-----------------------

Fill in this information to identify your case: Check one box only as directed in this form and in 

Form 122A-1Supp: 

Debtor 1 Gregory Martin Chaires 

First Name Middle Name Last Name 

[) 1. There is no presumption of abuse. 

Debtor 2 

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

United States Bankruptcy Court for the: __ :.c:N-=O-'-R.::..:T_:_H.:..:E=-=R-'-N-'--=D'-'I-=-S-'-T'-'R"-IC=--T=---=0-'-F--'I-=L-=L-'-'IN-'-O=--I'-'S--

0 2. The calculation to determine if a presumption of 

abuse applies will be made under Chapter 7 

Means Test Calculation (Official Form 122A-2). 

Case number (If known) 

0 3. The Means Test does not apply now because of 

qualified military service but it could apply later. 

0 Check if this is an amended filing 

Official Form 122A-1 

Chapter 7 Statement of Your Current Monthly Income 12/15 

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

space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any 

additional pages, write your name and case number (if known). If you believe that you are exempted from a presumption of abuse because you 

do not have primarily consumer debts or because of qualifying military service, complete and file Statement of Exemption from Presumption of 

Abuse Under§ 707(b)(2) (Official Form 122A-1Supp) with this form. 

Calculate Your Current Mont hly Incom e 

1. What is your marital and filing status? Check one only. 

0 Not married. Fill out Column A. lines 2-11 . 

0 Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11 . 

0 Married and your spouse is NOT filing with you. You and your spouse are: 

0 Living in the same household and are not legally separated. Fill out both Columns A and B, lines 2-11 . 

0 Living separately or are legally separated. Fill out Column A, lines 2-11; do not fill out Column B. By checking this box, you declare 

under penalty of perjury that you and your spouse are legally separated under nonbankruptcy law that applies or that you and your 

spouse are living apart for reasons that do not include evading the Means Test requirements. 11 U.S.C. § 707(b)(7)(B). 

Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this 

bankruptcy case. 11 U.S.C. § 101 (1 OA). For example, if you are filing on September 15, the 6-month period would be March 1 through 

August 31. If the amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6. 

Fill in the result. Do not include any income amount more than once. For example, if both spouses own the same rental property, put the 

income from that property in one column only. If you have nothing to report for any line, write $0 in the space. 

2. Your gross wages, salary, tips, bonuses, overtime, and commissions 

(before all payroll deductions). 

3. Alimony and maintenance payments. Do not include payments from a spouse if 

Column B is filled in. 

4. All amounts from any source which are regularly paid for household expenses 

of you or your dependents, including child support. Include regular contributions 

from an unmarried partner, members of your household, your dependents, parents, 

and roommates. Include regular contributions from a spouse only if Column B is not 

filled in. Do not include payments you listed on line 3. 

5. Net income from operating a business, profession, Debtor 1 Debtor 2 or farm 

Gross receipts (before all deductions) $ 4,416.00 $ ---

Ordinary and necessary operating expenses - $ 1,408.00 - $ ___ 

Net monthly income from a business, profession, or farm $ 3,008.00 $ Copy 

--- here-+ 

6. Net income from rental and other real property Debtor 1 Debtor 2 

Gross receipts (before all deductions) $ 0.00 $ __ ---

Ordinary and necessary operating expenses - $ ____QJ!Q_ - $ ---

Net monthly income from rental or other real property Copy 

$ 0.00 $ here-+ --- --- 7. Interest, dividends, and royalties 

ColumnA 

Debtor 1 

$ __ -=.o:.o:.o-=-o 

$ __ _,0-'-".0"'-0 

$ __ -=.O:.o: .0-=-0 

$ 3,008.00 

$ 0.00 

$ 0.00 

Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income 

Column 8 

Debtor 2 or 

non-filing spouse 

$ ___ _ 

$ ___ _ 

$ ___ _ 

$ ___ _ 

$ ___ _ 

$ ___ __ 

page 1 

Case 16-27613 Doc 1 Filed 08/29/16 Entered 08/29/16 11:03:20 Desc Main

 Document Page 1 of 2
Debtor 1 Gregory Martin Chaires Case number (If known)'-------------- First Name Middle Name Last Name 

8. Unemployment compensation 

Do not enter the amount if you contend that the amount received was a benefit 

under the Social Security Act. Instead, list it here: ................................ ~ 

For you .................................................................................... $ 0.00 

For your spouse.................................................................... $ _____ _ 

9. Pension or retirement income. Do not include any amount received that was a 

benefit under the Social Security Act. 

1 0. Income from all other sources not listed above. Specify the source and amount. 

Do not include any benefits received under the Social Security Act or payments received 

as a victim of a war crime, a crime against humanity, or international or domestic 

terrorism. If necessary, list other sources on a separate page and put the total below. 

N/A 

Total amounts from separate pages, if any. 

11. Calculate your total current monthly income. Add lines 2 through 1 0 for each 

column. Then add the total for Column A to the total for Column B. 

Determine Whether the Means Test Applies to You 

12. Calculate your current monthly income for the year. Follow these steps: 

ColumnA 

Debtor 1 

$. __ _,0=.0=0 

$. __ ...=0:::.0:=.0 

$ 0.00 

$ 

+s 0.00 

$ 3,008.00 

Columna 

Debtor2or 

non-filing spouse 

$ ___ _ 

$. ___ _ 

$ 

$ 

+$ 

1+1 $ 

12a. Copy your total current monthly income from line 11 ...................................................................................... Copy line 11 here+ 

Multiply by 12 (the number of months in a year). 

12b. The result is your annual income for this part of the form. 12b. 

13. Calculate the median family income that applies to you. Follow these steps: 

Fill in the state in which you live. lnlinois 

Fill in the number of people in your household. 

Fill in the median family income for your state and size of household .................................................................................................. 13. 

To find a list of applicable median income amounts, go online using the link specified in the separate 

instructions for this form. This list may also be available at the bankruptcy clerk's office. 

14. How do the lines compare? 

14a. l:il Line 12b is less than or equal to line 13. On the top of page 1, check box 1, There is no presumption of abuse. 

Go to Part3. 

l=ls 3,008.00 1 

Total current 

monthly Income 

$ 3,008.00 

X 12 

$ 36,096.00 

$ 49,741.00 

14b. Cl Line 12b is more than line 13. On the top of page 1, check box 2, The presumption of abuse is determined by Form 122A-2. 

Go to Part 3 and fill out 

Sign Below 

penalty of pe~ury that the information on this statement and in any attachments is true and correct. 

If you checked line 14a, do NOT fill out or file Fonn 122A-2. 

If you checked line 14b, fill out Fonn 122A-2 and file It with this form. 

Signature of Debtor 2 

Date -:-:-:-:-:-=--:-=~­ MM/ DD /YYYY 

Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page2 

Case 16-27613 Doc 1 Filed 08/29/16 Entered 08/29/16 11:03:20 Desc Main

 Document Page 2 of 2