Form B22A (Chapter 7) (10/05)
In re: According to the calculations required by this statement:
Case
No: The presumption does not arise
STATEMENT OF CURRENT MONTHLY INCOME AND MEANS TEST CALCULATION
FOR USE IN CHAPTER 7 ONLY
In addition to Schedule I and J, this statement must be completed by every individual Chapter 7 debtor, whether or not filing
jointly, whose debts are primarily consumer debts. Joint debtors may complete one statement only.
Part I. EXCLUSION FOR DISABLED VETERANS
If you are a disabled veteran described in the Veteran’s Declaration in this Part I, (1) type the letter "X" in the box below
next to the Veteran’s Declaration, and (2) complete the verification in Part VIII. Do not complete any of the remaining parts
of this statement.
1 Veteran’s Declaration. By typing the letter "X" in this box, I declare under penalty of perjury that I am a
disabled veteran (as defined in 38 U.S.C. § 3741(1)) whose indebtedness occurred primarily during a period
in which I was on active duty (as defined in 10 U.S.C. § 101(d)(1)) or while I was performing a homeland
defense activity (as defined in 32 U.S.C. §901(1)).
Part II. CALCULATION OF MONTHLY INCOME FOR § 707(b)(7) EXCLUSION
Marital/filing status. Place an "X" in the box that applies and complete the balance of this part of this statement as directed.
a. Unmarried. Complete only Column A ("Debtor's Income) for Lines 3-11.
Married, not filing jointly, with declaration of separate households. By checking this box, debtor
declares under penalty of perjury: "My spouse and I are legally separated under applicable non-
b. bankruptcy law or my spouse and I are living apart other than for the purpose of evading the
requirements of § 707(b)(2)(A) of the Bankruptcy Code.” Complete only Column A
(“Debtor’s Income”) for Lines 3-11.
2 Married, not filing jointly, without the declaration of separate households set out in Line 2.b
c. above. Complete both Column A (“Debtor’s Income”) and Column B ("Spouse’s
Income") for Lines 3-11.
Married, filing jointly. Complete both Column A (“Debtor’s Income”) and Column B
d.
("Spouse’s Income") for Lines 3-11.
All figures must reflect average monthly income for the six calendar months prior to filing the Column A Column B
bankruptcy case, ending on the last day of the month before the filing. If you received different Debtor's Spouse's
amounts of income during these six months, you must total the amounts received during the six Income Income
months, divide this total by six, and enter the result on the appropriate line.
3 Gross wages, salary, tips, bonuses, overtime, commissions.
Income from the operation of a business, profession or farm. Enter gross receipts from business
in Line a and ordinary and necessary expenses in Line b. Do not include any part of the
business expenses entered on Line b as a deduction in Part V.
4 a. Gross receipts
b. Ordinary and necessary business expenses
c. Business income $ -
Rent and other real property income. Enter gross receipts from real property in Line a and
ordinary and necessary expenses in Line b. Do not include any part of the operating
expenses entered on Line b as a deduction in Part V.
5
a. Gross receipts
b. Ordinary and necessary business expenses
c. Business income $ -
6 Interest, dividends and royalties.
7 Pension and retirement income. $ -
Regular contributions to the household expenses of the debtor or the debtor's dependents,
8 including child or spousal support. Do not include contributions from the debtor's spouse if
Column B is completed.
Form B22A (Ch. 7) Page 1 of 45 Fla. M.D., S.D., N.D.
Unemployment compensation. Enter the amount in Column A and, if applicable, Column B.
However, if you contend that unemployment compensation received by you or your spouse was a
benefit under the Social Security Act, do not list the amount of such compensation in
Column A or B, but instead state the amount in the space below:
9
Unemployment compensation claimed to be a benefit under Social Security paid to
Debtor.
Unemployment compensation claimed to be a benefit under Social Security paid to
Spouse.
Income from all other sources. If necessary, list additional sources on a separate page. Do not
include any benefits received under the Social Security Act or payments received as a victim of a
10 war crime, crime against humanity, or as a victim of international or domestic terrorism. Specify
source below and amount in Collumn A or B, as applicable.
Describe:
Total income from other sources:
11 Subtotal of Current Monthly Income for § 707(b)(7). $ - $ -
12 Total Current Monthly Income for § 707(b)(7). $ -
Part III. APPLICATION OF § 707(b)(7) EXCLUSION
13 Annualized Current Monthly Income for § 707(b)(7). $ -
List number of individuals in your household:
14
Applicable median family income for Florida residents: $ -
Application of Section 707(b)(7):
15 Because your family income does not exceed the median income for a family of similar size for your state, the
presumption of abuse in your case does not arise; do not complete Parts IV, V, VI, and VII of this form.
Complete Parts IV, V, VI, and VII of this statement only if required. (See Line 15).
Part IV. CALCULATION OF CURRENT MONTHLY INCOME FOR § 707(b)(2)
16 Amount from Line 12. $ -
Marital adjustment. If you checked the box at Line 2.c, enter the amount of the income listed in Line 11,
17 Column B that was NOT regularly contributed to the household expenses of the debtor or the debtor's $ -
dependents. If you did not check box at Line 2.c, enter zero.
18 Current monthly income for § 707(b)(2). $ -
Part V. CALCULATION OF DEDUCTIONS ALLOWED UNDER § 707(b)(2)
Subpart A: Deductions under Standards of the Internal Revenue Service (IRS)
19 National Standards: food, clothing, household supplies, personal care, and miscellaneous. $ -
20 Choose the county in which you reside from the drop down menu: Hillsborough
A Local Standards: housing and utilities; non-mortgage expenses. $ -
Local Standards: housing and utilities; mortgage/rental expenses. The amount of your Average
20
Monthly Payments for any debts secured by your home as listed in Line 42 below will be deducted from the
B
mortgage/rent expense set forth in Line 20. $ -
Local Standards: housing and utilities; adjustment. If you contend that the process set out in Lines 20A
and 20B does not accurately compute the allowance to which you are entitled under the IRS Housing and
Utilities Standards, enter any additional amount to which you contend you are entitled, and state the basis for
21 your contention in the space below:
Form B22A (Ch. 7) Page 2 of 45 Fla. M.D., S.D., N.D.
