Official Form 103A Application for Individuals to Pay the Filing Fee in Installments

Official Form 103A 

Application for Individuals to Pay the Filing Fee in Installments 12/15

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct 

information. 

Part 1: Specify Your Proposed Payment Timetable 

1. Which chapter of the Bankruptcy Code

are you choosing to file under?

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

2. You may apply to pay the filing fee in up to

four installments. Fill in the amounts you

propose to pay and the dates you plan to

pay them. Be sure all dates are business

days. Then add the payments you propose

to pay.

You must propose to pay the entire fee no

later than 120 days after you file this

bankruptcy case. If the court approves your

application, the court will set your final

payment timetable.

You propose to pay... 

$_____________ 

 With the filing of the

petition

 On or before this date ........

______________ 

MM / DD / YYYY

$_____________ On or before this date ........... ______________ 

MM / DD / YYYY

$_____________ On or before this date ........... ______________ 

MM / DD / YYYY

+ $_____________ On or before this date ........... ______________ 

MM / DD / YYYY

Total $______________ ◄Your total must equal the entire fee for the chapter you checked in line 1.

Part 2: Sign Below 

By signing here, you state that you are unable to pay the full filing fee at once, that you want to pay the fee in installments, and that you 

understand that: 

 You must pay your entire filing fee before you make any more payments or transfer any more property to an attorney, bankruptcy petition

preparer, or anyone else for services in connection with your bankruptcy case.

 You must pay the entire fee no later than 120 days after you first file for bankruptcy, unless the court later extends your deadline. Your

debts will not be discharged until your entire fee is paid.

 If you do not make any payment when it is due, your bankruptcy case may be dismissed, and your rights in other bankruptcy proceedings

may be affected.

_________________________________ ___________________________________ _______________________________________

 Signature of Debtor 1 Signature of Debtor 2 Your attorney’s name and signature, if you used one 

Date _________________ Date ________________ Date _________________ 

MM / DD / YYYY MM / DD / YYYY MM / DD / YYYY 

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

Keith V Elzey Northern District of Illinois ✔

77.50 ✔

08/05/2016 77.50 09/05/2016 77.50 10/05/2016 77.50 11/05/0201 310.00 /s/Keith V Elzey 07/31/2016

Case 16-24628 Doc 8 Filed 07/31/16 Entered 07/31/16 22:54:16 Desc Main

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Order Approving Payment of Filing Fee in Installments 

After considering the Application for Individuals to Pay the Filing Fee in Installments (Official Form 103A), the 

court orders that: 

[ ] The debtor(s) may pay the filing fee in installments on the terms proposed in the application.

[ ] The debtor(s) must pay the filing fee according to the following terms: 

 You must pay... On or before this date... 

$_____________ _____________ 

Month / day / year

$_____________ _____________ 

Month / day / year

$_____________ _____________ 

Month / day / year

+ $_____________ _____________ 

Month / day / year

Total $_____________ 

Until the filing fee is paid in full, the debtor(s) must not make any additional payment or transfer any 

additional property to an attorney or to anyone else for services in connection with this case.

_____________ 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) 

Chapter filing under: 

 Chapter 7 

 Chapter 11 

 Chapter 12 

 Chapter 13

 Fill in this information to identify the case: 

Keith V Elzey Northern District of Illinois ✔

✔

Case 16-24628 Doc 8 Filed 07/31/16 Entered 07/31/16 22:54:16 Desc Main

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