Official Form 122C-1 - Chapter 13 Statement of Your Current Monthly Income
Worksheet only. Transfer data to the official form or e-filing software. Confirm state median income chart (with source/date) for your household size and district.
United States Bankruptcy Court
District of [District]
In re: [Debtor Name(s)]
Case No.: [if known]
Chapter: 13
Instructions
Collect six months of income data to compute Current Monthly Income (CMI) and determine the applicable commitment period. Use continuation sheets if needed.
Part 1: Marital/Household Status (maps to Official Form Part 1)
- Filing status: [Single filer / Joint with spouse].
- Is spouse filing? [Yes/No]. If no, include non-filing spouse income unless separated.
- Household size: [Number].
- Marital adjustment (non-filing spouse income used solely for their expenses): $[ ]
Part 2: Six-Month Lookback (actuals, then average)
Enter total income received in 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 (maps to Official Form total): $[Total]
Annualized CMI (Combined CMI × 12): $[Annualized]
Part 3: Income Source Breakdown (average monthly)
| Source | Debtor 1 | Debtor 2 / Non-filing Spouse |
|---|---|---|
| Wage, salary, overtime, tips | $[ ] | $[ ] |
| Business/farm income (net) | $[ ] | $[ ] |
| Rental/real property income (net) | $[ ] | $[ ] |
| Interest/dividends/royalties | $[ ] | $[ ] |
| Pension/retirement | $[ ] | $[ ] |
| Unemployment/public benefits (non-SSA) | $[ ] | $[ ] |
| Social Security benefits (excluded from CMI) | $[0 or note exclusion] | $[0 or note exclusion] |
| Veterans’ disability benefits (excluded from CMI) | $[0 or note exclusion] | $[0 or note exclusion] |
| Child support/alimony received | $[ ] | $[ ] |
| Other income (describe) | $[ ] | $[ ] |
Subtotal monthly income: Debtor 1 $[ ], Debtor 2/Spouse $[ ]
Combined monthly income: $[Total]
Part 4: Compare to State Median and Determine Commitment Period
- Applicable state median income (household size above): $[Median].
- If combined CMI ≤ median: applicable commitment period generally 36 months (subject to plan feasibility).
- If combined CMI > median: complete Official Form 122C-2; applicable commitment period generally 60 months (subject to court/feasibility).
- Median chart source/date: [Citation/date].
- State/county used for median lookup: [ ].
Part 5: Business Expense Adjustments (if any)
- Gross business income: $[ ]
- Ordinary/necessary business expenses: $[ ]
- Net business income carried to CMI: $[ ]
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: __________
Transfer this data into the official Form 122C-1 before filing and retain supporting pay/benefit documentation per local rules.