Official Form 122A 2 – Fill Out and Use This 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:		__________ District of __________
Case number	___________________________________________
(If known)

Official Form 122A–2

Chapter 7 Means Test Calculation

Check the appropriate box as directed in lines 40 or 42:

According to the calculations required by this Statement:

 1. There is no presumption of abuse.

 2. There is a presumption of abuse.

 Check if this is an amended filing

12/15

State each purpose for which the income was used

For example, the income is used to pay your spouse’s tax debt or to support people other than you or your dependents

Fill in the amount you are subtracting from your spouse’s income

4. Adjust your current monthly income. Subtract the total on line 3 from line 1.

$_________

People who are 65 years of age or older
7d.	Out-of-pocket health care allowance per person	$____________
7e.	Number of people who are 65 or older	X ______
7f.	Subtotal. Multiply line 7d by line 7e.	$____________		Copy here + $___________
7g.	Total. Add lines 7c and 7f				$___________

Copy total here $________

	___________________________________	$____________
	___________________________________	$____________
	___________________________________ + $____________
			Copy
	Total average monthly payment	$____________
			here

9c. Net mortgage or rent expense.

Subtract line 9b (total average monthly payment) from line 9a (mortgage or

rent expense). If this amount is less than $0, enter $0. ..................................................................

─ $___________	Repeat this
	amount on
	line 33a.
	Copy	$___________
$___________
	here

Explain why:

_________________________________________________________________

_________________________________________________________________

Name of each creditor for Vehicle 1

_____________________________________

_____________________________________

Total average monthly payment

Average monthly payment

$____________

+$____________

$____________

	Copy	─		Repeat this
			$____________	amount on
	here
				line 33b.

13c. Net Vehicle 1 ownership or lease expense

Subtract line 13b from line 13a. If this amount is less than $0, enter $0. .............................

$____________

Copy net Vehicle 1 expense

here.....  $_________

Name of each creditor for Vehicle 2

Average monthly payment

Other Necessary Expenses In addition to the expense deductions listed above, you are allowed your monthly expenses for the following IRS categories.

16.Taxes: The total monthly amount that you will actually owe for federal, state and local taxes, such as income taxes, self- employment taxes, Social Security taxes, and Medicare taxes. You may include the monthly amount withheld from your pay for these taxes. However, if you expect to receive a tax refund, you must divide the expected refund by 12 and subtract that number from the total monthly amount that is withheld to pay for taxes.

Do not include real estate, sales, or use taxes.

17.Involuntary deductions: The total monthly payroll deductions that your job requires, such as retirement contributions, union dues, and uniform costs.

Do not include amounts that are not required by your job, such as voluntary 401(k) contributions or payroll savings.

18.Life insurance: The total monthly premiums that you pay for your own term life insurance. If two married people are filing together, include payments that you make for your spouse’s term life insurance. Do not include premiums for life insurance on your dependents, for a non-filing spouse’s life insurance, or for any form of life insurance other than term.

19.Court-ordered payments: The total monthly amount that you pay as required by the order of a court or administrative agency, such as spousal or child support payments.

Do not include payments on past due obligations for spousal or child support. You will list these obligations in line 35.

20.Education: The total monthly amount that you pay for education that is either required:

as a condition for your job, or

for your physically or mentally challenged dependent child if no public education is available for similar services.

21.Childcare: The total monthly amount that you pay for childcare, such as babysitting, daycare, nursery, and preschool. Do not include payments for any elementary or secondary school education.

22.Additional health care expenses, excluding insurance costs: The monthly amount that you pay for health care that is required for the health and welfare of you or your dependents and that is not reimbursed by insurance or paid by a health savings account. Include only the amount that is more than the total entered in line 7.

Payments for health insurance or health savings accounts should be listed only in line 25.

23.Optional telephones and telephone services: The total monthly amount that you pay for telecommunication services for you and your dependents, such as pagers, call waiting, caller identification, special long distance, or business cell phone service, to the extent necessary for your health and welfare or that of your dependents or for the production of income, if it is not reimbursed by your employer.

Do not include payments for basic home telephone, internet and cell phone service. Do not include self-employment expenses, such as those reported on line 5 of Official Form 122A-1, or any amount you previously deducted.

24.Add all of the expenses allowed under the IRS expense allowances. Add lines 6 through 23.

$________

$________

$________

$________

$________

$_______

$________

+$_______

$_______

Health insurance

Disability insurance

Health savings account

Total

Do you actually spend this total amount?

 No. How much do you actually spend?

Yes

$____________

$____________

+$____________

$____________

$___________

Copy total here

$________

26.Continuing contributions to the care of household or family members. The actual monthly 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. These expenses may include contributions to an account of a qualified ABLE program. 26 U.S.C. § 529A(b).

