Payment for any debts secured by Vehicle 2, as stated in Line 42 Net ownership/lease expense for Vehicle 2 $ $ Subtract Line b from Line a. $

24

25

Other Necessary Expenses: taxes. Enter the total average monthly expense that you actually incur
for all federal, state and local taxes, other than real estate and sales taxes, such as income taxes, self employment taxes, social security taxes, and Medicare taxes. Do not include real estate or sales taxes.

Other Necessary Expenses: mandatory payroll deductions. Enter the total average monthly
26 payroll deductions that are required for your employment, such as mandatory retirement contributions, union dues, and uniform costs. Do not include discretionary amounts, such as non-mandatory 401(k) contributions. $

Form B 22A (Chapter 7) (10/05)
27

4
$

Other Necessary Expenses: life insurance. Enter average monthly premiums that you actually
pay for term life insurance for yourself. Do not include premiums for insurance on your dependents, for whole life or for any other form of insurance.

28

Other Necessary Expenses: court-ordered payments. Enter the total monthly amount that

you are required to pay pursuant to court order, such as spousal or child support payments. Do not include payments on past due support obligations included in Line 44.

$

29

Other Necessary Expenses: education for employment or for a physically or mentally challenged child. Enter the total monthly amount that you actually expend for education that is a

condition of employment and for education that is required for a physically or mentally challenged dependent child for whom no public education providing similar services is available.

$ $

30

Other Necessary Expenses: childcare. Enter the average monthly amount that you actually expend on childcare. Do not include payments made for children's education.

31

Other Necessary Expenses: health care. Enter the average monthly amount that you actually

expend on health care expenses that are not reimbursed by insurance or paid by a health savings account. Do not include payments for health insurance listed in Line 34.

$

Other Necessary Expenses: telecommunication services. Enter the average monthly ex32 penses that you actually pay for cell phones, pagers, call waiting, caller identification, special long distance or internet services necessary for the health and welfare of you or your dependents. Do not include any amount previously deducted. $ $

33

Total Expenses Allowed under IRS Standards. Enter the total of Lines 19 through 32.

Subpart B: Additional Expense Deductions under § 707(b)
Note: Do not include any expenses that you have listed in Lines 19-32 Health Insurance, Disability Insurance and Health Savings Account Expenses. List the
average monthly amounts that you actually expend in each of the following categories and enter the total. a. 34 b. c. Health Insurance Disability Insurance Health Savings Account $ $ $ Total: Add Lines a, b and c $

Continued contributions to the care of household or family members. Enter the actual
35

monthly expenses that you will continue to pay for the reasonable and necessary care and support of an elderly, chronically ill, or disabled member of your household or member of your immediate family who is unable to pay for such expenses.

$

36

Protection against family violence. Enter any average monthly expenses that you actually incurred to maintain the safety of your family under the Family Violence Prevention and Services Act or other applicable federal law. $

Home energy costs in excess of the allowance specified by the IRS Local Standards.
37

Enter the average monthly amount by which your home energy costs exceed the allowance in the IRS Local Standards for Housing and Utilities. You must provide your case trustee with documentation demonstrating that the additional amount claimed is reasonable and necessary.

$

Education expenses for dependent children less than 18. Enter the average monthly ex38

penses that you actually incur, not to exceed $125 per child, in providing elementary and secondary education for your dependent children less than 18 years of age. You must provide your case trustee with documentation demonstrating that the amount claimed is reasonable and necessary and not already accounted for in the IRS Standards.

$

Additional food and clothing expense. Enter the average monthly amount by which your food and
39

clothing expenses exceed the combined allowances for food and apparel in the IRS National Standards, not to exceed five percent of those combined allowances. (This information is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) You must provide your case trustee with documentation demonstrating that the additional amount claimed is reasonable and necessary.

$ $ $

40 41

Continued charitable contributions. Enter the amount that you will continue to contribute in the
form of cash or financial instruments to a charitable organization as defined in 26 U.S.C. § 170(c)(1)-(2).

