| Your
Name |
| Marital
Status |
| Married |
Single |
Divorced |
Separated |
Widowed |
| List
all dependents of you and your spouse, their ages, and their
relationship to you. |
|
NAME |
AGE |
RELATIONSHIP
|
|
|
|
| PART
A. DEBTOR'S INCOME |
| 1.
What is your occupation? |
| 2.
Name and Address of your employer. |
| 3.
How long have you been employed there? |
| 4.
What is the gross amount of your paycheck, before taxes and, other
deductions are taken out? |
5.
How often do you get paid? once
a week every
two weeks twice
a month
once a
month other |
| 6.
Do you receive overtime pay outside of your salary? If so how much a
month? |
| 7.
How much is taken out of each paycheck for taxes and social security?
|
| 8.
How much is taken out for insurance? |
| 9.
How much for union dues? |
| 10.
Are there any other deductions? What are they and how much? |
| Do
you receive...... |
| a)
income from business operations outside of your regular paycheck
listed above? If so, what is the business and how much do you receive
per month? |
| b)
income from real estate property? If so, how much per month? |
| c)
interest or dividends? if so how much per month? |
| d)
alimony or family support payments for your use or for the care
of your dependents? If so, how much per month? |
| e)
social security or other forms of monetary government assistance, if
so how much? |
| f)
retirement or pension money? |
| PART
B. JOINT DEBTOR'S INCOME |
| 1.
What is your spouse's occupation? |
| 2.
Name and address of your spouse's employer: |
| 3.
How long employed there? |
| 4.
What is the amount of your spouse's paycheck, before taxes/other
deductions? |
5.
How often does your spouse get paid? once
a week every
two weeks twice
a month
once a
month other |
| 6.
Does your spouse receive overtime pay outside of your salary?
If so
how much a month? |
| 7.
How much is taken out of each paycheck for taxes and social security?
|
| 8.
How much is taken out for insurance? |
| 9.
How much for union dues? |
| 10.
Are there any other deductions? If so, what are they and how much?
|
| Does
your spouse receive... |
|
a) income from business operations outside of your regular paycheck
listed above? If so, what is the business and how much do you receive
per month? |
|
b) income from real estate property? If so, how much per month? |
|
c) interest or dividends? if so how much per month? |
|
d) alimony or family support payments for your use or for the care
of your dependents? If so, how much per month? |
|
e) social security or other forms of monetary government assistance, if
so how much? |
|
f)
retirement or pension money? |