27.Protection against family violence. The reasonably necessary monthly expenses that you incur to maintain the safety of you and your family under the Family Violence Prevention and Services Act or other federal laws that apply.

By law, the court must keep the nature of these expenses confidential.

28.Additional home energy costs. Your home energy costs are included in your insurance and operating expenses on line 8.

If you believe that you have home energy costs that are more than the home energy costs included in expenses on line 8, then fill in the excess amount of home energy costs.

You must give your case trustee documentation of your actual expenses, and you must show that the additional amount claimed is reasonable and necessary.

29.Education expenses for dependent children who are younger than 18. The monthly expenses (not more than $156.25* per child) that you pay for your dependent children who are younger than 18 years old to attend a private or public elementary or secondary school.

You must give your case trustee documentation of your actual expenses, and you must explain why the amount claimed is reasonable and necessary and not already accounted for in lines 6-23.

* Subject to adjustment on 4/01/16, and every 3 years after that for cases begun on or after the date of adjustment.

30.Additional food and clothing expense. The monthly amount by which your actual food and clothing expenses are higher than the combined food and clothing allowances in the IRS National Standards. That amount cannot be more than 5% of the food and clothing allowances in the IRS National Standards.

To find a chart showing the maximum additional allowance, go online using the link specified in the separate instructions for this form. This chart may also be available at the bankruptcy clerk’s office.

You must show that the additional amount claimed is reasonable and necessary.

31.Continuing charitable contributions. The amount that you will continue to contribute in the form of cash or financial instruments to a religious or charitable organization. 26 U.S.C. § 170(c)(1)-(2).

32.Add all of the additional expense deductions. Add lines 25 through 31.

$________

$________

$________

$________

$_______

+$_______

$_______

	Mortgages on your home:
33a. Copy line 9b here					
	Loans on your first two vehicles:				
33b. Copy line 13b here					
33c. Copy line 13e here					. 
33d. List other secured debts:
					
	Name of each creditor for other		Identify property that		Does payment
	secured debt		secures the debt		include taxes
					or insurance?

Average monthly payment

$_____________

$_____________

$_____________

33e. Total average monthly payment. Add lines 33a through 33d.....................................................

34.Are any debts that you listed in line 33 secured by your primary residence, a vehicle, or other property necessary for your support or the support of your dependents?

No. Go to line 35.

Yes. State any amount that you must pay to a creditor, in addition to the payments listed in line 33, to keep possession of your property (called the cure amount). Next, divide by 60 and fill in the information below.

$____________

Copy total

here $_________

Name of the creditor		Identify property that
		secures the debt
_______________________	____________________
_______________________	____________________
_______________________	____________________

Total cure amount

$__________	÷ 60 =
$__________	÷ 60 =
$__________	÷ 60 =
	Total

Monthly cure amount

$_____________

$_____________

+$_____________

$_____________

	Copy total	$________
	here

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

36.Are you eligible to file a case under Chapter 13? 11 U.S.C. § 109(e).

For more information, go online using the link for Bankruptcy Basics specified in the separate instructions for this form. Bankruptcy Basics may also be available at the bankruptcy clerk’s office.

Part 3: Determine Whether There Is a Presumption of Abuse

$________

40.Find out whether there is a presumption of abuse. Check the box that applies:

 The line 39d is less than $7,475*. On the top of page 1 of this form, check box 1, There is no presumption of abuse. Go to Part 5.

 The line 39d is more than $12,475*. On the top of page 1 of this form, check box 2, There is a presumption of abuse. You may fill out Part 4 if you claim special circumstances. Then go to Part 5.

 The line 39d is at least $7,475*, but not more than $12,475*. Go to line 41.

* Subject to adjustment on 4/01/16, and every 3 years after that for cases filed on or after the date of adjustment.

Official Form 122A–2

Chapter 7 Means Test Calculation

page 8

x .25

	41b. 25% of your total nonpriority unsecured debt. 11 U.S.C. § 707(b)(2)(A)(i)(I).	$___________
	Multiply line 41a by 0.25

42.Determine whether the income you have left over after subtracting all allowed deductions is enough to pay 25% of your unsecured, nonpriority debt.

Check the box that applies:

Line 39d is less than line 41b. On the top of page 1 of this form, check box 1, There is no presumption of abuse. Go to Part 5.

Line 39d is equal to or more than line 41b. On the top of page 1 of this form, check box 2, There is a presumption of abuse. You may fill out Part 4 if you claim special circumstances. Then go to Part 5.

Part 4:	Give Details About Special Circumstances

Copy here

$________





No. Go to Part 5.

Yes. Fill in the following information. All figures should reflect your average monthly expense or income adjustment for each item. You may include expenses you listed in line 25.

You must give a detailed explanation of the special circumstances that make the expenses or income adjustments necessary and reasonable. You must also give your case trustee documentation of your actual expenses or income adjustments.