Official Form 103B Application to Have the Chapter 7 Filing Fee Waived page 1

Official Form 103B

Application to Have the Chapter 7 Filing Fee Waived 12/15

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

information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number 

(if known). 

Part 1: Tell the Court About Your Family and Your Family’s Income

1. What is the size of your family?

Your family includes you, your

spouse, and any dependents listed

on Schedule J: Your Expenses

(Official Form 106J).

Check all that apply: 

 You

 Your spouse

 Your dependents ___________________

How many dependents?

_____________________ 

Total number of people

2. Fill in your family’s average

monthly income.

Include your spouse’s income if

your spouse is living with you, even

if your spouse is not filing.

Do not include your spouse’s

income if you are separated and

your spouse is not filing with you.

That person’s average 

monthly net income 

(take-home pay)

Add your income and your spouse’s income. Include the 

value (if known) of any non-cash governmental assistance 

that you receive, such as food stamps (benefits under the 

Supplemental Nutrition Assistance Program) or housing 

subsidies. 

If you have already filled out Schedule I: Your Income, see 

line 10 of that schedule. 

You.................. $_________________

Your spouse ... + $_________________

Subtotal............. $_________________

Subtract any non-cash governmental assistance that you 

included above. – $_________________

Your family’s average monthly net income Total................. $_________________

3. Do you receive non-cash

governmental assistance?

 No

 Yes. Describe...........

Type of assistance

4. Do you expect your family’s

average monthly net income to

increase or decrease by more than

10% during the next 6 months?

 No

 Yes. Explain. .............

5. Tell the court why you are unable to pay the filing fee in

installments within 120 days. If you have some additional

circumstances that cause you to not be able to pay your filing

fee in installments, explain them.

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:__________________________________

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

3

I don't have enough income.

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2,989.70

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2,989.70

0.00

Florida - Southern

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2,989.70

Alejandra Pena

2

0.00

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Case 21-11134-LMI Doc 6 Filed 02/05/21 Page 1 of 4
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________ 

First Name Middle Name Last Name

Official Form 103B Application to Have the Chapter 7 Filing Fee Waived page 2

Part 2: Tell the Court About Your Monthly Expenses

6. Estimate your average monthly expenses.

Include amounts paid by any government assistance that you

reported on line 2.

If you have already filled out Schedule J, Your Expenses, copy

line 22 from that form.

$___________________

7. Do these expenses cover anyone

who is not included in your family 

as reported in line 1?

 No

 Yes. Identify who........ 

8. Does anyone other than you

regularly pay any of these

expenses?

If you have already filled out

Schedule I: Your Income, copy the

total from line 11.

 No

 Yes. How much do you regularly receive as contributions? $_________ monthly

9. Do you expect your average

monthly expenses to increase or

decrease by more than 10% during

the next 6 months?

 No

 Yes. Explain ...............

Part 3: Tell the Court About Your Property

If you have already filled out Schedule A/B: Property (Official Form 106A/B) attach copies to this application and go to Part 4.

10. How much cash do you have?

Examples: Money you have in

your wallet, in your home, and on

hand when you file this application

Cash: $_________________

11. Bank accounts and other deposits

of money?

Examples: Checking, savings,

money market, or other financial

accounts; certificates of deposit;

shares in banks, credit unions,

brokerage houses, and other

similar institutions. If you have

more than one account with the

same institution, list each. Do not

include 401(k) and IRA accounts.

Institution name:

Checking account: __________________________________________________

Savings account: __________________________________________________

Other financial accounts: __________________________________________________

Other financial accounts: __________________________________________________

Amount: 

$__________________

$__________________

$__________________

$__________________

12. Your home? (if you own it outright or

are purchasing it)

Examples: House, condominium,

manufactured home, or mobile home

_______________________________________________________ 

Number Street

_______________________________________________________

City State ZIP Code

Current value:

Amount you owe 

on mortgage and 

liens:

$_________________

$_________________ 

13. Other real estate?

_______________________________________________________ 

Number Street

_______________________________________________________

City State ZIP Code

Current value:

Amount you owe 

on mortgage and 

liens:

$_________________ 

$_________________ 

14. The vehicles you own?

Examples: Cars, vans, trucks,

sports utility vehicles, motorcycles,

tractors, boats

Make: _____________________

Model: _____________________

Year: ____________

Mileage _____________________

Current value:

Amount you owe 

on liens:

$_________________

$_________________ 

Make: _____________________

Model: _____________________

Year: ____________

Mileage _____________________

Current value:

Amount you owe 

on liens:

$_________________

$_________________

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2,966.00

Alejandra Pena

■

Case 21-11134-LMI Doc 6 Filed 02/05/21 Page 2 of 4
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________ 

First Name Middle Name Last Name

Official Form 103B Application to Have the Chapter 7 Filing Fee Waived page 3

15. Other assets?

Do not include household items

and clothing.

