Form 122A-1Supp Worksheet - Statement of Exemption from Presumption of Abuse

Worksheet only. Not the official form. Transfer to Official Form 122A-1Supp or e-filing software. Use only in Chapter 7 cases when claiming the presumption of abuse does not arise.

United States Bankruptcy Court
District of [District]

In re: [Debtor Name(s)]
Case No.: [if known]
Chapter: 7

Part 1: Disabled Veteran Exemption (11 U.S.C. §707(b)(2)(D))

• Are you a disabled veteran? [Yes/No]
• Disability rating: [ ]%
• Did you incur the debt while on active duty, or while performing a homeland defense activity? [Yes/No]
• Are you claiming exemption on this basis? [Yes/No]

Part 2: Non-Consumer Debt Exemption (11 U.S.C. §707(b))

• Are your debts primarily non-consumer debts (i.e., not incurred primarily for personal, family, or household purposes)? [Yes/No]
• Are you claiming exemption on this basis? [Yes/No]

Part 3: Military Service (if applicable)

• Are you a member of a reserve component or National Guard called to active duty or performing a homeland defense activity? [Yes/No]
• Call to active duty / defense activity start date: [ ]
• Expected end date (if known): [ ]

Signature

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

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

If you do not qualify for an exemption, complete Form 122A-1 and, if applicable, Form 122A-2.