Local Standards: transportation; vehicle operation/public transportation expense. You are entitled to
an expense allowance in this category regardless of whether you pay the expenses of operating a vehicle and
regardless of whether you use public transportation.
22
Enter no. of vehicles for which you pay operating expenses or for which the operating expenses
are included as a contribution to your household expenses in Line 8.
Select from dropdown menu Miami, Tampa, or Other as city of residence: Other $ -
Local Standards: transportation ownership/lease expense; Vehicle 1. The amount of your Average
Monthly Payments for any debts secured by this vehicle as listed in Line 42 below will be deducted from the
ownership/lease expense expense set forth in Line 23.
23
Enter the number of vehicles for which you claim an ownership/lease expense in the space
provided to the right below. (You may not claim an ownership/lease expense for more than two
vehicles.) $ -
Local Standards: transportation ownership/lease expense; Vehicle 2. The amount of your Average
24 Monthly Payments for any debts secured by this vehicle as listed in Line 42 below will be deducted from the
ownership/lease expense expense set forth in Line 24. $ -
Other Necessary Expenses: taxes. Enter the total average monthly expense that you actually incur for all
25 federal, state and local taxes, other than real estate and sales taxes, such as income taxes, self employment
taxes, social security taxes, and Medicare taxes. Do not include real estate or sales taxes.
Other Necessary Expenses: mandatory payroll deductions. Enter the total average monthly payroll
deductions that are required for your employment, such as mandatory retirement contributions, union dues,
26
and uniform costs. Do not include discretionary amounts, such as non-mandatory 401(k)
contributions.
Other Necessary Expenses: life insurance. Enter average monthly premiums that you actually pay for
27 term life insurance for yourself. Do not include premiums for insurance on your dependents, for whole
life or for any other form of insurance.
Other Necessary Expenses: court-ordered payments. Enter the total monthly amount that you are
28 required to pay pursuant to court order, such as spousal or child support payments. Do not include
payments on past due support obligations included in Line 44.
Other Necessary Expenses: education for employment or for a physically or mentally challenged
child. Enter the total monthly amount that you actually expend for education that is a condition of
29
employment and for education that is required for a physically or mentally challenged dependent child for
whom no public education providing similar services is available.
Other Necessary Expenses: childcare. Enter the average monthly amount that you actually expend on
30
childcare. Do not include payments made for children's education.
Other Necessary Expenses: health care. Enter the average monthly amount that you actually expend on
31 health care expenses that are not reimbursed by insurance or paid by a health savings account. Do not
include payments for health insurance listed in Line 34.
Other Necessary Expenses: telecommunication services. Enter the average monthly expenses that you
actually pay for cell phones, pagers, call waiting, caller identification, special long distance or internet services
32
necessary for the health and welfare of you or your dependents. Do not include any amount previously
deducted.
33 Total Expenses Allowed under IRS Standards. $ -
Subpart B: Additional Expense Deductions under § 707(b)
Note: Do not include any expenses that you have listed in Lines 19-32
Health Insurance, Disability Insurance and Health Savings Account Expenses. List the average
monthly amounts that you actually expend in each of the following categories and enter the total.
34 a. Health Insurance
b. Disability Insurance
c. Health Savings Account
Total of Lines a, b, and c: $ -
Continued contributions to the care of household or family members. Enter the actual monthly
expenses that you will continue to pay for the reasonable and necessary care and support of an elderly,
35
chronically ill, or disabled member of your household or member of your immediate family who is unable to
pay for such expenses.
Protection against family violence. Enter any average monthly expenses that you actually incurred to
36 maintain the safety of your family under the Family Violence Prevention and Services Act or other applicable
federal law.
Form B22A (Ch. 7) Page 3 of 45 Fla. M.D., S.D., N.D.
Home energy costs in excess of the allowance specified by the IRS Local Standards. Enter the
37 average monthly amount by which your home energy costs exceed the allowance in the IRS Local Standards
for Housing and Utilities. You must provide your case trustee with documentation demonstrating that
the additional amount claimed is reasonable and necessary.
Education expenses for dependent children less than 18. Enter the average monthly expenses that you
actually incur, not to exceed $125 per child, in providing elementary and secondary education for your
38 dependent children less than 18 years of age. You must provide your case trustee with documentation
demonstrating that the amount claimed is reasonable and necessary and not already accounted for
in the IRS Standards.
Additional food and clothing expense. You must provide your case trustee with documentation
demonstrating that the additional amount claimed is reasonable and necessary. Enter the amount
actually expended for food and apparel on a monthly basis in the spaces provided to the right
39 below. $ -
Actual Food:
Actual Apparel:
40 Continued charitable contributions. Enter the amount that you will continue to contribute in the form of
cash or financial instruments to a charitable organization as defined in 26 U.S.C. § 170(c)(1)-(2).
41 Total Additional Deductions under § 707(b). $ -
Subpart C: Deductions for Debt Payments
Future payments on secured claims. For each of your debts that is secured by an interest in property that
you own, list the name of creditor, identify the property securing the debt, and state the Average Monthly
Payment. The Average Monthly Payment is the total of all amounts contractually due to each Secured Creditor
in the 60 months following the filing of the bankruptcy case, divided by 60. Mortgage debts should include
payments of taxes and insurance required by the mortgage. If necessary, list additional entries on a separate
page.
42 Name of Creditor Property Securing the Debt Ave. Monthly Payment
a. 1st mortgage on residence:
b. 2nd mortgage on residence:
c. Auto #1 loan:
d. Auto #2 loan:
e. $ -
Total of Lines a, b, c and d $ -
Past due payments on secured claims. If any of the debts listed in Line 42 are in default, and the property
securing the debt is necessary for your support or the support of your dependents, you may include in your
deductions 1/60th of the amount that you must pay the creditor as a result of the default (the “cure amount”)
in order to maintain possession of the property. List any such amounts in the following chart and enter the
total. If necessary, list additional entries on a separate page.
43
Name of Creditor Property Securing the Debt 1/60 of the Cure Amount
a.
b.
c. $ -
Total of lines a, b, and c $ -
Payments on priority claims. Enter the total amount of all priority claims (including priority child support
44
and alimony claims), divided by 60.
