Questionnaire #11 - Means Test

Please complete this questionnaire regarding your last six months income. The are the instructions on the Form 122A-1 form, "Be as complete and accurate as possible.  If two married people are filing together, both are equally responsible for being accurate.  If more space is needed, attach a separate sheet to this form.  Include the line number to which the additional information applies.  On the top of any additional pages, write your name and case number (if known).  If you believe that you are exempted from a presumption of abuse because you do not have primarily consumer debts or because of qualifying military service, complete and file Statement of Exemption from Presumption of Abuse Under § 707(b)(2) (Official Form 122A-1Supp) with this form."

 

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in

Questionnaire 11 - Means Test

Name*

Phone*

Email Address

*

Primary Filer last six months Gross Wages

Secondary Filer last six months Gross Wages

Primary Filer last six months Unemployment

Joint Filer last six months Unemployment

Primary Filer last six months Pension or Retirement

Joint Filer last six months Pension or Retirement

Primary Filer last six months Alimony

Joint Filer last six months Alimony

Primary Filer last six months Child Support

Joint Filer last six months Child Support

All amounts from any source which are regularly paid for household expenses of you or your dependents, including child support. Include regular contributions from an unmarried partner, members of your household, your dependents, parents, and roommate and separated, non-filing spouse

Net income from operating a business, profession, or farm List Business Owner(s) Gross receipts (before all deductions) AND Ordinary and necessary operating expenses from a business, profession, or farm

Income from all other sources not listed above. Specify the source and amount. Do not include any benefits received under the Social Security Act or payments received as a victim of a war crime, a crime against humanity, or international or domestic terrorism. If necessary, list other sources on a separate page and put the total below.

PLEASE HIT SUBMIT

THANK-YOU

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