CACB — Schedule I: Your Income (106I)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/106I.pdf

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: ____________________DistrictDistrictof ___________of __________

Case number ___________________________________________ Check if this is: (If known) An amended filing A supplement showing postpetition chapter 13 income as of the following date: Official Form 106I ________________MM / DD / YYYY

12/15Schedule I: Your Income

Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your spouse. If you are separated and your spouse is not filing with you, do not include information about your spouse. 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). Answer every question.

Part 1: Describe Employment

1. Fill in your employment information. Debtor 1 Debtor 2 or non-filing spouse

   If you have more than one job, attach a separate page with Employment status Employed Employed information about additional

employers. Not employed Not employed

Include part-time, seasonal, or
self-employed work.
Occupation __________________________________ __________________________________

Occupation may include student or homemaker, if it applies.

Employer’s name __________________________________ __________________________________

Employer’s address _______________________________________ ________________________________________
Number Street Number Street

_______________________________________ ________________________________________

_______________________________________ ________________________________________

---

City State ZIP Code City State ZIP Code

How long employed there? _______ _______

Part 2: Give Details About Monthly Income

Estimate monthly income as of the date you file this form. If you have nothing to report for any line, write $0 in the space. Include your non-filing spouse unless you are separated. If you or your non-filing spouse have more than one employer, combine the information for all employers for that person on the lines below. If you need more space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or
non-filing spouse

2. List monthly gross wages, salary, and commissions (before all payroll deductions). If not paid monthly, calculate what the monthly wage would be. 2. $___________ $____________

3. Estimate and list monthly overtime pay. 3. + $___________ + $____________

4. Calculate gross income. Add line 2 + line 3. 4. $__________ $____________

Official Form 106I Schedule I: Your Income page 1

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

For Debtor 1 For Debtor 2 or
non-filing spouse

Copy line 4 here ............................................................................................... 4. $___________ $_____________

5. List all payroll deductions:

   5a. Tax, Medicare, and Social Security deductions 5a. $____________ $_____________

   5b. Mandatory contributions for retirement plans 5b. $____________ $_____________

   5c. Voluntary contributions for retirement plans 5c. $____________ $_____________

   5d. Required repayments of retirement fund loans 5d. $____________ $_____________

   5e. Insurance 5e. $____________ $_____________

   5f. Domestic support obligations 5f. $____________ $_____________ 5g. Union dues 5g. $____________ $_____________ 5h. Other deductions. Specify: __________________________________ 5h. + $____________ + $_____________

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h. 6. $____________ $_____________

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $____________ $_____________

8. List all other income regularly received:

   8a. Net income from rental property and from operating a business, profession, or farm Attach a statement for each property and business showing gross receipts, ordinary and necessary business expenses, and the total $____________ $_____________ monthly net income. 8a. 8b. Interest and dividends 8b. $____________ $_____________ 8c. Family support payments that you, a non-filing spouse, or a dependent regularly receive Include alimony, spousal support, child support, maintenance, divorce $____________ $_____________ settlement, and property settlement. 8c.

   8d. Unemployment compensation 8d. $____________ $_____________ 8e. Social Security 8e. $____________ $_____________

8f. Other government assistance that you regularly receive Include cash assistance and the value (if known) of any non-cash assistance that you receive, such as food stamps (benefits under the Supplemental Nutrition Assistance Program) or housing subsidies. Specify: ___________________________________________________ 8f. $____________ $_____________

8g. Pension or retirement income 8g. $____________ $_____________
8h. Other monthly income. Specify: _______________________________ 8h. + $____________ + $_____________

9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h. 9. $____________ $_____________

10. Calculate monthly income. Add line 7 + line 9. $___________ + $_____________ = $_____________ Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse. 10.

11. State all other regular contributions to the expenses that you list in Schedule J. Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and other friends or relatives. Do not include any amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J. Specify: _______________________________________________________________________________ 11. + $_____________

12. Add the amount in the last column of line 10 to the amount in line 11. The result is the combined monthly income. Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies 12. $_____________ Combined monthly income

13. Do you expect an increase or decrease within the year after you file this form? No. Yes. Explain:

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