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
Districtofof___________
__________
Case number
(If known)
___________________________________________ Check if this is an
amended filing
Official Form 103B
Application to Have the Chapter 7 Filing Fee Waived 12/15
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 You
on Schedule J: Your Expenses Your spouse
(Official Form 106J).
Your dependents ___________________ _____________________
How many dependents? Total number of people
2. Fill in your family’s average
monthly income. That person’s average
monthly net income
Include your spouse’s income if (take-home pay)
your spouse is living with you, even Add your income and your spouse’s income. Include the
if your spouse is not filing. value (if known) of any non-cash governmental assistance
You .................. $_________________
that you receive, such as food stamps (benefits under the
Do not include your spouse’s Supplemental Nutrition Assistance Program) or housing
income if you are separated and subsidies.
your spouse is not filing with you.
If you have already filled out Schedule I: Your Income, see Your spouse .... + $_________________
line 10 of that schedule.
Subtotal............. $_________________
Subtract any non-cash governmental assistance that you
included above. – $_________________
Your family’s average monthly net income Total .................. $_________________
Type of assistance
3. Do you receive non-cash No
governmental assistance?
Yes. Describe. ...........
4. Do you expect your family’s No
average monthly net income to
increase or decrease by more than
Yes. Explain. .............
10% during the next 6 months?
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.
Official Form 103B Application to Have the Chapter 7 Filing Fee Waived page 1
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
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 No
who is not included in your family
as reported in line 1?
Yes. Identify who ........
8. Does anyone other than you
regularly pay any of these No
expenses? Yes. How much do you regularly receive as contributions? $_________ monthly
If you have already filled out
Schedule I: Your Income, copy the
total from line 11.
9. Do you expect your average No
monthly expenses to increase or
decrease by more than 10% during
Yes. Explain ................
the next 6 months?
Part 3: Tell the Court About Your Property
If you have already filled out Schedule A/B: Property (Official Form 106A/B) 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 Cash: $_________________
hand when you file this application
11. Bank accounts and other deposits Institution name: Amount:
of money?
Examples: Checking, savings, Checking account: __________________________________________________ $__________________
money market, or other financial
accounts; certificates of deposit; Savings account: __________________________________________________ $__________________
shares in banks, credit unions,
brokerage houses, and other Other financial accounts: __________________________________________________ $__________________
similar institutions. If you have
more than one account with the $__________________
same institution, list each. Do not Other financial accounts: __________________________________________________
include 401(k) and IRA accounts.
12. Your home? (if you own it outright or
_______________________________________________________
are purchasing it) Number Street Current value: $_________________
Examples: House, condominium, _______________________________________________________ Amount you owe
manufactured home, or mobile home City State ZIP Code on mortgage and $_________________
liens:
13. Other real estate?
_______________________________________________________ Current value: $_________________
Number Street
Amount you owe
_______________________________________________________ on mortgage and $_________________
City State ZIP Code liens:
14. The vehicles you own? Make: _____________________
Current value: $_________________
Examples: Cars, vans, trucks, Model: _____________________
sports utility vehicles, motorcycles, Year: ____________ Amount you owe
tractors, boats on liens: $_________________
Mileage _____________________
Make: _____________________
Model: _____________________ Current value: $_________________
Year: ____________
Amount you owe
Mileage _____________________ on liens: $_________________
Official Form 103B Application to Have the Chapter 7 Filing Fee Waived page 2
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
15. Other assets? Describe the other assets:
Current value: $_________________
Do not include household items $_________________
and clothing. Amount you owe
on liens:
16. Money or property due you? Who owes you the money or property? How much is owed? Do you believe you will likely receive
payment in the next 180 days?
Examples: Tax refunds, past due
or lump sum alimony, spousal ___________________________________________ $_________________ No
support, child support,
maintenance, divorce or property
___________________________________________ $_________________
Yes. Explain:
settlements, Social Security
benefits, workers’ compensation,
personal injury recovery
Part 4: Answer These Additional Questions
17. Have you paid anyone for No
services for this case, including
filling out this application, the
Yes. Whom did you pay? Check all that apply: How much did you pay?
bankruptcy filing package, or the An attorney
schedules? $______________________
A bankruptcy petition preparer, paralegal, or typing service
Someone else ________________________________________
18. Have you promised to pay or do No
you expect to pay someone for
services for your bankruptcy
Yes. Whom do you expect to pay? Check all that apply:
How much do you
case? An attorney expect to pay?
A bankruptcy petition preparer, paralegal, or typing service
$_______________________
Someone else _________________________________________
19. Has anyone paid someone on No
your behalf for services for this
case?
Yes. Who was paid on your behalf? Who paid? How much did
Check all that apply: Check all that apply: someone else pay?
An attorney Parent
$______________________
A bankruptcy petition preparer, Brother or sister
paralegal, or typing service Friend
Someone else _________________ Pastor or clergy
Someone else __________
20. Have you filed for bankruptcy No
within the last 8 years?
Yes. District _____________________________ When _____________ Case number _____________________
MM/ DD/ YYYY
District _____________________________ When _____________ Case number _____________________
MM/ DD/ YYYY
District _____________________________ When _____________ Case number _____________________
MM/ DD/ YYYY
Part 5: Sign Below
By signing here under penalty of perjury, I declare that I cannot afford to pay the filing fee either in full or in installments. I also declare
that the information I provided in this application is true and correct.
_____________________________________________ _____________________________________________
Signature of Debtor 1 Signature of Debtor 2
Date __________________ Date __________________
MM / DD / YYYY MM / DD / YYYY
Official Form 103B Application to Have the Chapter 7 Filing Fee Waived page 3
Fill in this information to identify the 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)
Order on the Application to Have the Chapter 7 Filing Fee Waived
After considering the debtor’s Application to Have the Chapter 7 Filing Fee Waived (Official Form 103B), the court
orders that the application is:
[ ] Granted. However, the court may order the debtor to pay the fee in the future if developments in
administering the bankruptcy case show that the waiver was unwarranted.
[ ] Denied. The debtor must pay the filing fee according to the following terms:
You must pay… On or before this date…
_____________
$_____________ Month / day / year
$_____________ _____________
Month / day / year
$_____________ _____________
Month / day / year
+ $_____________ _____________
Month / day / year
Total
If the debtor would like to propose a different payment timetable, the debtor must file a
motion promptly with a payment proposal. The debtor may use Application for Individuals to
Pay the Filing Fee in Installments (Official Form 103A) for this purpose. The court will
consider it.
The debtor must pay the entire filing fee before making any more payments or transferring any
more property to an attorney, bankruptcy petition preparer, or anyone else in connection with the
bankruptcy case. The debtor must also pay the entire filing fee to receive a discharge. If the
debtor does not make any payment when it is due, the bankruptcy case may be dismissed and
the debtor’s rights in future bankruptcy cases may be affected.
[ ] Scheduled for hearing.
A hearing to consider the debtor’s application will be held
on _____________ at _________ AM / PM at _________________________________________.
Month / day / year Address of courthouse
If the debtor does not appear at this hearing, the court may deny the application.
_____________ By the court: _____________________________________
Month / day / year United States Bankruptcy Judge
Print Save As... Add Attachment Reset
