Form 103A Worksheet - Application for Individuals to Pay the Filing Fee in Installments

Worksheet only. Not the official form. Transfer to Official Form 103A or e-filing software. You must propose full payment within 120 days of filing (business days); court may extend to 180 days for cause.

United States Bankruptcy Court
District of [District]

In re: [Debtor Name(s)]
Case No.: [if known]
Chapter (check one): [ ] 7 [ ] 11 [ ] 12 [ ] 13
Check if amended filing: [ ]

Part 1: Request to Pay in Installments

• Filing fee amount for this chapter: $[ ]
• I cannot pay the filing fee except in installments. [Yes/No]
• I understand my case may be dismissed if I fail to pay on time. [Yes/No]
• I understand I will not receive a discharge until the filing fee is paid in full. [Yes/No]
• I understand I must not pay an attorney, bankruptcy petition preparer, or anyone else for services in connection with this case until the filing fee is paid in full, unless the court orders otherwise. [Yes/No]

Part 2: Proposed Payment Schedule

List proposed installment amounts and dates. You may pay with the petition (Payment 0). Dates must be on business days. Total must equal the filing fee. Last payment must be due no later than 120 days after filing (extendable to 180 days for cause).

Total of all payments: $[ ] (must equal filing fee)

Part 3: Other Case Information

• Any prior installment applications in this case? [Yes/No]
• Any pending motions to waive fee (103B)? [Yes/No]

Signature

Under penalty of perjury, I declare that the information provided is true and correct.

Debtor 1 Signature: __________________________ Date: __________
Debtor 2 Signature (if joint): __________________________ Date: __________

Attorney (if any)
Name: [ ]
Signature: __________________________ Date: __________

Note: Service/notice to the trustee or U.S. Trustee may be required by local rule.