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

Official Form 122A─1 

Chapter 7 Statement of Your Current Monthly Income 04/20

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.

Part 1: Calculate Your Current Monthly Income

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

 Not married. Fill out Column A, lines 2-11.

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

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

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

 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(10A). 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. 

Column A

Debtor 1

Column B

Debtor 2 or

non-filing spouse

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,

or farm Debtor 1 Debtor 2

Gross receipts (before all deductions) $______ $______

Ordinary and necessary operating expenses – $______ – $______

Net monthly income from a business, profession, or farm $______ $______

Copy 

here $_________ $__________

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

Gross receipts (before all deductions) $______ $______

Ordinary and necessary operating expenses – $______ – $______

Net monthly income from rental or other real property $______ $______

Copy 

here $_________ $__________

7. Interest, dividends, and royalties $_________ $__________

 Check if this is an amended filing

 1. There is no presumption of abuse.

 2. The calculation to determine if a presumption of

abuse applies will be made under Chapter 7

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

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

qualified military service but it could apply later.

Check one box only as directed in this form and in 

Form 122A-1Supp:

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: 

0.00

0.00

0.00

0.00

0.00

0.00

Southern District of Florida

0.00

0.00

0.00

0.00

Roger Castells

0.00

✔

0.00

✔

0.00

0.00

197.33

2,087.64

111.27

1,976.38 1,976.38

0.00

0.00

0.00

0.00

Case 20-18810-SMG Doc 4 Filed 08/14/20 Page 1 of 3
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 2

Column A

Debtor 1

Column B

Debtor 2 or

non-filing spouse

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 .................................................................................. $______________

For your spouse .................................................................. $______________

$__________ $___________

$_________ $___________

$_________ $___________

+ $_________ + $___________

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

benefit under the Social Security Act. Also, except as stated in the next sentence, do

not include any compensation, pension, pay, annuity, or allowance paid by the United

States Government in connection with a disability, combat-related injury or disability, or

death of a member of the uniformed services. If you received any retired pay paid

under chapter 61 of title 10, then include that pay only to the extent that it does not

exceed the amount of retired pay to which you would otherwise be entitled if retired

under any provision of title 10 other than chapter 61 of that title.

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

not include any benefits received under the Social Security Act; payments made under

the Federal law relating to the national emergency declared by the President under the

National Emergencies Act (50 U.S.C. 1601 et seq.) with respect to the coronavirus

disease 2019 (COVID-19); payments received as a victim of a war crime, a crime

against humanity, or international or domestic terrorism; or compensation, pension,

pay, annuity, or allowance paid by the United States Government in connection with a

disability, combat-related injury or disability, or death of a member of the uniforces. If

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

______________________________________

______________________________________

Total amounts from separate pages, if any.

11. Calculate your total current monthly income. Add lines 2 through 10 for each

column. Then add the total for Column A to the total for Column B. $_________ + $___________ 

= $__________

Total current 

monthly income Part 2: Determine Whether the Means Test Applies to You

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

12a. Copy your total current monthly income from line 11...................................................................................... Copy line 11 here $__________

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

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.

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.  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 Part 3. Do NOT fill out or file Official Form 122A-2.

14b.  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 Form 122A–2.

0.00 0.00

4

Roger Castells

SNAP Food Assistance

82,560.00

33,836.52

2,819.71

2,819.71

2,819.71 0.00

FL

0.00 0.00

0.00 0.00

646.00 0.00

0.00 0.00

0.00

0.00

✔

Case 20-18810-SMG Doc 4 Filed 08/14/20 Page 2 of 3
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 3

Part 3: Sign Below

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

__________________________________________________________  ______________________________________

 Signature of Debtor 1 Signature of Debtor 2 

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

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

If you checked line 14b, fill out Form 122A–2 and file it with this form.

 ̄ ̄ ̄ ̄ ̄

Roger Castells

08/14/2020

/s/ Roger Castells

Case 20-18810-SMG Doc 4 Filed 08/14/20 Page 3 of 3