Chapter 13 administrative expenses. If you are eligible to file a case under Chapter 13 you may deduct
Chapter 13 administrative expenses as set forth below.
45 a. Projected average monthly Chapter 13 plan payment. $ -
b. Current multiplier for Middle District of Florida 10%
c. Average monthly administrative expense of Chapter 13 case. $ -
46 Total Deductions for Debt Payments. $ -
Subpart D: Total Deductions Allowed under § 707(b)(2)
47 Total of all deductions under § 707(b)(2). $ -
Form B22A (Ch. 7) Page 4 of 45 Fla. M.D., S.D., N.D.
Part VI. DETERMINATION OF § 707(b)(2) PRESUMPTION
48 Current Monthly Income for § 707(b)(2). $ -
49 Total of all deductions under § 707(b)(2). $ -
50 Monthly disposable income under § 707(b)(2). $ -
51 60-month disposable income under § 707(b)(2). $ -
Initial presumption determination:
52 Because the amount on Line 51 is less than $6,000, the presumption does not arise. Complete the verification in
Part VIII. Do not complete the remainder of Part VI.
53 Enter the amount of your total non-priority unsecured debt
54 Threshold debt payment amount. $ -
Secondary presumption determination:
55
Threshold Debt Calculation Not Applicable
Part VII: ADDITIONAL EXPENSE CLAIMS
Other Expenses. List and describe any monthly expenses, not otherwise stated in this form, that are required
for the health and welfare of you and your family and that you contend should be an additional deduction from
your current monthly income under § 707(b)(2)(A)(ii)(I). If necessary, list additional sources on a separate
page. All figures should reflect your average monthly expense for each item.
56 Monthly
Expense Description Amt.
a.
b.
c.
Total of Lines a, b, and c: $ -
Part VIII: VERIFICATION
I declare under penalty of perjury that the information provided in this statement is true and correct. (If this is
a joint case, both debtors must sign.)
57 Date: Signature (Debtor):
Date: Signature (Joint Debtor, if any):
Form B22A (Ch. 7) Page 5 of 45 Fla. M.D., S.D., N.D.
Form B22A (Ch. 7) Page 6 of 45 Fla. M.D., S.D., N.D.
403 Fam 1
620 Fam 2
835 Fam 3
881 Fam 4
Fam >4
345
Utilities Mort/Rent
0 0 Alachua
0 0 Baker
Form B22A (Ch. 7) Page 7 of 45 Fla. M.D., S.D., N.D.
0 0 Bay
0 0 Bradford
0 0 Brevard
0 0 Broward Miami $ -
0 0 Calhoun Tampa $ -
0 0 Charlotte Other $ -
0 0 Citrus
0 0 Clay
0 0 Collier
0 0 Columbia
0 0 DeSoto
0 0 Dixie
0 0 Duval
0 0 Escambia
0 0 Flagler
0 0 Franklin
0 0 Gadsen
0 0 Gilchrist
0 0 Glades
0 0 Gulf
0 0 Hamilton
0 0 Hardee
0 0 Hendry
0 0 Hernando Food Apparel 5% Food 5% Apparel Total 5% F&A
Form B22A (Ch. 7) Page 8 of 45 Fla. M.D., S.D., N.D.
0 0 Highlands 197 60 0 0 0
0 0 Hillsborough 336 81 0 0 0
0 0 Holmes 467 132 0 0 0
0 0 Indian River 468 146 0 0 0
0 0 Jackson 183 57 0 0 0
0 0 Jefferson
0 0 Lafayette
0 0 Lake
0 0 Lee
0 0 Leon
0 0 Levy
0 0 Liberty
0 0 Madison
0 0 Manatee
0 0 Marion
0 0 Martin
0 0 Miami-Dade
0 0 Monroe
0 0 Nassau
0 0 Okaloosa
0 0 Okeechobee
0 0 Orange
0 0 Osceola
0 0 Palm Beach
0 0 Pasco District Multiplier
0 0 Pinellas Middle District of Florida 10.00%
0 0 Polk Southern District of Florida 10.00%
0 0 Putnam Northern District of Florida 10.00%
0 0 Santa Rosa
0 0 Sarasota
0 0 Seminole
Form B22A (Ch. 7) Page 9 of 45 Fla. M.D., S.D., N.D.
0 0 St. Johns
0 0 St. Lucie
0 0 Sumter
0 0 Suwanee
0 0 Taylor
0 0 Union Because the amount on Line 51 is less than $6,000, the presumption does not arise. Complete the verification in Part V
0 0 Volusia Because the amount in Line 51 is more than $10,000, the presumption arises. Do not complete the remainder of Part V
0 0 Wakulla Because the amount on Line 51 is at least $6,000, but not more than $10,000, complete the remainder of Part VI (Lin
0 0 Walton Because the amount on Line 51 is less than the amount on Line 54, the presumption does not arise. Complete the ve
0 0 Washington Because the amount on Line 51 is equal to or greater than the amount on Line 54, the presumption arises. Complete
Form B22A (Ch. 7) Page 10 of 45 Fla. M.D., S.D., N.D.
Form B22A (Ch. 7) Page 11 of 45 Fla. M.D., S.D., N.D.
Form B22A (Ch. 7) Page 12 of 45 Fla. M.D., S.D., N.D.
Form B22A (Ch. 7) Page 13 of 45 Fla. M.D., S.D., N.D.
Form B22A (Ch. 7) Page 14 of 45 Fla. M.D., S.D., N.D.
omplete the verification in Part VIII. Do not complete the remainder of Part VI.
omplete the remainder of Part VI. Complete the verification in Part VIII
e the remainder of Part VI (Lines 53 through 55)
oes not arise. Complete the verification in Part VIII.
presumption arises. Complete the verification in Part VIII.
Form B22A (Ch. 7) Page 15 of 45 Fla. M.D., S.D., N.D.
Form B 22C (Chapter 13)(10/05) 16
In re: According to the calculations required by this statement:
Case
No: The applicable commitment period is 3 years.
Disposable income is not determined under § 1325(b)(3).
STATEMENT OF CURRENT MONTHLY INCOME AND MEANS TEST CALCULATION
AND CALCULATION OF COMMITMENT PERIOD AND DISPOSABLE INCOME
FOR USE IN CHAPTER 13 ONLY
In addition to Schedule I and J, this statement must be completed by every individual Chapter 13 debtor, whether or not
filing jointly. Joint debtors may complete one statement only.
