CACB — Check if this is an amended filing (122B)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/122B.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: Central______________________District of CaliforniaDistrict of __________ (State) Case number ___________________________________________ (If known) Check if this is an amended filing

Official Form 122B Chapter 11 Statement of Your Current Monthly Income 12/21 You must file this form if you are an individual and are filing for bankruptcy under Chapter 11 (other than under Subchapter V). 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, or farm Debtor 1 Debtor 2 Gross receipts (before all deductions) $______ $______ Ordinary and necessary operating expenses – $______ – $______ Net monthly income from a business, profession, or farm $______ $______ Copy 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

Debtor 1 _______________________________________________________ Case number (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 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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