Total Additional Expense Deductions under § 707(b). Enter the total of Lines 34 through 40

Form B 22A (Chapter 7) (10/05)
Subpart C: Deductions for Debt Payment
Future payments on secured claims. For each of your debts that is secured by an interest in property that you own, list the name of the creditor, identify the property securing the debt, and state the Average Monthly Payment. The Average Monthly Payment is the total of all amounts contractually due to each Secured Creditor in the 60 months following the filing of the bankruptcy case, divided by 60. Mortgage debts should include payments of taxes and insurance required by the mortgage. If necessary, list additional entries on a separate page. 42 a. b. c. Name of Creditor Property Securing the Debt $ $ $ Total: Add Lines a, b and c. $ 60-month Average Payment

5

Past due payments on secured claims. If any of the debts listed in Line 42 are in default, and the
property securing the debt is necessary for your support or the support of your dependents, you may include in your deductions 1/60th of the amount that you must pay the creditor as a result of the default (the "cure amount") in order to maintain possession of the property. List any such amounts in the following chart and enter the total. If necessary, list additional entries on a separate page. 43 Name of Creditor a. b. c. Property Securing the Debt in Default $ $ $ Total: Add Lines a, b and c 44 $ $ 1/60th of the Cure Amount

Payments on priority claims. Enter the total amount of all priority claims (including priority child
support and alimony claims), divided by 60.

Chapter 13 administrative expenses. If you are eligible to file a case under Chapter 13, complete

the following chart, multiply the amount in line a by the amount in line b, and enter the resulting administrative expense. a. 45 b. Projected average monthly Chapter 13 plan payment. Current multiplier for your district as determined under schedules issued by the Executive Office for United States Trustees. (This information is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) Average monthly administrative expense of Chapter 13 case Total: Multiply Lines a and b 46 $ $ $

x

c.

Total Deductions for Debt Payment. Enter the total of Lines 42 through 45.

Subpart D: Total Deductions Allowed under § 707(b)(2)
47

Total of all deductions allowed under § 707(b)(2). Enter the total of Lines 33, 41, and 46.

$

Part VI. DETERMINATION OF § 707(b)(2) PRESUMPTION
48 49 50 51

Enter the amount from Line 18 (Current monthly income for § 707(b)(2)) Enter the amount from Line 47 (Total of all deductions allowed under § 707(b)(2))
result

$ $ $ $

Monthly disposable income under § 707(b)(2). Subtract Line 49 from Line 48 and enter the 60-month disposable income under § 707(b)(2). Multiply the amount in Line 50 by the number 60 and enter the result.

Form B 22A (Chapter 7) (10/05)
Initial presumption determination. Check the applicable box and proceed as directed. The amount on Line 51 is less than $6,000 Check the box for "The presumption does not arise" at the top of
page 1 of this statement, and complete the verification in Part VIII. Do not complete the remainder of Part VI. 52

6

The amount set forth on Line 51 is more than $10,000. Check the box for "The presumption arises" at the
top of page 1 of this statement, and complete the verification in Part VIII. You may also complete Part VII. Do not complete the remainder of Part VI. VI (Lines 53 through 55).

The amount on Line 51 is at least $6,000, but not more than $10,000. Complete the remainder of Part
53 54

Enter the amount of your total non-priority unsecured debt Threshold debt payment amount. Multiply the amount in Line 53 by the number 0.25 and enter
the result.

$ $

Secondary presumption determination. Check the applicable box and proceed as directed. The amount on Line 51 is less than the amount on Line 54. Check the box for "The presumption does not
55 arise" at the top of page 1 of this statement, and complete the verification in Part VIII.

The amount on Line 51 is equal to or greater than the amount on Line 54. Check the box for "The presumption arises" at the top of page 1 of this statement, and complete the verification in Part VIII. You may also complete Part VII.

Part VII: ADDITIONAL EXPENSE CLAIMS
Other Expenses. List and describe any monthly expenses, not otherwise stated in this form, that are required for the
health and welfare of you and your family and that you contend should be an additional deduction from your current monthly income under § 707(b)(2)(A)(ii)(I). If necessary, list additional sources on a separate page. All figures should reflect your average monthly expense for each item. Total the expenses. 56 a. b. c. Total: Add Lines a, b and c Expense Description $ $ $ $ Monthly Amount

Part VIII: VERIFICATION
I declare under penalty of perjury that the information provided in this statement is true and correct. (If this a joint case, both debtors must sign.) 57 Date: ________________________ Date: ________________________ Signature: ________________________
(Debtor)

Signature: ________________________
(Joint Debtor, if any)