Part I. REPORT OF INCOME
Marital/filing status. Place an "X" in the box that applies and complete the balance of this part of this statement as
directed.
a. Unmarried. Complete only Column A ("Debtor's Income) for Lines 2-10.
Married. Complete both Column A (“Debtor’s Income”) and Column B ("Spouse’s
b.
1 Income") for Lines 2-10.
All figures must reflect average monthly income for the six calendar months prior to filing
the bankruptcy case, ending on the last day of the month before the filing. If you received Column A Column B
different amounts of income during these six months, you must total the amounts Debtor's Spouse's
received during the six months, divide this total by six, and enter the result on the Income Income
appropriate line.
2 Gross wages, salary, tips, bonuses, overtime, commissions.
Income from the operation of a business, profession or farm. Enter gross receipts
from business in Line a and ordinary and necessary expenses in Line b. Do not include
3 any part of the business expenses entered on Line b as a deduction in Part IV.
a. Gross receipts
b. Ordinary and necessary business expenses
c. Business income $ -
Rent and other real property income. Enter gross receipts from real property in Line a
and ordinary and necessary expenses in Line b. Do not include any part of the
4 operating expenses entered on Line b as a deduction in Part IV.
a. Gross receipts
b. Ordinary and necessary business expenses
c. Business income $ -
5 Interest, dividends and royalties.
6 Pension and retirement income. $ -
Regular contributions to the household expenses of the debtor or the debtor's
7 dependents, including child or spousal support. Do not include contributions from
the debtor's spouse.
Unemployment compensation. Enter the amount in the appropriate columns of Line 8.
However, if you contend that unemployment compensation received by you or your
spouse was a benefit under the Social Security Act, do not list the amount of such
8 compensation in Column A or B, but instead state the amount in the space below:
Unemployment compensation claimed to be a benefit under Social Security
paid to Debtor.
Unemployment compensation claimed to be a benefit under Social Security
paid to Spouse.
Income from all other sources. Specify source and amount. If necessary, list
additional sources on a separate page. Do not include any benefits received under the
Social Security Act or payments received as a victim of a war crime, crime against
9
humanity, or as a victim of international or domestic terrorism.
Describe:
Total income from other sources:
10 Subtotal for each spouse. $ - $ -
11 Total. $ -
Form B 22C (Chapter 13)(10/05) 17
Part II. CALCULATION OF § 1325(b)(4) COMMITMENT PERIOD
12 Amount from Line 11. $ -
Marital adjustment. If you are married, but are not filing jointly with your spouse, AND if you
13 contend that calculation of the commitment period under § 1325(b)(4) does not require inclusion of the $ -
income of your spouse, enter the amount of the income listed in Line 10, Column B that was NOT
regularly contributed to the household expenses of you or your dependents. Otherwise, enter zero.
14 Current monthly income for § 1325(b)(4). $ -
15 Annualized current monthly inccome for § 1325(b)(4). $ -
List number of individuals in your household:
16
Applicable median family income for Florida residents: $ -
Application of § 1325(b)(4):
17 The amount on Line 15 is less than the amount on Line 16. The applicable commitment period is 3 years.
Do not complete Parts III, IV, V or VI.
Part III. APPLICATION § 1325(b)(3) FOR DETERMINING DISPOSABLE INCOME
18 Amount from Line 11. $ -
Marital adjustment. If you are married, but are not filing jointly with your spouse, enter the amount
of the income listed in Line 10, Column B that was NOT regularly contributed to the household
19 expenses of you or your dependents. If you are unmarried or married and filing jointly with your $ -
spouse, enter zero.
20 Current monthly income for § 1325(b)(3). $ -
21 Annualized current monthly inccome for § 1325(b)(3). $ -
List number of individuals in your household:
22
Applicable median family income for Florida residents: $ -
Application of § 1325(b)(3):
23 The amount on Line 21 is not more than the amount on Line 22. Disposable income is not determined under §
1325(b)(3). Complete Part VII of this statement. Do not complete Parts IV, V, or VI.
Part IV. CALCULATION OF DEDUCTIONS ALLOWED UNDER § 707(b)(2)
Subpart A: Deductions under Standards of the Internal Revenue Service (IRS)
24 National Standards: food, clothing, household supplies, personal care, and miscellaneous. $ -
25 Choose the county in which you reside from the drop down menu: Indian River
A Local Standards: housing and utilities; non-mortgage expenses. $ -
Local Standards: housing and utilities; mortgage/rental expenses. The amount of your Average
25
Monthly Payments for any debts secured by your home as listed in Line 47 below will be deducted from
B
the mortgage/rent expense set forth in Line 25B. $ -
Local Standards: housing and utilities; adjustment. If you contend that the process set out in
Lines 25A and 25B does not accurately compute the allowance to which you are entitled under the IRS
Housing and Utilities Standards, enter any additional amount to which you contend you are entitled,
26 and state the basis for your contention in the space below:
Local Standards: transportation; vehicle operation/public transportation expense. You are
entitled to an expense allowance in this category regardless of whether you pay the expenses of
operating a vehicle and regardless of whether you use public transportation.
27
Enter no. of vehicles for which you pay operating expenses or for which the operating
expenses are included as a contribution to your household expenses in Line 7.
Select from dropdown menu Miami, Tampa, or Other as city of residence: Other $ -
Form B 22C (Chapter 13)(10/05) 18
Local Standards: transportation ownership/lease expense; Vehicle 1. The amount of your
Average Monthly Payments for any debts secured by this vehicle as listed in Line 47 below will be
deducted from the ownership/lease expense expense set forth in Line 28.
28
Enter the number of vehicles for which you claim an ownership/lease expense in the
space provided to the right below. (You may not claim an ownership/lease expense for
more than two vehicles.) $ -
Local Standards: transportation ownership/lease expense; Vehicle 2. The amount of your
29 Average Monthly Payments for any debts secured by this vehicle as listed in Line 42 below will be
deducted from the ownership/lease expense expense set forth in Line 24. $ -
Other Necessary Expenses: taxes. Enter the total average monthly expense that you actually incur
for all federal, state and local taxes, other than real estate and sales taxes, such as income taxes, self
30
employment taxes, social security taxes, and Medicare taxes. Do not include real estate or sales
taxes.
