Annual Statement (Chapter 13) {13-22}

FLNB Local Form 13-22 (Rev. 08/2011) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA DIVISION In re: Case No.: Chapter: 13 Debtor(s) ANNUAL STATEMENT (Pursuant to 11 U.S.C. § 521(f) and Standing Order of this Court) COMES NOW the Debtor(s), by and through the undersigned attorney(s), if applicable, and files this Annual Statement in accordance with 11 U.S.C. § 521(f) and Standing Order of this Court, and hereby states as follows: 1. The income and expenditures of the Debtor(s) during the tax year most recently concluded before this Annual Statement is filed are detailed on the attached Schedule I and J worksheets. The method of calculation of the Debtor(s)' monthly income and expenditures is detailed on the attached Schedules I and J worksheets. The attached Schedule I and J worksheets are not intended to amend previously filed schedules. 2. The Debtor(s)' monthly income is disclosed as follows: a. The amount and source of income of the Debtor(s): b. The identity of any person who shares responsibility for the support of any dependent(s) of the Debtor(s): c. The identity of any person who contributed, and the amount contributed, to the household in which the Debtor(s) resides: Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. The debtor(s) will or will not be filing a Motion to Modify Chapter 13 Plan due to changes in income and expenses as shown on the attached Schedules I and J worksheets. 4. The Debtor(s) has complied with related provisions for the submission of tax returns to the Chapter 13 Trustee. The Debtor(s)' attorney, if Debtor(s) is represented, is now eligible for disbursement of $250.00, and the Trustee is authorized to disburse said funds, if available. RESPECTFULLY SUBMITTED this day of , 20 . Debtor OR Debtor(s)' Attorney Signature CERTIFICATE OF SERVICE I HEREBY certify that a true and accurate copy of the foregoing has been furnished by electronic filing or first class mail to: on the day of , . Page 2 American LegalNet, Inc. www.FormsWorkFlow.com