Debtor 1 Rosie L. Clark 

First Name Middle Name Last Name

Debtor 2

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

16-28392 

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

1. Which chapter of the Bankruptcy Code

are you choosing to file under?

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 mCase. If the court approves

your application, the court will set your final payment

timetable.

$310.00

$ 

$ 

+$ 

Total $310.00 ◂Your total must equal the entire fee for the chapter you

checked in line 1.

◼ 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.

û/s/ Rosie Clark

Signature of Debtor 1

Date 9/2/2016

MM / DD / YYYY

û

Signature of Debtor 2

Date

MM / DD / YYYY

û/s/ Tej Shastri

Your attorney's name and signature, if you used one

Date 9/2/2016

MM / DD / YYYY

Official Form 103A Application for Individuals to Pay the Filind Fee in Installments page 1

Official Form 103A

Application for Individuals to Pay the Filing Fee in Installments

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

Chapter 7

Chapter 11

Chapter 12

Chapter 13

You propose to pay...

MM / DD / YYYY

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.......

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:

Case 16-28392 Doc 8 Filed 09/02/16 Entered 09/02/16 15:52:15 Desc Main

 Document Page 1 of 2
United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Chapter filing under:

Official Form 103A Application for Individuals to Pay the Filind Fee in Installments page 2

Fill in this information to identify your case:

Debtor 1 Rosie L. Clark

First Name Middle Name Last Name

Debtor 2

(Spouse, if filing) First Name Middle Name Last Name

Case number

(if known) 16-28392

Chapter 7

Chapter 11

Chapter 12

Chapter 13

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.

Month / day / year

By the court:

United States Bankruptcy Judge

Case 16-28392 Doc 8 Filed 09/02/16 Entered 09/02/16 15:52:15 Desc Main

 Document Page 2 of 2