Other Necessary Expenses: mandatory payroll deductions. Enter the total average monthly
payroll deductions that are required for your employment, such as mandatory retirement contributions,
31
union dues, and uniform costs. Do not include discretionary amounts, such as non-mandatory
401(k) contributions.
Other Necessary Expenses: life insurance. Enter average monthly premiums that you actually pay
32 for term life insurance for yourself. Do not include premiums for insurance on your dependents,
for whole life or for any other form of insurance.
Other Necessary Expenses: court-ordered payments. Enter the total monthly amount that you
33 are required to pay pursuant to court order, such as spousal or child support payments. Do not
include payments on past due support obligations included in Line 44.
Other Necessary Expenses: education for employment or for a physically or mentally
34 challenged child. Enter the total monthly amount that you actually expend for education that is a
condition of employment and for education that is required for a physically or mentally challenged
dependent child for whom no public education providing similar services is available.
Other Necessary Expenses: childcare. Enter the average monthly amount that you actually expend
35
on childcare. Do not include payments made for children's education.
Other Necessary Expenses: health care. Enter the average monthly amount that you actually
36
expend on health care expenses that are not reimbursed by insurance or paid by a health savings
account. Do not include payments for health insurance listed in Line 39.
Other Necessary Expenses: telecommunication services. Enter the average monthly expenses
that you actually pay for cell phones, pagers, call waiting, caller identification, special long distance or
37
internet services necessary for the health and welfare of you or your dependents. Do not include any
amount previously deducted.
38 Total Expenses Allowed under IRS Standards. $ -
Subpart B: Additional Expense Deductions under § 707(b)
Note: Do not include any expenses that you have listed in Lines 24-37
Health Insurance, Disability Insurance and Health Savings Account Expenses. List the average
monthly amounts that you actually expend in each of the following categories and enter the total.
39 a. Health Insurance
b. Disability Insurance
c. Health Savings Account
Total of Lines a, b, and c: $ -
Continued contributions to the care of household or family members. Enter the actual monthly
40 expenses that you will continue to pay for the reasonable and necessary care and support of an
elderly, chronically ill, or disabled member of your household or member of your immediate family who
is unable to pay for such expenses. Do not include payments listed in Line 34.
Protection against family violence. Enter any average monthly expenses that you actually incurred
41 to maintain the safety of your family under the Family Violence Prevention and Services Act or other
applicable federal law.
Form B 22C (Chapter 13)(10/05) 19
Home energy costs in excess of the allowance specified by the IRS Local Standards. Enter the
42 average monthly amount by which your home energy costs exceed the allowance in the IRS Local
Standards for Housing and Utilities. You must provide your case trustee with documentation
demonstrating that the additional amount claimed is reasonable and necessary.
Education expenses for dependent children less than 18. Enter the average monthly expenses
that you actually incur, not to exceed $125 per child, in providing elementary and secondary education
43 for your dependent children less than 18 years of age. You must provide your case trustee with
documentation demonstrating that the amount claimed is reasonable and necessary and not
already accounted for in the IRS Standards.
Additional food and clothing expense. Enter the amount actually expended for food and apparel on
a monthly basis in the spaces provided to the right below. You must provide your case trustee
with documentation demonstrating that the additional amount claimed is reasonable and
44 necessary. $ -
Actual Food:
Actual Apparel:
Continued charitable contributions. Enter the amount that you will continue to contribute in the
45 form of cash or financial instruments to a charitable organization as defined in 26 U.S.C. § 170(c)(1)-
(2).
46 Total Additional Deductions under § 707(b). $ -
Subpart C: Deductions for Debt Payments
Future payments on secured claims. For each of your debts that is secured by an interest in
property that you own, list the name of creditor, identify the property securing the debt, and state the
Average Monthly Payment. The Average Monthly Payment is the total of all amounts contractually due
to each Secured Creditor in the 60 months following the filing of the bankruptcy case, divided by 60.
Mortgage debts should include payments of taxes and insurance required by the mortgage. If
necessary, list additional entries on a separate page.
47 Name of Creditor Property Securing the Debt Ave. Monthly Payment
a. 1st mortgage on residence:
b. 2nd mortgage on residence:
c. Auto #1 loan:
d. Auto #2 loan:
e. $ -
Total of Lines a, b, c and d $ -
Past due payments on secured claims. If any of the debts listed in Line 47 are in default, and the
property securing the debt is necessary for your support or the support of your dependents, you may
include in your deductions 1/60th of the amount that you must pay the creditor as a result of the
default (the “cure amount”) in order to maintain possession of the property. List any such amounts in
the following chart and enter the total. If necessary, list additional entries on a separate page.
48
1/60 of the Cure
Name of Creditor Property Securing the Debt Amount
a.
b.
c. $ -
Total of lines a, b, and c $ -
Payments on priority claims. Enter the total amount of all priority claims (including priority child
49
support and alimony claims), divided by 60.
Chapter 13 administrative expenses.
a. Projected average monthly Chapter 13 plan payment. $ -
50
b. Current multiplier for Middle District of Florida 10%
c. Average monthly administrative expense of Chapter 13 case. $ -
51 Total Deductions for Debt Payments. $ -
Form B 22C (Chapter 13)(10/05) 20
Subpart D: Total Deductions Allowed under § 707(b)(2)
52 Total of all deductions under § 707(b)(2). $ -
Part V. DETERMINATION OF DISPOSABLE INCOME UNDER § 1325(b)(2)
53 Total current monthly income from Line 20. $ -
Support income. Enter the monthly average of any child support payments, foster care payments, or
54 disability payments for a dependent child, included in Line 7, that you received in accordance with
applicable nonbankruptcy law, to the extent reasonably necessary to be expended for such child.
