Free 341 Declaration - Chapter 13 (re: Pay Advices, Tax Returns, DSOs) - Hawaii

UNITED STATES BANKRUPTCY COURT DISTRICT OF HAWAII
Name of Debtor or Joint Debtor (Complete for each individual): Case No.:
(if known)

Chapter 13

"341 DECLARATION" CHAPTER 13 DEBTOR'S DECLARATION AND CHECKLIST REGARDING DEBTOR'S RESPONSIBILITIES
Instructions: The Chapter 13 Trustee requires the information in this declaration for your examination at the § 341 meeting of creditors. Mail this declaration to the Trustee at least 7 days before the meeting date. If you have an attorney, your attorney may be able to transmit your declaration electronically. Do not file this declaration with the court. Declaration Under Penalty of Perjury. The undersigned states the following under penalty of perjury. A. Payment Advices (or other evidence of payment such as wage statements, pay stubs, etc.) I have submitted or will be submitting copies of payment advices for all payments received from an employer during the 60 days before the date of filing of my bankruptcy petition. I am not submitting payment advices received from my employer because: I was not employed during these dates: from ____________________ to ____________________. I was employed but have not received any payment advices or other evidence of payment from my employer during the 60day period before filing my petition. I am selfemployed and do not receive any evidence of payment from an employer. Other reason [Explain on page 2]. B. Most Recent Federal Income Tax Return or Transcript I have submitted or will be submitting my federal income tax return or transcript for the most recent tax year ending immediately before the date of filing of my bankruptcy petition. I am not submitting my federal income tax return or transcript for the most recent tax year ending immediately before the date of filing of my bankruptcy petition because: I had insufficient gross income to require the filing of a federal tax return for tax year: ___________. My income for that tax year was: $__________________. Other reason [Explain on page 2]. C. Tax Returns for Prior Years (Federal, State, Local) I have filed all returns for federal, state, and local taxes due for the 4 years preceding this case. D. Domestic Support Obligation(s) (child support, alimony, obligations under divorce agreement, etc.) I have one or more domestic support obligations requiring payment to an individual or governmental unit. The name and address of each payee is provided on page 2. E. Adequate Protection Payment(s) I am including in my payment to the Trustee a preconfirmation adequate protection amount to be paid to a creditor secured by personal property. The payment information for each creditor is provided on page 2. F. Lease Payment(s) I am including in my payment to the Trustee a preconfirmation amount to be paid to a lessor of personal property. The payment information for each lessor is provided on page 2. Date: ____________________ /s/____________________________ Signature of Debtor

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A. Payment Advices ­ Additional information: B. Most Recent Federal Income Tax Return ­ Additional information: C. Tax Returns for Prior Years ­ Additional information: D. Domestic Support Obligation(s) ­ Name and address of each payee: E. Adequate Protection Payment(s) Payee Name and Address Account # F. Lease Payment(s) Payee Name and Address Account #

Property Description

Payment Amount

Property Description

Payment Amount

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