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Means Test
Name
*
First
Last
Are your debts primarily Consumer Debts? (non-business & non-tax debts)
Yes
No
County of residence
Including yourself & your spouse, how many people reside in your home?
Household Member #1
Name
Age
Relationship to you
Dependent? (Y/N)
Contribute Income? (Y/N)
Household Member #2
Name
Age
Relationship to you
Dependent? (Y/N)
Contribute Income? (Y/N)
Household Member #3
Name
Age
Relationship to you
Dependent? (Y/N)
Contribute Income? (Y/N)
Household Member #4
Name
Age
Relationship to you
Dependent? (Y/N)
Contribute Income? (Y/N)
Household Member #5
Name
Age
Relationship to you
Dependent? (Y/N)
Contribute Income? (Y/N)
Household Member #6
Name
Age
Relationship to you
Dependent? (Y/N)
Contribute Income? (Y/N)
Household Member #7
Name
Age
Relationship to you
Dependent? (Y/N)
Contribute Income? (Y/N)
Household Member #8
Name
Age
Relationship to you
Dependent? (Y/N)
Contribute Income? (Y/N)
IRS Standard Deductions: Transportation
How many vehicles does your household operate?
Who pays the vehicles' operating expenses?
Of these vehicles, how many do you make loan or lease payments on?
If you do make loan or lease payments, for which vehicles do you make these payments?
Do you also use public transportation?
Yes
No
Necessary Expenses
Enter the monthly amount in dollars ($) you actually pay for the following expenses.
Taxes
Federal, State, and Local Taxes. Exclude real estate & sales taxes. (Example: $335 Federal Taxes)
Involuntary Payroll Deductions
Payroll deductions REQUIRED for employment. Ex.) Union Dues. Do not include discretionary payroll deductions. Ex.) nonmandatory 401k contributions.
Term Life Insurance
Term life insurance for you and your spouse.
Court Ordered Payments
Ex.) Alimony, Child Support
Education Expenses for (1) your employment or (2) physically/mentally challenged child.
Child Care
Ex.) Daycare, babysitting
Health Care
For you, your spouse, and your dependents not reimbursed by insurance or paid by a health savings account.
Telecommunication
Exclude basic home phone & cell service.Include internet service, pagers, call waiting, etc.
Additional Living Expense Deductions
Health Insurance
Not deducted from paycheck.
Disability Insurance
Not deducted from paycheck.
Health Savings Account
Not deducted from paycheck.
Care for chronically ill or disabled family member
Not deducted from paycheck.
Home security system
Not deducted from paycheck.
Home energy
NOTE TO ATTORNEY: Amount must exceed IRS allowance.
Tuition for kid under 18
Private or public tuition for a dependent under the age of 18
Charitable Contributions
You have been making these contributions for the past several months.
Debt Payments
NOTE TO ATTORNEY: Payments that end within 60 months = Prorate. SURRENDER PROPERTY: Chapter 7 = take secured debt payment deductions for property surrendered. Chapter 13 = cannot.
1st Mortgage Payment
2nd Mortgage Payment
HOA Payment
Auto Payment
Auto Payment
Auto Payment
Are you behind on mortgage payments?
Yes
No
If you are behind on Mortgage, Car, or HOA payments, how much do you owe in late payments?
Do you owe delinquent TAX, CHILD SUPPORT, or ALIMONY?
Yes
No
If you are behind on TAXES, CHILD SUPPORT, or ALIMONY, how much do you owe in late payments?
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Bankruptcy Attorney
Adam Garcia
Bankruptcy Attorney
(916) 500-0704
Mon-Sat
8 AM – 6 PM
Related Pages
Chapter 13 Bankruptcy
Credit Card Fraud
Discharge
Gambling Debt
Student Loans
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