$ -
Qualified retirement deductions. Enter the monthly average of (a) all contributions or wage
55 deductions made to qualified retirement plans, as specified in § 541(b)(7) and (b) all repayments of
loans from retirement plans, as specified in § 362(b)(19). $ -
56 Total of all deductions under § 707(b)(2). $ -
Total adjustments to determine disposable income. Total of the amounts on Lines 54, 55, and
57
56. $ -
58 Monthly disposable income under § 1325(b)(2). $ -
Part VI: ADDITIONAL EXPENSE CLAIMS
Other Expenses. List and describe any monthly expenses, not otherwise stated in this form, that are required for
the health and welfare of you and your family and that you contend should be an additional deduction from your
current monthly income under § 707(b)(2)(A)(ii)(I). If necessary, list additional sources on a separate page. All
figures should reflect your average monthly expense for each item. Monthly
59 Expense Description Amt.
a.
b.
c.
Total of Lines a, b, and c: $ -
Part VII: VERIFICATION
I declare under penalty of perjury that the information provided in this statement is true and correct. (If
Date: Signature (Debtor):
60
Date: Signature (Joint Debtor, if any):
Form B 22C (Chapter 13)(10/05) 21
Form B 22C (Chapter 13)(10/05) 22
403
620 Fam 2
835 Fam 3
881 Fam 4
Fam >4
345
Utilities Mort/Rent
0 0 Alachua
0 0 Baker
0 0 Bay
0 0 Bradford
0 0 Brevard
Form B 22C (Chapter 13)(10/05) 23
0 0 Broward Miami $ -
0 0 Calhoun Tampa $ -
0 0 Charlotte Other $ -
0 0 Citrus
0 0 Clay
0 0 Collier
0 0 Columbia
0 0 DeSoto
0 0 Dixie
0 0 Duval
0 0 Escambia
0 0 Flagler
0 0 Franklin
0 0 Gadsen
0 0 Gilchrist
0 0 Glades
0 0 Gulf
0 0 Hamilton
0 0 Hardee
0 0 Hendry
0 0 Hernando Food Apparel 5% Food 5% Apparel Total 5% F&A
Form B 22C (Chapter 13)(10/05) 24
0 0 Highlands 197 60 0 0 0
0 0 Hillsborough 336 81 0 0 0
0 0 Holmes 467 132 0 0 0
0 0 Indian River 468 146 0 0 0
0 0 Jackson 183 57 0 0 0
0 0 Jefferson
0 0 Lafayette
0 0 Lake
0 0 Lee
0 0 Leon
0 0 Levy
0 0 Liberty
0 0 Madison
0 0 Manatee
0 0 Marion
0 0 Martin
0 0 Miami-Dade
0 0 Monroe
0 0 Nassau
0 0 Okaloosa
0 0 Okeechobee
0 0 Orange
0 0 Osceola
0 0 Palm Beach
0 0 Pasco District Multiplier
0 0 Pinellas Middle District of Florida 10.00%
0 0 Polk Southern District of Florida 10.00%
0 0 Putnam Northern District of Florida 10.00%
Form B 22C (Chapter 13)(10/05) 25
0 0 Santa Rosa
0 0 Sarasota
0 0 Seminole
0 0 St. Johns
0 0 St. Lucie
0 0 Sumter
0 0 Suwanee
0 0 Taylor
0 0 Union Because the amount on Line 51 is less than $6,000, the presumption does not arise. Complete the verification in
0 0 Wakulla Because the amount on Line 51 is at least $6,000, but not more than $10,000, complete the remainder of Part VI
0 0 Walton Because the amount on Line 51 is less than the amount on Line 54, the presumption does not arise. Complete t
0 0 Washington Because the amount on Line 51 is equal to or greater than the amount on Line 54, the presumption arises. Com
Form B 22C (Chapter 13)(10/05) 26
Form B 22C (Chapter 13)(10/05) 27
Form B 22C (Chapter 13)(10/05) 28
Form B 22C (Chapter 13)(10/05) 29
Form B 22C (Chapter 13)(10/05) 30
se. Complete the verification in Part VIII. Do not complete the remainder of Part VI.
plete the remainder of Part VI (Lines 53 through 55)
ion does not arise. Complete the verification in Part VIII.
the presumption arises. Complete the verification in Part VIII.
Effective January 1, 2005 IRS Website for National Standards
One Person National Standards
Based on Gross Monthly Income
Item less than $833 to $1,250 to $1,667 to $2,500 to $3,334 to $4,167 to $5,834 and
$833 $1,249 $1,666 $2,499 $3,333 $4,166 $5,833 over
Food 197 215 231 258 300 339 369 543
Housekeeping
supplies 19 20 25 26 29 36 37 51
Apparel & services 60 61 70 75 100 124 134 207
Personal care
products & services 19 24 26 27 40 42 43 44
Miscellaneous 108 108 108 108 108 108 108 108
Total $403 $428 $460 $494 $577 $649 $691 $953
Two Persons National Standards
Based on Gross Monthly Income
Item less than $833 to $1,250 to $1,667 to $2,500 to $3,334 to $4,167 to $5,834 and
$833 $1,249 $1,666 $2,499 $3,333 $4,166 $5,833 over
Food 336 337 338 424 439 487 559 691
Housekeeping
supplies 36 37 38 48 52 53 107 108
Apparel & services 81 88 91 95 125 132 164 276
Personal care
products & services 33 34 35 43 44 51 56 71
Miscellaneous 134 134 134 134 134 134 134 134
Total $620 $630 $636 $744 $794 $857 $1,020 $1,280
National Standards Page 31 of 45
Three Persons National Standards
Based on Gross Monthly Income
Item less than $833 to $1,250 to $1,667 to $2,500 to $3,334 to $4,167 to $5,834 and
$833 $1,249 $1,666 $2,499 $3,333 $4,166 $5,833 over
Food 467 468 469 470 490 546 622 778
Housekeeping
supplies 41 42 43 49 53 55 108 109
Apparel & services 132 144 157 158 159 188 204 303
Personal care
products & services 34 36 37 44 45 52 61 79
Miscellaneous 161 161 161 161 161 161 161 161
Total $835 $851 $867 $882 $908 $1,002 $1,156 $1,430
Four Persons National Standards
