Application To Have Chapter 7 Filing Fee Waived And Order {NYEB 103B}

Fill in this information to identify your case: Debtor 1 Debtor 2 ________________________________________________________________ First Name Middle Name Last Name (Spouse, if filing) First Name ________________________________________________________________ Middle Name Last Name United States Bankruptcy Court for the: __________________________ District of ________ (If known) Check if this is an amended filing Case number ___________________________________________ Official Form B 3B Application to Have the Chapter 7 Filing Fee Waived 12/13 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? Check all that apply: Your family includes you, your spouse, and any dependents listed on Schedule J: Current Expenditures of Individual Debtor(s) (Official Form B 6J). You Your spouse Your dependents ___________________ How many dependents? _____________________ Total number of people 2. Fill in your family's average monthly income. Include your spouse's income if your spouse is living with you, even if your spouse is not filing. Do not include your spouse's income if you are separated and your spouse is not filing with you. 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. That person's average monthly net income (take-home pay) 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-cash governmental assistance? No Yes. Describe. ........... Type of assistance 4. Do you expect your family's average monthly net income to increase or decrease by more than 10% during the next 6 months? No Yes. Explain. ............. 5. Tell the court why you are unable to pay the filing fee in installments within 120 days. If you have some additional circumstances that cause you to not be able to pay your filing fee in installments, explain them. Application to Have the Chapter 7 Filing Fee Waived page 1 American LegalNet, Inc. www.FormsWorkFlow.com Official Form B 3B Debtor 1 First Name _______________________________________________________ Middle Name Last Name Case number (if known)_____________________________________ Part 2: Tell the Court About Your Monthly Expenses 6. Estimate your average monthly expenses. Include amounts paid by any government assistance that you reported on line 2. If you have already filled out Schedule J, Your Expenses, copy line 22 from that form. 7. Do these expenses cover anyone $___________________ who is not included in your family as reported in line 1? 8. Does anyone other than you No Yes. Identify who ........ regularly pay any of these expenses? If you have already filled out Schedule I: Your Income, copy the total from line 11. 9. Do you expect your average No Yes. How much do you regularly receive as contributions? $_________ monthly monthly expenses to increase or decrease by more than 10% during the next 6 months? No Yes. Explain ............... Part 3: Tell the Court About Your Property If you have already filled out Schedule A: Real Property (Official Form B 6A) and Schedule B: Personal Property (Official Form B 6B), 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, and on hand when you file this application 11. Bank accounts and other deposits Cash: $_________________ of money? Examples: Checking, savings, money market, or other financial accounts; certificates of deposit; shares in banks, credit unions, brokerage houses, and other similar institutions. If you have more than one account with the same institution, list each. Do not include 401(k) and IRA accounts. 12. Your home? (if you own it outright or Institution name: Checking account: Savings account: Other financial accounts: Other financial accounts: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Amount: $__________________ $__________________ $__________________ $__________________ are purchasing it) _______________________________________________________ Number Street _______________________________________________________ ZIP Code City State Current value: Amount you owe on mortgage and liens: Current value: Amount you owe on mortgage and liens: $_________________ $_________________ Examples: House, condominium, manufactured home, or mobile home 13. Other real estate? _______________________________________________________ Number Street _______________________________________________________ City State ZIP Code $_________________ $_________________ 14. The vehicles you own? Make: Model: Year: Mileage Make: Model: Year: Mileage _____________________ _____________________ ____________ _____________________ _____________________ _____________________ ____________ _____________________ Examples: Cars, vans, trucks, sports utility vehicles, motorcycles, tractors, boats Current value: Amount you owe on liens: $_________________ $_________________ Current value: Amount you owe on liens: $_________________ $_________________ Official Form B 3B Application to Have the Chapter 7 Filing Fee Waived page 2 American LegalNet, Inc. www.FormsWorkFlow.com Debtor 1 First Name _______________________________________________________ Middle Name Last Name Case number (if known)_____________________________________ 15. Other assets? Describe the other assets: Do not include household items and clothing. Current value: Amount you owe on liens: $_________________ $_________________ 16. Money or property due you? Who owes you the money or property? ___________________________________________ __________________________________