Official Form 122C-1

Chapter 13 Statement of Your Current Monthly Income

12/15 

Part 1: Calculate Your Average Monthly Income

1.

 Check if this is an amended filing

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842





Not married.

Married.

Fill out Column A, lines 2-11.

Fill out both Columns A and B, lines 2-11.

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(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through

Check as directed in lines 17 and 21:







1.

2.

3.

and Calculation of Commitment Period

 4.

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).

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.

Disposable income is not determined 

under 11 U.S.C. § 1325(b)(3).

Disposable income is determined 

under 11 U.S.C. § 1325(b)(3).

The commitment period is 3 years.

According to the calculations required by this 

Statement:

The commitment period is 5 years.

Column B

Debtor 2 or

Column A

Debtor 1

non-filing spouse

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

(before all payroll deductions).

$8,115.12 $0.00 

3. Alimony and maintenance payments. Do not include payments from a spouse. $0.00 $0.00 

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

expenses of you or your dependents, including child support. Include

$0.00 $0.00 

regular contributions from an unmarried partner, members of your household, 

your dependents, parents, and roommates. Do not include payments from a 

spouse. Do not include payments you listed on line 3.

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

Gross receipts (before all

Ordinary and necessary operating

Net monthly income from a business,

Copy

here ($459.47) $0.00 

$0.00 

$0.00 

$0.00 

–

Debtor 1 Debtor 2

$480.71 

–

($459.47) 

$940.18 

expenses

profession, or farm

deductions)

Official Form 122C-1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 1 

Case 19-21842-AJC Doc 15 Filed 10/14/19 Page 1 of 3
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

Column B

Debtor 2 or

Column A

Debtor 1

non-filing spouse

6. Net income from rental and other real property

Gross receipts (before all

Ordinary and necessary operating

Net monthly income from rental or

Copy

here

$0.00 

$0.00 

$0.00  $0.00 $0.00 

–

Debtor 1 Debtor 2

$0.00 

$0.00 

$0.00 

– expenses

other real property

deductions)

7. Interest, dividends, and royalties $0.00 $0.00 

8. Unemployment compensation

For you...............................................................................

For your spouse.................................................................

$0.00 

$0.00 

$0.00 $0.00 

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

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

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

was a benefit under the Social Security Act.

$0.00 $0.00 

10. Income from all other sources not listed above. Specify the source and

Total amounts from separate pages, if any. + + 

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.

11. Calculate your total average monthly income.

+ =

Total average

monthly income

Add lines 2 through 10 for each column. $7,655.65 $0.00 $7,655.65 

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

Part 2: Determine How to Measure Your Deductions from Income

12. Copy your total average monthly income from line 11. ......................................................................................................... $7,655.65 

13. Calculate the marital adjustment. Check one:







You are not married. Fill in 0 below.

You are married and your spouse is filing with you. Fill in 0 below.

You are married and your spouse is not filing with you.

Total................................................................................................... Copy here  $0.00 

+ 

$0.00 –

Fill in the amount of the income listed in line 11, Column B, that was NOT regularly paid for the household expenses 

of you or your dependents, such as payment of the spouse's tax liability or the spouse's support of someone other 

than you or your dependents.

Below, specify the basis for excluding this income and the amount of income devoted to each purpose. If 

necessary, list additional adjustments on a separate page.

If this adjustment does not apply, enter 0 below.

14. Your current monthly income. Subtract the total in line 13 from line 12. $7,655.65 

Official Form 122C-1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 2 

Case 19-21842-AJC Doc 15 Filed 10/14/19 Page 2 of 3
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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

15a. Copy line 14 here  $7,655.65 

Multiply line 15a by 12 (the number of months in a year). X 12

15b. The result is your current monthly income for the year for this part of the form. ............................................................... $91,867.80 

......................................................................................................................................................

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

Fill in the state in which you live.

Fill in the number of people in your household.

Fill in the median family income for your state and size of household............................................................................... $60,400.00 

Florida

2

16a.

16b.

16c.

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.

17. How do the lines compare?

17a.  Line 15b is less than or equal to line 16c. On the top of page 1 of this form, check box 1,

Go to Part 3.

Disposable income is not determined

17b.  Line 15b is more than line 16c. On the top of page 1 of this form, check box 2,

Go to Part 3 and fill out Calculation of Your Disposable Income (Official Form 122C-2).

Disposable income is determined under

under 11 U.S.C. § 1325(b)(3). Do NOT fill out Calculation of Your Disposable Income (Official Form 122C-2).

11 U.S.C. § 1325(b)(3).

On line 39 of that form, copy your current monthly income from line 14 above.

Part 3: Calculate Your Commitment Period Under 11 U.S.C. § 1325(b)(4)

18. Copy your total average monthly income from line 11. ...................................................................................................... $7,655.65 

19. Deduct the marital adjustment if it applies. If you are married, your spouse is not filing with you, and you contend

If the marital adjustment does not apply, fill in 0 on line 19a. ....................................................................................... – $0.00 

Subtract line 19a from line 18. $7,655.65 

19a.

19b.

that calculating the commitment period under 11 U.S.C. § 1325(b)(4) allows you to deduct part of your spouse's 

income, copy the amount from line 13.

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

20a. Copy line 19b $7,655.65 

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

20b. The result is your current monthly income for the year for this part of the form. $91,867.80 

...................................................................................................................................................................

20c. Copy the median family income for your state and size of household from line 16c. ...................................................... $60,400.00 

21. How do the lines compare?

 Line 20b is less than line 20c. Unless otherwise ordered by the court, on the top of page 1 of this form,

The commitment period is 3 years.

 Line 20b is more than or equal to line 20c. Unless otherwise ordered by the court, on the top of page 1

The commitment period is 5 years.

Go to Part 4.

of this form, check box 4,

check box 3,

Go to Part 4.

By signing here, under penalty of perjury I declare that the information on this statement and in any attachments is true and correct.

Date Date

X X

Ana Maria Restrepo, Debtor 1 Signature of Debtor 2

10/8/2019

/s/ Ana Maria Restrepo

Part 4: Sign Below

MM / DD / YYYY MM / DD / YYYY

If you checked 17a, do NOT fill out or file Form 122C-2.

If you checked 17b, fill out Form 122C-2 and file it with this form. On line 39 of that form, copy your current monthly income from line 14 above.

Official Form 122C-1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 3 

Case 19-21842-AJC Doc 15 Filed 10/14/19 Page 3 of 3