Bankruptcy Means Test Information
Please fill in the information below using MONTHLY AMOUNTS. If additional explanation of the expense is needed, please provide it on an additional page. If the amount is zero, put a zero. If the requested information was provided on the questionnaire or expense sheet, indicate that in the space provided.
Name: 1. Income How often are you paid? Is each paycheck the same? Other income source amount Name of employer Please provide 6 months paychecks 2. Income: Spouse How often are you paid? Is each paycheck the same? Other income source amount Name of employer Please provide 6 months paychecks Weekly Yes $ Bi-Weekly No Semi-Monthly Monthly Phone No.: Date:
Weekly Yes $
Bi-Weekly No
Semi-Monthly
Monthly
3. Health Care Expense: Do not include health care premiums or heath savings accounts Co-pays $ Dental $ Persciptions $ Optical $ Vitamins $ Other $ 4. Homestead Monthly Housing Expenses (residence) Property Address
Approx value of property from www.zillow.com $
Loan Balance $ Total Monthly Payments $ Do payments include taxes? Do payments include insurance? Are your payments current? Do you have a 2nd mortgage? Do you have a 3rd mortgage?
Yes Yes Yes Yes Yes
No No No No No
If yes, how much for taxes? If yes, how much for insurance? If no, how many months in arrears? Loan balance $ Loan balance $
$ $
2nd Real Property Monthly Housing Expenses Property Address
Approx value of property from www.zillow.com $
Loan Balance $ Total Monthly Payments $ Do payments include taxes? Do payments include insurance? Are your payments current? Do you have a 2nd mortgage? Do you have a 3rd mortgage?
Yes Yes Yes Yes Yes
No No No No No
If yes, how much for taxes? If yes, how much for insurance? If no, how many months in arrears? Loan balance $ Loan balance $
$ $
For any additional property, please ask for separate Real Estate Info Sheet
5. Car Value & Monthly Expenses Approximate Value $ # of Payments Left $ Are your payments current? Insurance Premium $ 2nd Car Monthly Expenses Approximate Value $ # of Payments Left Are your payments current? Insurance Premium $
Loan Balance $ Monthly Payment $ Yes No If no, how many months in arrears? Monthly Every 6 months
Loan Balance $ Monthly Payment $ Yes No If no, how many months in arrears? Monthly Every 6 months
Other Necessary Monthly Expenses: Please indicate monthly amount and whether they are deducted from wages or paid by check Federal Taxes $ Involuntary Wage Deductions: Union Dues $ Retirement $ Uniforms $ Loan Repays $ Life Insurance Monthly Premium: Term $ Whole Life $ Court Ordered payments amount: Alimony $ Child Support $ Garnishment $ Other $ Education for employment or mentally challeneged child $ Child Care $ Wage Deduction or Wage Deduction or Paid by check Paid by check
Telecommunications: (do not include home or cell phone) Internet $ Long Distance, Caller ID, Call Waiting, etc. $ Telephone Expenses: Home phone $ Cell phone $ 6. Additional Expenses Insurances: $ $ $
Health Disability Health Savings Account
$ $ $ $ $ $ $ $ $ $ $
Care and Support for Elderly or Disabled Protection against Family Violence(alarm system) Home energy costs Charitable Contribution Sunpass Tax Preparation (Annual) Cigarettes Online Accounts Grooming Pet food, vet bills Other