Based on Gross Monthly Income
Item less than $833 to $1,250 to $1,667 to $2,500 to $3,334 to $4,167 to $5,834 and
$833 $1,249 $1,666 $2,499 $3,333 $4,166 $5,833 over
Food 468 525 526 527 528 640 722 868
Housekeeping
supplies 42 43 44 50 54 61 109 110
Apparel & services 146 169 170 171 174 189 217 317
Personal care
products & services 37 42 43 45 46 53 62 81
Miscellaneous 188 188 188 188 188 188 188 188
Total $881 $967 $971 $981 $990 $1,131 $1,298 $1,564
More than Four Persons National Standards
Based on Gross Monthly Income
Item less than $833 to $1,250 to $1,667 to $2,500 to $3,334 to $4,167 to $5,834 and
$833 $1,249 $1,666 $2,499 $3,333 $4,166 $5,833 over
For each additional
person, add to four
person total
allowance: $134 $145 $155 $166 $177 $188 $199 $209
Food for each
additional person $71 $79 $84 $89 $94 $106 $111 $116
Apparel for each
additional person $22 $25 $27 $29 $31 $31 $33 $42
National Standards Page 32 of 45
A B C D E F G
1 M.D. Florida - Housing and Utilities Allowable Living Expenses
2 IRS Website for Housing and Utilities Collection Financial Standards
3 Financial Analysis - Local Standards: Housing and Utilities (effective 1/1/2005)
4 Maximum Monthly Allowance
5 County Family=4
Non- Mortgage/ Non- Mortgage/ Non- Mortgage/
6 Mortgage Rent Mortgage Rent Mortgage Rent
7 Alachua $328 $622 $386 $732 $444 $842
8 Baker $317 $540 $373 $635 $428 $731
9 Bay $296 $594 $348 $699 $401 $803
10 Bradford $311 $452 $366 $531 $421 $611
11 Brevard $306 $627 $359 $738 $413 $849
12 Broward $357 $919 $420 $1,081 $483 $1,243
13 Calhoun $296 $376 $348 $442 $401 $508
14 Charlotte $341 $560 $401 $659 $461 $758
15 Citrus $293 $479 $345 $563 $397 $647
16 Clay $291 $714 $342 $841 $393 $967
17 Collier $399 $812 $470 $955 $540 $1,099
18 Columbia $325 $449 $382 $528 $440 $607
19 DeSoto $324 $403 $381 $475 $438 $546
20 Dixie $313 $360 $368 $423 $423 $487
21 Duval $298 $647 $351 $760 $403 $875
22 Escambia $290 $560 $341 $659 $392 $758
23 Flagler $321 $640 $378 $753 $435 $866
24 Franklin $332 $584 $391 $687 $450 $789
25 Gadsen $328 $499 $386 $587 $444 $675
26 Gilchrist $342 $423 $402 $499 $462 $574
27 Glades $330 $426 $388 $502 $446 $577
28 Gulf $324 $467 $381 $549 $438 $632
29 Hamilton $334 $335 $393 $394 $452 $453
30 Hardee $330 $338 $388 $398 $446 $458
31 Hendry $330 $338 $388 $398 $446 $458
32 Hernando $321 $513 $377 $604 $434 $694
33 Highlands $307 $427 $362 $501 $416 $577
34 Hillsborough $331 $716 $390 $842 $448 $968
35 Holmes $285 $320 $335 $376 $386 $432
36 Indian River $345 $570 $405 $672 $466 $772
37 Jackson $305 $430 $358 $506 $412 $582
38 Jefferson $328 $513 $386 $603 $444 $693
39 Lafayette $327 $368 $385 $432 $442 $498
40 Lake $326 $598 $383 $704 $441 $810
41 Lee $354 $642 $416 $756 $479 $868
42 Leon $325 $729 $382 $858 $440 $987
43 Levy $338 $366 $398 $430 $457 $496
Florida Housing Page 33 of 45
A B C D E F G
44 Liberty $317 $433 $373 $509 $428 $586
45 Madison $344 $365 $404 $430 $465 $494
46 Manatee $347 $680 $409 $800 $470 $920
47 Marion $311 $479 $366 $563 $421 $647
48 Martin $352 $803 $414 $945 $476 $1,086
49 Miami-Dade $370 $868 $436 $1,021 $501 $1,174
50 Monroe $467 $964 $550 $1,133 $632 $1,304
51 Nassau $323 $719 $380 $846 $437 $973
52 Okaloosa $289 $647 $340 $762 $391 $876
53 Okeechobee $319 $419 $376 $493 $432 $567
54 Orange $316 $739 $371 $871 $427 $1,001
55 Osceola $306 $677 $359 $797 $413 $917
56 Palm Beach $371 $830 $436 $977 $501 $1,124
57 Pasco $309 $552 $364 $648 $419 $745
58 Pinellas $348 $647 $410 $760 $471 $875
59 Polk $329 $547 $387 $644 $445 $740
60 Putnam $299 $435 $352 $511 $405 $588
61 Santa Rosa $279 $670 $329 $788 $378 $907
62 Sarasota $368 $643 $433 $756 $498 $869
63 Seminole $315 $805 $370 $948 $426 $1,090
64 St. Johns $343 $894 $403 $1,052 $464 $1,209
65 St. Lucie $314 $563 $369 $663 $425 $761
66 Sumter $317 $475 $373 $559 $428 $644
67 Suwanee $351 $350 $413 $412 $475 $474
68 Taylor $333 $435 $392 $512 $451 $588
69 Union $324 $446 $381 $525 $438 $604
70 Volusia $319 $563 $376 $661 $432 $761
71 Wakulla $324 $557 $381 $655 $438 $753
72 Walton $301 $525 $354 $618 $407 $710
73 Washington $302 $444 $355 $523 $408 $601
Florida Housing Page 34 of 45
H I J K L M N
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2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
Florida Housing Page 35 of 45
Allowable Living Expenses for Transportation
IRS Website for Allowable Living Expenses for Transportation
Collection Financial Standards
Financial Analysis - Local Standards: Transportation *
Ownership Costs
National First Car Second Car
$475 $338
Operating Costs & Public Transportation Costs
Region No Car One Car Two Cars
Northeast Region $230 $298 $393
New York $302 $384 $479
Philadelphia $236 $298 $392
Boston $259 $284 $380
Pittsburgh $161 $286 $380
Midwest Region $194 $251 $345
Chicago $257 $329 $422
Detroit $312 $376 $469
Milwaukee $212 $247 $341
Minneapolis-St. Paul $276 $303 $397
Cleveland $198 $293 $387
