Form B3B

(04/09/06)

**Application for Waiver of the Chapter 7 Filing Fee**

**for Individuals Who Cannot Pay the Filing Fee**

**in Full or in Installments**

The court fee for filing a case under chapter 7 of the Bankruptcy Code
is \$299.

If you cannot afford to pay the full fee at the time of filing, you may
apply to pay the fee in installments. A form, which is available from
the bankruptcy clerk's office, must be completed to make that
application. If your application to pay in installments is approved, you
will be permitted to file your petition, completing payment of the fee
over the course of four to six months.

If you cannot afford to pay the fee either in full at the time of filing
or in installments, then you may request a waiver of the filing fee by
completing this application and filing it with the Clerk of Court. A
judge will decide whether you have to pay the fee. By law, the judge may
waive the fee [only if]{.underline} your income is less than 150 percent
of the official poverty line applicable to your family size
[and]{.underline} you are unable to pay the fee in installments. You may
obtain information about the poverty guidelines at
[www.uscourts.gov](http://www.uscourts.gov/) or in the bankruptcy
clerk's office.

**Required information**. Complete all items in the application, and
attach requested schedules. Then sign the application on the last page.
If you and your spouse are filing a joint bankruptcy petition, you both
must provide information as requested and sign the application.

Form B3B

(04/09/06)

> In re: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Case No.
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Debtor(s) (if known)

**APPLICATION FOR WAIVER OF THE CHAPTER 7 FILING FEE**

**FOR INDIVIDUALS WHO CANNOT PAY THE FILING FEE IN FULL OR IN
INSTALLMENTS**

**Part A. Family Size and Income**

1.  Including yourself, your spouse, and dependents you have listed or
    will list on Schedule I (Current Income of Individual Debtors(s)),
    how many people are in your family? (Do not include your spouse if
    you are separated AND are not filing a joint petition.)
    \_\_\_\_\_\_\_\_\_\_

2\. Restate the following information that you provided, or will
provide, on Line 16 of Schedule I. Attach a completed copy of Schedule
I, if it is available.

> Total Combined Monthly Income (Line 16 of Schedule I):
> \$\_\_\_\_\_\_\_\_\_

3\. State the monthly net income, if any, of dependents included in
Question 1 above. Do not include any income already reported in Item 2.
If none, enter \$0.

\$\_\_\_\_\_\_\_\_\_

4\. Add the "Total Combined Monthly Income" reported in Question 2 to
your dependents' monthly net income from Question 3.

\$\_\_\_\_\_\_\_\_\_

5\. Do you expect the amount in Question 4 to increase or decrease by
more than 10% during the next 6 months? Yes \_\_\_ No \_\_\_

> If yes, explain.

**Part B: Monthly Expenses**

6\. EITHER (a) attach a completed copy of Schedule J (Schedule of
Monthly Expenses), and state your total monthly expenses reported on
Line 18 of that Schedule, OR (b) if you have not yet completed Schedule
J, provide an estimate of your total monthly expenses.

\$ \_\_\_\_\_\_\_\_\_\_

7\. Do you expect the amount in Question 6 to increase or decrease by
more than 10% during the next 6 months? Yes \_\_\_ No \_\_\_

If yes, explain.

**Part C. Real and Personal Property**

EITHER (1) attach completed copies of Schedules A (Real Property) and
Schedule B (Personal Property), OR (2) if you have not yet completed
those schedules, answer the following questions.

8.  State the amount of cash you have on hand: \$ \_\_\_\_\_\_\_\_\_\_

9.  State below any money you have in savings, checking, or other
    accounts in a bank or other financial institution.

+------------------------+-------------------+------------------------+
| > Bank or Other        | Type of Account   | > Amount:              |
| > Financial            | such as savings,  |                        |
| > Institution:         | checking, CD:     |                        |
+------------------------+-------------------+------------------------+
| > **\_\_\_\_           | **\_\_\_          | > \$                   |
| \_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\ | > \_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_** | _\_\_\_\_\_\_\_** |                        |
+------------------------+-------------------+------------------------+
| > \_\_\_\_             | \_\_              | > \$                   |
| \_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\ | > \_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_ |                        |
+------------------------+-------------------+------------------------+

Form B3B Cont.

