Fillable Printable Application to Have the Chapter 7 Filing Fee Waived - U.S.
Fillable Printable Application to Have the Chapter 7 Filing Fee Waived - U.S.
Application to Have the Chapter 7 Filing Fee Waived - U.S.
Official Form B 3B Application to Have the Chapter 7 Filing Fee Waived page 1
Official Form B 3B
Application to Have the Chapter 7 Filing Fee Waived 12/14
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information. If more space is needed, attach a separate sheet to this form. On the top of any additional pa ges, w rite your name and case number
(if known).
Part 1: Tell the Court About Your Family and Your Family’s Income
1. What is the size of your family?
Your family includes you, your
spouse, and any dependents listed
on Schedule J: Current
Expenditures of Individual
Debtor(s) (Official Form 6J).
Check all that apply:
You
Your spouse
Your dependents ___________________
How many dependents?
_
_____
_
______________
Total number of people
2. Fill in your family’s average
monthl y income .
Include your spouse’s income if
your spouse is living with you, even
if your spouse is not filing.
Do not include your spouse’s
income if you are separated and
your spouse is not filing with you.
That person’s average
monthly net i ncome
(take-home pay)
Add your income and your spouse’s income. Include the
value (if known) of any non-cash governmental assistance
that you r eceive, such as food sta mps (ben efits under the
Supplemental Nutrition Assi sta nc e P rogr am) or housing
subsidies.
If you have already filled out Schedule I: Your Inco me, see
line 10 of that sched ule.
You .................. $_________________
Your spouse ....
+ $_________________
Subtotal ............. $_________________
Subtract any non-cash governmental assistance that you
included above.
– $_________________
Your family’s average monthl y net income
Total ..................
$_________________
3. Do you recei ve non-cas h
governmental assistance?
No
Yes. Describe. ...........
Type of assistance
4. Do you ex pect your family’s
average monthl y net income to
increase or decrease by more than
10 % during the next 6 months?
No
Yes. Explain. .............
5. Tell the court why you are unable to pay the filing fee in
installments within 120 days. If you have some additional
circumstances that cause you to not be able to pay your filing
fee in installments, explain them.
Debtor 1 ________________________________________________________________
First Name Middle Name Last Name
Debtor 2 ________________________________________________________________
(Spouse, if filing) First Name Middle Name Last Name
United States Bankruptcy Court for the: _____________________ District of ___________
Case number ___________________________________________
(If known)
Fill in this information to identify your case:
Check if this is an
amended filing
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form B 3B Application to Have the Chapter 7 Filing Fee Waived page 2
Part 2: Tell the Court About Your Monthly Expenses
6. Estimate your average monthly expenses.
Include amounts paid by any government assistance that you
reported on line 2.
If you have already filled out Schedule J, Your Expenses, copy
line 22 from that form.
$___________________
7. Do these expenses cover anyone
who is not included i n your family
as reported in line 1?
No
Yes. Identify who ........
8. Does anyone other than you
regularly pa y any of these
expenses?
If you have already filled out
Schedule I: Your Income, copy the
total from line 11.
No
Yes. How much do you regularl y receive as contributions? $_________ monthly
9. Do you ex pect your average
monthly expenses to increase or
decrease by more than 10% during
the next 6 months?
No
Yes. Explain ................
Part 3: Tell the Court About Your Property
If you have already filled out Schedu le A: Real Property (Official Form B 6A) and Schedule B: Personal Property (Official Form B 6B),
attach copies to this application and go to Part 4.
10. How much cash do you ha ve?
Examples: Money you have in
your wallet, in your home, and on
hand when you file this application
Cash: $_________________
11. Bank accounts and other depo sits
of money?
Examples: Checking, savings,
money market, or other financial
accounts; certificates of deposit;
shares in banks, credit unions,
brokerage houses, and other
similar institutions. If you have
more than one account with the
same institution, list each. Do not
include 401(k) and IRA accounts.
Institution name:
Checkin g account: __________________________________________________
Savings ac count : __________________________________________________
Other financial accounts: __________________________________________________
Other financial accounts: __________________________________________________
Amount:
$__________________
$__________________
$__________________
$__________________
12. Your home? (if you own it outright or
are purchasing it)
Examples: House, condominium,
manufactured home, or mobile home
_______________________________________________________
Number Street
_______________________________________________________
City State ZIP Code
Current value:
Amount you owe
on mortgage and
liens:
$_________________
$_________________
13. Other real estate?
_______________________________________________________
Number Street
_______________________________________________________
City State ZIP Code
Current value:
Amount you owe
on mortgage and
liens:
$_________________
$_________________
14. The vehicles you ow n?
Examples: Cars, vans, trucks,
sports utility vehicles, motorcycles,
tractors, boats
Make: _____________________
Model: _____________________
Year: ____________
Mileage _____________________
Current value:
Amount you owe
on liens:
$_________________
$_________________
Make: _____________________
Model: _____________________
Year: ____________
Mileage _____________________
Current value:
Amount you owe
on liens:
$_________________
$_________________
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form B 3B Application to Have the Chapter 7 Filing Fee Waived page 3
15. Other assets?
Do not include household items
and clothing.
