Official Form 22A (Chapter 7) (04/07)
In re ______________________________
Debtor(s)
Case Number: __________________
(If known)
According to the calculations required by this statement:
The presumption arises.
The presumption does not arise.
(Check the box as directed in Parts I, III, and VI of this statement.)
CHAPTER 7 STATEMENT OF CURRENT MONTHLY INCOME
AND MEANS-TEST CALCULATION
In addition to Schedule I and J, this statement must be completed by every individual Chapter 7 debtor, whether or not filing jointly,
whose debts are primarily consumer debts. Joint debtors may complete one statement only.
Part I. EXCLUSION FOR DISABLED VETERANS
1
If you are a disabled veteran described in the Veteran’s Declaration in this Part I, (1) check the box at the beginning of the
Veteran’s Declaration, (2) check the box for “The presumption does not arise” at the top of this statement, and (3) complete
the verification in Part VIII. Do not complete any of the remaining parts of this statement.
Veteran’s Declaration. By checking this box, I declare under penalty of perjury that I am a disabled veteran (as de-
fined in 38 U.S.C. § 3741(1)) whose indebtedness occurred primarily during a period in which I was on active duty (as de-
fined in 10 U.S.C. § 101(d)(1)) or while I was performing a homeland defense activity (as defined in 32 U.S.C. §901(1)).
Part II. CALCULATION OF MONTHLY INCOME FOR § 707(b)(7) EXCLUSION
2
Marital/filing status. Check the box that applies and complete the balance of this part of this statement as directed.
a.
Unmarried. Complete only Column A (“Debtor’s Income”) for Lines 3-11.
b.
Married, not filing jointly, with declaration of separate households. By checking this box, debtor declares under pen-
alty of perjury: “My spouse and I are legally separated under applicable non-bankruptcy law or my spouse and I are liv-
ing apart other than for the purpose of evading the requirements of § 707(b)(2)(A) of the Bankruptcy Code.” Com-
plete only Column