(04/09/06)

10. State below the assets owned by you. **Do not list ordinary
    household furnishings and clothing**.

+-----------+------------------------+--------------------------------+
| Home      | Address:               | Value: \$ \_\_\_\_\_\_\_\_\_\_ |
|           |                        |                                |
|           | **\_\_\_\_\_\_\_       | Amount owed on mortgages and   |
|           | \_\_\_\_\_\_\_\_\_\_\_ | liens: \$ \_\_\_\_\_\_\_\_\_\_ |
|           | \_\_\_\_\_\_\_\_\_\_** |                                |
|           |                        |                                |
|           | **\_\_\_\_\_\_\_       |                                |
|           | \_\_\_\_\_\_\_\_\_\_\_ |                                |
|           | \_\_\_\_\_\_\_\_\_\_** |                                |
+-----------+------------------------+--------------------------------+
| Other     | Address:               | Value: \$ \_\_\_\_\_\_\_\_\_\_ |
| real      |                        |                                |
| estate    | **\_\_\_\_\_\_\_       | Amount owed on mortgages and   |
|           | \_\_\_\_\_\_\_\_\_\_\_ | liens: \$ \_\_\_\_\_\_\_\_\_\_ |
|           | \_\_\_\_\_\_\_\_\_\_** |                                |
|           |                        |                                |
|           | **\_\_\_\_\_\_\_\_     |                                |
|           | \_\_\_\_\_\_\_\_\_\_\_ |                                |
|           | \_\_\_\_\_\_\_\_\_\_** |                                |
+-----------+------------------------+--------------------------------+
| Motor     | Model/Year:            | Value: \$ \_\_\_\_\_\_\_\_\_\_ |
| vehicle   | **\_\_\_\_\_\_\_\_\_   |                                |
|           | \_\_\_\_\_\_\_\_\_\_** | Amount owed: \$                |
|           |                        | \_\_\_\_\_\_\_\_\_\_           |
|           | **\_\_\_\_\_\_\_       |                                |
|           | \_\_\_\_\_\_\_\_\_\_\_ |                                |
|           | \_\_\_\_\_\_\_\_\_\_** |                                |
+-----------+------------------------+--------------------------------+
| Motor     | Model/Year:            | Value: \$ \_\_\_\_\_\_\_\_\_\_ |
| vehicle   | **\_\_\_\_\_\_\_\_\_   |                                |
|           | \_\_\_\_\_\_\_\_\_\_** | Amount owed: \$                |
|           |                        | \_\_\_\_\_\_\_\_\_\_           |
|           | **\_\_\_\_\_\_\_       |                                |
|           | \_\_\_\_\_\_\_\_\_\_\_ |                                |
|           | \_\_\_\_\_\_\_\_\_\_** |                                |
+-----------+------------------------+--------------------------------+
| Other     | Descripti              | Value: \$ \_\_\_\_\_\_\_\_\_\_ |
|           | on**\_\_\_\_\_\_\_\_\_ |                                |
|           | \_\_\_\_\_\_\_\_\_\_** | Amount owed: \$                |
|           |                        | \_\_\_\_\_\_\_\_\_\_           |
|           | **\_\_\_\_\_\_         |                                |
|           | \_\_\_\_\_\_\_\_\_\_\_ |                                |
|           | \_\_\_\_\_\_\_\_\_\_** |                                |
+-----------+------------------------+--------------------------------+

11. State below any person, business, organization, or governmental unit
    that owes you money and the amount that is owed.

+----------------------------------+-----------------------------------+
| > Name of Person, Business, or   | > Amount Owed                     |
| > Organization that Owes You     |                                   |
| > Money                          |                                   |
+----------------------------------+-----------------------------------+
| > \_\_                           | > \$ \_\_\_\_\_\_\_\_\_\_         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
+----------------------------------+-----------------------------------+
| > \_\_                           | > \$ \_\_\_\_\_\_\_\_\_\_         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
+----------------------------------+-----------------------------------+

**Part D. Additional Information.**

12. Have you paid an **attorney** any money for services in connection
    with this case, including the completion of this form, the
    bankruptcy petition, or schedules? Yes \_\_\_ No \_\_\_

If yes, how much have you paid? \$ \_\_\_\_\_\_\_\_\_\_

13. Have you promised to pay or do you anticipate paying an **attorney**
    in connection with your bankruptcy case? Yes \_\_\_ No \_\_\_

> If yes, how much have you promised to pay or do you anticipate paying?
> \$ \_\_\_\_\_\_\_\_\_\_

14. Have you paid **anyone other than an attorney** (such as a
    bankruptcy petition preparer, paralegal, typing service, or another
    person) any money for services in connection with this case,
    including the completion of this form, the bankruptcy petition, or
    schedules? Yes \_\_\_ No \_\_\_

If yes, how much have you paid? \$ \_\_\_\_\_\_\_\_\_\_

15\. Have you promised to pay or do you anticipate paying **anyone other
than an attorney** (such as a bankruptcy petition preparer, paralegal,
typing service, or another person) any money for services in connection
with this case, including the completion of this form, the bankruptcy
petition, or schedules?