Describe the other assets:
Current value:
Amount you owe
on liens:
$_________________
$_________________
16. Mone y or property due you?
Examples: Tax refunds, past due
or lump sum alimony, spousal
support, child support,
maintenance, divorce or property
settlements, Social Security
benefits, Workers’ compensation,
personal injury recovery
Who owes you the mone y or propert y?
___________________________________________
___________________________________________
How much is owed?
$_________________
$_________________
Do you believe you will likely receive
payment in the next 180 days?
No
Yes. Explain:
Part 4: Answer These Additional Questions
17. Have you paid anyone for
services for this case, including
filling out this applicatio n, the
bankruptcy filing package, or the
schedules?
No
Yes. Whom did you pa y? Check all that apply:
An attorney
A bankruptcy petition preparer, paralegal, or typing service
Someone else ________________________________________
How much did you pay?
$______________________
18. Have you promised to pay or do
you expect to pay someone for
services for your bankruptcy
case?
No
Yes. Whom do you expect to pay? Check all that apply:
An attorney
A bankruptcy petition preparer, paralegal, or typing service
Someone else _________________________________________
How much do you
expect to pa y?
$_______________________
19. Has anyone paid someone on
your behalf for services for this
case?
No
Yes. Who was paid on your behalf?
Check all that apply:
An attorney
A bankruptcy petition preparer,
paralegal, or typing service
Someone else _________________
Who paid?
Check all that apply:
Parent
Brother or sister
Friend
Pastor or clergy
Someone else __________
How much did
someone else pay?
$______________________
20. Have you filed for bankruptcy
within the last 8 years?
No
Yes. District ___________________________ __ When _____________ Case number _____________________
MM/ DD/ YYYY
District _____________________________ When _____________ Case number _____________________
MM/ DD/ YYYY
District _____________________________ When _____________ Case number _______________ ______
MM/ DD/ YYYY
Part 5: Sign Below
By signing here under penalty of perjury, I declare that I cannot afford to pay the filing fee either in full or in installments. I also declare
that the information I provided in this application is true and correct.
_____________________________________________ _____________________________________________
Signature of Debtor 1 Signature of Debtor 2
Date __________________ Date __________________
MM / DD / YYYY MM / DD / YYYY
Order on the Application to Have the Chapter 7 Filing Fee Waived
After considering the debtor’s Application to Have the Chapter 7 Filing Fee Waived (Official Form B 3B), the court orders
that the application is:
[ ] Granted. However, the court may order the debto r to pay the fee in the future if developments in
administering the bankruptcy ca se show that the waiver was unwarranted.
[ ] Denied
. The debtor must pay the filing fee according to the following terms:
You m
ust pay…
On or be fore this date…
$_____________
_____________
Month / day / year
$_____________
_____________
Month / day / year
$_____________
_____________
Month / day / year
+ $_____________
_____________
Month / day / year
Total
If the debtor would like to propose a different payment timetable, the debtor m ust file a
motion promptly with a payment proposal. The debtor may use Application for Individuals to
Pay the Filing Fee in Installm ents (Official Form B 3A) for this purpose. The court will
consider it.
The debtor must pay the e ntire filing fee before makin g any more payments or transferri ng any
more property to an attorney, bankruptcy petition preparer, or anyone else in connection with the
bankruptcy case. The debtor mu st also pay the entire filing fee to receive a discharge. If the
debtor does not make any payment when it is due, the bankruptcy case may be dismi ssed an d
the debtor’s rights in future bankruptcy cases may be affected.
[ ] Scheduled for hearing.
A hearing to consid er the debtor’s application will be held
on _____________ at _________ AM / PM at _________________________________________.
Month / day / year Address of courthouse
If the debtor does not appear at this hearing, the court may deny the application.
_____________ By the court: ______________ ______ ____ ______ ____ ___
Month / day / year United States Bankruptcy Judge
Debtor 1 ________________________________________________________________
First Name Middle Name Last Name
Debtor 2 ________________________________________________________________
(Spouse, if filing) First Name Middle Name Last Name
United States Bankruptcy Court for the: _________________________ District of __________
Case number _____________________________________________
(If known)
Fill in this information to identify the case:
