Official Form 122A-1 - Chapter 7 Statement of Your Current Monthly Income
Worksheet only. Transfer data into the official court form or e-filing software before filing. Check your district’s local rules/median charts.
United States Bankruptcy Court
District of [District]
In re: [Debtor Name(s)]
Case No.: [if known]
Chapter: 7
Quick definitions and scope
- Current Monthly Income (CMI) = average monthly income from all sources during the six full calendar months before filing.
- Exclude: Social Security benefits; payments received for others that are not household support.
- Non-filing spouse: include their income unless you are separated or can take a marital adjustment (see 122A-2).
- State median income: varies by state and household size; insert the correct chart value below.
Part 1: Marital/Household Filing Status
- Filing status: [Single filer / Joint with spouse / Separate households].
- Is spouse filing? [Yes/No]. If no, include non-filing spouse income unless separated.
- Household size: [Number].
Part 2: Six-Month Income Detail (average becomes CMI)
Enter income for each of the six full calendar months before filing (Month -6 is oldest; Month -1 is the month before filing). Sum and divide by 6.
| Month (MM/YYYY) | Debtor 1 Total | Debtor 2 / Non-filing Spouse Total | Notes (irregular items) |
|---|---|---|---|
| Month -6 | $[ ] | $[ ] | [ ] |
| Month -5 | $[ ] | $[ ] | [ ] |
| Month -4 | $[ ] | $[ ] | [ ] |
| Month -3 | $[ ] | $[ ] | [ ] |
| Month -2 | $[ ] | $[ ] | [ ] |
| Month -1 | $[ ] | $[ ] | [ ] |
Six-month totals: Debtor 1 $[ ], Debtor 2/Spouse $[ ]
Average (divide each total by 6): Debtor 1 $[ ], Debtor 2/Spouse $[ ]
Combined CMI: $[Total]
Part 3: Income Source Breakdown (average monthly, mirrors official lines)
| Source | Debtor 1 | Debtor 2 / Non-filing Spouse |
|---|---|---|
| Wages, salary, overtime, tips | $[ ] | $[ ] |
| Business/farm income (net) | $[ ] | $[ ] |
| Rental/real property income (net) | $[ ] | $[ ] |
| Interest/dividends/royalties | $[ ] | $[ ] |
| Pension/retirement | $[ ] | $[ ] |
| Unemployment/public benefits (non-SSA) | $[ ] | $[ ] |
| Child support/alimony received | $[ ] | $[ ] |
| Other (describe) | $[ ] | $[ ] |
Subtotal monthly income: Debtor 1 $[ ], Debtor 2/Spouse $[ ]
Combined monthly income for median comparison: $[Total]
Part 4: Compare to State Median & Next Steps
- Applicable state median (household size above): $[Median].
- If combined CMI ≤ median: Chapter 7 generally permitted (still subject to abuse review).
- If combined CMI > median: complete Official Form 122A-2 (Means Test Calculation).
- District/local addenda required: [List any].
Part 5: Statutory Exemptions/Bypasses
- Disabled veteran exemption claimed? [Yes/No].
- Primarily non-consumer debts? [Yes/No].
- Recent active duty service (per statute)? [Yes/No].
Signature
I declare under penalty of perjury that the information provided is true and correct.
Debtor 1 Signature: __________________________ Date: __________
Debtor 2 Signature (if joint): __________________________ Date: __________
Attach pay stubs, business ledgers, or benefit statements only as required by your district’s local rules.