Cincinnati $222 $272 $365
St. Louis $203 $287 $383
Kansas City $246 $291 $384
South Region $197 $242 $336
Washington, D.C. $289 $313 $407
Baltimore $225 $240 $334
Atlanta $283 $258 $351
Miami $284 $344 $439
Tampa $255 $265 $359
Dallas-Ft. Worth $309 $332 $425
Houston $281 $367 $462
West Region $246 $305 $399
Los Angeles $275 $353 $448
San Francisco $317 $373 $466
San Diego $311 $318 $415
Portland $189 $246 $339
Seattle $258 $335 $427
Honolulu $295 $314 $409
Anchorage $312 $336 $431
Phoenix $273 $326 $420
Denver $302 $351 $442
* Does not include personal property taxes. (effective January 1, 2005)
For Use with Allowable Transportation Expenses Table
The Operating Costs and Public Transportation Costs sections of the Transportation Standards are provided by
Page 36 of 45
Northeast Census Region
Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut,
MSA COUNTIES
New York in NY: Bronx, Dutchess, Kings,
Nassau, New York, Orange,
Putnam, Queens,
Richmond, Rockland,
Suffolk, Westchester
in NJ: Bergen, Essex, Hudson,
Hunterdon, Mercer,
Middlesex, Monmouth,
Morris, Ocean, Passaic,
Somerset, Sussex, Union,
Warren
in CT: Fairfield, Litchfield,
Middlesex, New Haven
in PA: Pike
Philadelphia in PA: Bucks, Chester, Delaware,
Montgomery, Philadelphia
in NJ: Atlantic, Burlington,
Camden, Cape May,
Cumberland, Gloucester,
Salem
in DE: New Castle
in MD: Cecil
Boston in MA: Bristol, Essex, Hampden,
Middlesex, Norfolk,
Plymouth, Suffolk,
Worcester
in NH: Hillsborough, Merrimack,
Rockingham, Strafford
in CT: Windham
in ME: York
Pittsburgh in PA: Allegheny, Beaver, Butler, Fayette, Washington,
Midwest Census Region
North Dakota, South Dakota, Nebraska, Kansas, Missouri, Illinois, Indiana, Ohio,
MSA COUNTIES (unless otherwise specified)
Chicago in IL: Cook, DeKalb, DuPage,
Grundy, Kane, Kankakee,
Kendall, Lake, McHenry, Will
in IN: Lake, Porter
in WI: Kenosha
Detroit in MI: Genesee, Lapeer, Lenawee, Livingston, Macomb,
Milwaukee in WI: Milwaukee, Ozaukee, Racine, Washington, Waukesha
Minneapolis-St. Paul in MN: Anoka, Carver, Chisago,
Dakota, Hennepin, Isanti,
Ramsey, Scott, Sherburne,
Washington, Wright
in WI: Pierce, St. Croix
Page 37 of 45
Cleveland in OH: Ashtabula, Cuyahoga, Geauga, Lake, Lorain, Medina,
Cincinnati in OH: Brown, Butler, Clermont,
Hamilton, Warren
in KY: Boone, Campbell, Gallatin,
Grant, Kenton, Pendleton
in IN: Dearborn, Ohio
St. Louis in MO: Crawford, Franklin,
Jefferson, Lincoln, St.
Charles, St. Louis, Warren,
St. Louis city
in IL: Clinton, Jersey, Madison,
Monroe, St.Clair
Kansas City in MO: Cass, Clay, Clinton,
Jackson, Lafayette, Platte,
Ray
in KS: Johnson, Leavenworth,
Miami, Wyandotte
South Census Region
Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Tennessee, Kentucky, West
MSA COUNTIES (unless otherwise specified)
Washington, D.C. in DC: District of Columbia
in MD: Calvert, Charles, Frederick,
Montgomery, Prince
George's, Washington
in VA: Arlington, Clarke,
Culpepper, Fairfax,
Fauquier, King George,
Loudoun, Prince William,
Spotsylvania, Stafford,
Warren, Alexandria city,
Fairfax city, Falls Church
city, Fredericksburg city,
Manassas city, Manassas
Park city
in WV: Berkeley, Jefferson
Baltimore in MD: Anne Arundel, Baltimore, Carroll, Harford, Howard,
Atlanta in GA: Barrow, Bartow, Carroll, Cherokee, Clayton, Cobb,
Miami in FL: Broward, Miami-Dade
Tampa in FL: Hernando, Hillsborough, Pasco, Pinellas
Dallas-Ft. Worth in TX: Collin, Dallas, Denton, Ellis, Henderson, Hood, Hunt,
Houston in TX: Brazoria, Chambers, Fort Bend, Galveston, Harris,
West Census Region:
New Mexico, Arizona, Colorado, Wyoming, Montana, Nevada, Utah, Washington,
MSA COUNTIES (unless otherwise specified)
Los Angeles in CA: Los Angeles, Orange, Riverside, San Bernadino,
San Francisco in CA: Alameda, Contra Costa, Marin, Napa, San Francisco,
San Diego in CA: San Diego
Page 38 of 45
Portland in OR: Clackamas, Columbia,
Marion, Multnomah, Polk,
Washington, Yamhill
in WA: Clark
Seattle in WA: Island, King, Kitsap, Pierce, Snohomish, Thurston
Honolulu in HI: Honolulu
Anchorage in AK: Anchorage borough
Phoenix in AZ: Maricopa, Pinal
Denver in CO: Adams, Arapahoe, Boulder, Denver, Douglas, Jefferson,
Page 39 of 45
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Page 43 of 45
Florida Median Income
Census Bureau Median Family Income (2004 inflation adj. $)
Set out below is the median family income data published by the United States Trustee Program for the year 2004, reproduced
a format designed for ease of use in completing Bankruptcy Forms B22A and B22C. The 2004 median income data should b
used for completing Bankruptcy Forms B22A and B22C until the data is adjusted in early 2006.
2-Person 3-Person 4-Person
State 1 Earner
Families Families Families
Florida $ 35,883.00 $ 44,831.00 $ 49,612.00 $ 59,798.00
Source: Census Bureau Website
lation adj. $)
ogram for the year 2004, reproduced in
2004 median income data should be
early 2006.