Describe the other assets:

Current value:

Amount you owe 

on liens:

$_________________

$_________________

16. Money or property due you?

Examples: Tax refunds, past due

or lump sum alimony, spousal

support, child support,

maintenance, divorce or property

settlements, Social Security

benefits, workers’ compensation,

personal injury recovery

Who owes you the money or property?

___________________________________________

___________________________________________

How much is owed?

$_________________ 

$_________________

Do you believe you will likely receive 

payment in the next 180 days? 

 No

 Yes. Explain:

Part 4: Answ er These Additional Questions

17. Have you paid anyone for

services for this case, including

filling out this application, the

bankruptcy filing package, or the

schedules?

 No

 Yes. Whom did you pay? Check all that apply:

 An attorney

 A bankruptcy petition preparer, paralegal, or typing service

 Someone else ________________________________________

How much did you pay?

$______________________ 

18. Have you promised to pay or do

you expect to pay someone for 

services for your bankruptcy 

case?

 No

 Yes. Whom do you expect to pay? Check all that apply:

 An attorney

 A bankruptcy petition preparer, paralegal, or typing service

 Someone else _________________________________________

How much do you 

expect to pay?

$_______________________ 

19. Has anyone paid someone on

your behalf for services for this 

case?

 No

 Yes. Who was paid on your behalf?

Check all that apply:

 An attorney

 A bankruptcy petition preparer,

paralegal, or typing service

 Someone else _________________

Who paid? 

Check all that apply:

 Parent

 Brother or sister

 Friend

 Pastor or clergy

 Someone else __________

How much did 

someone else pay?

$______________________

20. Have you filed for bankruptcy 

within the last 8 years?

 No

 Yes. District _____________________________ When _____________ Case number _____________________

MM/ DD/ YYYY

District _____________________________ When _____________ Case number _____________________

MM/ DD/ YYYY

District _____________________________ When _____________ Case number _____________________

MM/ DD/ YYYY

Part 5: Sign Below

By signing here under penalty of perjury, I declare that I cannot afford to pay the filing fee either in full or in installments. I also declare 

that the information I provided in this application is true and correct.

_____________________________________________ _____________________________________________

Signature of Debtor 1 Signature of Debtor 2 

Date __________________ Date __________________

MM / DD / YYYY MM / DD / YYYY

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/s/ Alejandra Pena

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1,200.00

■

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Alejandra Pena

■

02/05/2021

Case 21-11134-LMI Doc 6 Filed 02/05/21 Page 3 of 4
Order on the Application to Have the Chapter 7 Filing Fee Waived

After considering the debtor’s Application to Have the Chapter 7 Filing Fee Waived (Official Form 103B), the court 

orders that the application is:

[ ] Granted. However, the court may order the debtor to pay the fee in the future if developments in 

administering the bankruptcy case show that the waiver was unwarranted.

[ ] Denied. The debtor 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

If the debtor would like to propose a different payment timetable, the debtor must file a 

motion promptly with a payment proposal. The debtor may use Application for Individuals to 

Pay the Filing Fee in Installments (Official Form 103A) for this purpose. The court will 

consider it.

The debtor must pay the entire filing fee before making any more payments or transferring any 

more property to an attorney, bankruptcy petition preparer, or anyone else in connection with the 

bankruptcy case. The debtor must also pay the entire filing fee to receive a discharge. If the 

debtor does not make any payment when it is due, the bankruptcy case may be dismissed and 

the debtor’s rights in future bankruptcy cases may be affected. 

[ ] Scheduled for hearing.

A hearing to consider the debtor’s application will be held

on _____________ at _________ AM / PM at _________________________________________.

Month / day / year Address of courthouse

If the debtor does not appear at this hearing, the court may deny the application.

_____________ 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 __________

 (State)

Case number _____________________________________________ 

(If known)

 Fill in this information to identify the case:

Florida - Southern FL

Alejandra Pena

Case 21-11134-LMI Doc 6 Filed 02/05/21 Page 4 of 4