Form 103B Worksheet - Application to Have the Chapter 7 Filing Fee Waived

Worksheet only. Not the official form. Transfer to Official Form 103B or e-filing software. Eligibility is limited to Chapter 7 individual debtors; court approval required.

United States Bankruptcy Court
District of [District]

In re: [Debtor Name(s)]
Case No.: [if known]
Check if amended filing: [ ]

Part 1: Family Size and Income (with non-cash assistance handling)

• Chapter 7 individual debtor? [Yes/No]
• Family size (you, spouse, dependents as defined in form instructions): [ ]
• Do you need to include spouse’s income? [Yes/No] (include unless legally separated or not in the household per instructions)

Average monthly income (last 6 months, include spouse if required)

• Subtract total non-cash assistance: $[ ]
• Family’s average monthly net income (after subtracting non-cash): $[ ]
• 150% of HHS poverty guideline for family size (current figure): $[ ]
• Is net income below 150%? [Yes/No]
• Will income increase or decrease by more than 10% in the next 6 months? [Yes/No] If yes, explain: [ ]
• Explain why you cannot pay the fee in installments within 120 days: [ ]

Part 2: Expenses (average monthly)

• Will expenses increase or decrease by more than 10% in the next 6 months? [Yes/No] If yes, explain: [ ]

Part 3: Property (list values)

• Cash on hand: $[ ]
• Bank accounts (types/last 4/balances): [ ]
• Home/other real estate (value and amount owed): [ ]
• Vehicles (value and amount owed): [ ]
• Other personal property (describe/value): [ ]
• Money or property owed to you (describe/value; expected within 180 days?): [ ]

Part 4: Payments Related to This Case

• Have you paid anyone for services in connection with this bankruptcy? [Yes/No] Amount: $[ ] Recipient: [ ]
• Have you promised to pay or do you expect to pay anyone for services in connection with this case? [Yes/No] Amount: $[ ] Recipient: [ ]
• Has anyone paid anyone on your behalf for services related to this case? [Yes/No] Amount: $[ ] Payer/Recipient: [ ]
• Have you filed bankruptcy in the last 8 years? [Yes/No] If yes, case number/district/year: [ ]

Part 5: Certification and Signature

I request a waiver of the Chapter 7 filing fee. I declare under penalty of perjury that the information provided is true and correct.

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

Note: The court may order you to pay the fee in installments instead of waiving it. Some districts require additional documentation (pay stubs, bank statements, proof of benefits).