Official Form 122B "Chapter 11 Statement of Your Current Monthly Income"

What Is Official Form 122B?

This is a legal form that was released by the United States Bankruptcy Court on April 1, 2020 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest available edition released by the United States Bankruptcy Court;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Official Form 122B by clicking the link below or browse more documents and templates provided by the United States Bankruptcy Court.

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Download Official Form 122B "Chapter 11 Statement of Your Current Monthly Income"

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Fill in this information to identify your case:
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
_________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
___________
__________
United States Bankruptcy Court for the:
District of
__________ District of __________
Case number
___________________________________________
(If known)
Check if this is an amended filing
Official Form 122B
Chapter 11 Statement of Your Current Monthly Income
04/20
You must file this form if you are an individual and are filing for bankruptcy under Chapter 11. 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).
Part 1:
Calculate Your Current Monthly Income
1. What is your marital and filing status? Check one only.
Not married. Fill out Column A, lines 2-11.
Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11.
Married and your spouse is NOT filing with you. Fill out Column A, lines 2-11.
Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this bankruptcy
case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through August 31. If the
amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6. Fill in the result.
Do not include any income amount more than once. For example, if both spouses own the same rental property, put the income from that
property in one column only. If you have nothing to report for any line, write $0 in the space.
Column A
Column B
Debtor 1
Debtor 2
2. Your gross wages, salary, tips, bonuses, overtime, and commissions (before all
payroll deductions).
$____________
$__________
3. Alimony and maintenance payments. Do not include payments from a spouse if
Column B is filled in.
$____________
$__________
4. 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
roommates. Include regular contributions from a spouse only if Column B is not filled in.
$____________
$__________
Do not include payments you listed on line 3.
5. Net income from operating a business, profession,
Debtor 1
Debtor 2
or farm
$______
$______
Gross receipts (before all deductions)
Ordinary and necessary operating expenses
$______
$______
Copy
$______
$______
Net monthly income from a business, profession, or farm
here
$__________
$_________
6. Net income from rental and other real property
Debtor 1
Debtor 2
$______
$______
Gross receipts (before all deductions)
Ordinary and necessary operating expenses
$______
$______
Copy
Net monthly income from rental or other real property
$__________
$_________
$______
$______
here
Official Form 122B
Chapter 11 Statement of Your Current Monthly Income
page 1
Fill in this information to identify your case:
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
_________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
___________
__________
United States Bankruptcy Court for the:
District of
__________ District of __________
Case number
___________________________________________
(If known)
Check if this is an amended filing
Official Form 122B
Chapter 11 Statement of Your Current Monthly Income
04/20
You must file this form if you are an individual and are filing for bankruptcy under Chapter 11. 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).
Part 1:
Calculate Your Current Monthly Income
1. What is your marital and filing status? Check one only.
Not married. Fill out Column A, lines 2-11.
Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11.
Married and your spouse is NOT filing with you. Fill out Column A, lines 2-11.
Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this bankruptcy
case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through August 31. If the
amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6. Fill in the result.
Do not include any income amount more than once. For example, if both spouses own the same rental property, put the income from that
property in one column only. If you have nothing to report for any line, write $0 in the space.
Column A
Column B
Debtor 1
Debtor 2
2. Your gross wages, salary, tips, bonuses, overtime, and commissions (before all
payroll deductions).
$____________
$__________
3. Alimony and maintenance payments. Do not include payments from a spouse if
Column B is filled in.
$____________
$__________
4. 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
roommates. Include regular contributions from a spouse only if Column B is not filled in.
$____________
$__________
Do not include payments you listed on line 3.
5. Net income from operating a business, profession,
Debtor 1
Debtor 2
or farm
$______
$______
Gross receipts (before all deductions)
Ordinary and necessary operating expenses
$______
$______
Copy
$______
$______
Net monthly income from a business, profession, or farm
here
$__________
$_________
6. Net income from rental and other real property
Debtor 1
Debtor 2
$______
$______
Gross receipts (before all deductions)
Ordinary and necessary operating expenses
$______
$______
Copy
Net monthly income from rental or other real property
$__________
$_________
$______
$______
here
Official Form 122B
Chapter 11 Statement of Your Current Monthly Income
page 1
_______________________________________________________
Case number
_____________________________________
Debtor 1
(if known)
First Name
Middle Name
Last Name
Column A
Column B
Debtor 1
Debtor 2
7. Interest, dividends, and royalties
$____________
$__________
8. Unemployment compensation
$____________
$__________
Do not enter the amount if you contend that the amount received was a benefit
under the Social Security Act. Instead, list it here: ...............................
For you ........................................................................
$_________
For your spouse ...........................................................
$_________
9. Pension or retirement income. Do not include any amount received that was a
benefit under the Social Security Act. Also, except as stated in the next sentence,
do not include any compensation, pension, pay, annuity, or allowance paid by the
United States Government in connection with a disability, combat-related injury or
disability, or death of a member of the uniformed services. If you received any
retired pay paid under chapter 61 of title 10, then include that pay only to the
extent that it does not exceed the amount of retired pay to which you would
otherwise be entitled if retired under any provision of title 10 other than chapter 61
of that title.
$__________
$____________
10. Income from all other sources not listed above. Specify the source and amount.
Do not include any benefits received under the Social Security Act; payments made
under the Federal law relating to the national emergency declared by the President
under the National Emergencies Act (50 U.S.C. 1601 et seq.) with respect to the
coronavirus disease 2019 (COVID-19); payments received as a victim of a war
crime, a crime against humanity, or international or domestic terrorism; or
compensation, pension, pay, annuity, or allowance paid by the United States
Government in connection with a disability, combat-related injury or disability, or
death of a member of the uniformed services. If necessary, list other sources on a
separate page and put the total below.
$__________
________________________________________
$____________
$__________
________________________________________
$____________
+
+
Total amounts from separate pages, if any.
$____________
$__________
11. Calculate your total current monthly income.
+
=
Add lines 2 through 10 for each column.
Then add the total for Column A to the total for Column B.
$_______
$____________
$_________
Total current
monthly income
Part 2:
Sign Below
By signing here, under penalty of perjury I declare that the information on this statement and in any attachments is true and correct.
______________________________________
______________________________________________
Signature of Debtor 1
Signature of Debtor 2
_________________
_________________
Date
Date
MM / DD
/ YYYY
MM / DD
/ YYYY
Official Form 122B
Chapter 11 Statement of Your Current Monthly Income
page 2
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