Yes \_\_\_ No \_\_\_

If yes, how much have you promised to pay or do you anticipate paying?
\$ \_\_\_\_\_\_\_\_\_\_

16\. Has anyone paid an attorney or other person or service in
connection with this case, on your behalf? Yes \_\_\_ No \_\_\_

> If yes, explain.

Form B3B Cont.

(04/09/06)

17\. Have you previously filed for bankruptcy relief during the past
eight years? Yes \_\_\_ No \_\_\_

  ---------------------------------------- ---------------- ------------------------------ -----------------------------
  Case Number (if known)                   Year filed       Location of filing             Did you obtain a discharge?
                                                                                           (if known)

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_   Yes \_\_\_\_ No \_\_\_\_
                                                                                           Don\'t know \_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_   Yes \_\_\_\_ No \_\_\_\_
                                                                                           Don\'t know \_\_\_\_
  ---------------------------------------- ---------------- ------------------------------ -----------------------------

18\. Please provide any other information that helps to explain why you
are unable to pay the filing fee in installments.

19\. I (we) declare under penalty of perjury that I (we) cannot
currently afford to pay the filing fee in full or in installments and
that the foregoing information is true and correct.

Executed on: **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Date Signature of Debtor

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Date Signature of Co-debtor

**\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--**

**DECLARATION AND SIGNATURE OF BANKRUPTCY PETITION PREPARER (See 11
U.S.C. § 110)**

I declare under penalty of perjury that: (1) I am a bankruptcy petition
preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for
compensation and have provided the debtor with a copy of this document
and the notices and information required under 11 U.S.C. §§ 110(b),
110(h), and 342(b); and (3) if rules or guidelines have been promulgated
pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services
chargeable by bankruptcy petition preparers, I have given the debtor
notice of the maximum amount before preparing any document for filing
for a debtor or accepting any fee from the debtor, as required under
that section.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer
Social Security No. (Required by

11 U.S.C. §110.)

*If the bankruptcy petition preparer is not an individual, state the
name, title (if any), address, and social security number of the
officer, principal, responsible person, or partner who signs the
document.*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address

x\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Bankruptcy Petition Preparer Date

Names and Social Security numbers of all other individuals who prepared
or assisted in preparing this document, unless the bankruptcy petition
preparer is not an individual:

*If more than one person prepared this document, attach additional
signed sheets conforming to the appropriate Official Form for each
person.*

*A bankruptcy petition preparer's failure to comply with the provisions
of title 11 and the Federal Rules of Bankruptcy Procedure may result in
fines or imprisonment or both.* 11 U.S.C. § 110; 18 U.S.C. § 156.

Form B3B

(04/09/06)

United State Bankruptcy Court

\_\_\_\_\_\_\_\_\_ District of \_\_\_\_\_\_\_\_\_\_

> In re: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Case No.
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Debtor(s)

**ORDER ON DEBTOR'S APPLICATION FOR WAIVER OF THE CHAPTER 7 FILING FEE**

Upon consideration of the debtor's "Application for Waiver of the
Chapter 7 Filing Fee," the court orders that the application be:

\[ \] GRANTED.

This order is subject to being vacated at a later time if developments
in the administration of the bankruptcy case demonstrate that the waiver
was unwarranted.

\[ \] DENIED.

The debtor shall pay the chapter 7 filing fee according to the following
terms:

\$ \_\_\_\_\_\_\_\_\_\_ on or before \_\_\_\_\_\_\_\_\_\_

\$ \_\_\_\_\_\_\_\_\_\_ on or before \_\_\_\_\_\_\_\_\_\_

\$ \_\_\_\_\_\_\_\_\_\_ on or before \_\_\_\_\_\_\_\_\_\_

\$ \_\_\_\_\_\_\_\_\_\_ on or before \_\_\_\_\_\_\_\_\_\_

Until the filing fee is paid in full, the debtor shall not make any
additional payment or transfer any additional property to an attorney or
any other person for services in connection with this case.

IF THE DEBTOR FAILS TO TIMELY PAY THE FILING FEE IN FULL OR TO TIMELY
MAKE INSTALLMENT PAYMENTS, THE COURT MAY DISMISS THE DEBTOR'S CHAPTER 7
CASE.

\[ \] SCHEDULED FOR HEARING.

A hearing to consider the debtor's "Application for Waiver of the
Chapter 7 Filing Fee" shall be held on
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ at \_\_\_\_\_\_\_\_ am/pm at
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

(address of courthouse)

IF THE DEBTOR FAILS TO APPEAR AT THE SCHEDULED HEARING, THE COURT MAY
DEEM SUCH FAILURE TO BE THE DEBTOR'S CONSENT TO THE ENTRY OF AN ORDER
DENYING THE FEE WAIVER APPLICATION BY DEFAULT.

BY THE COURT:

DATE: \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

United States Bankruptcy Judge