Official Form 122A-1, Chapter 7 Statement of Your Current Monthly Income Completed Form Examples and Samples
Explore detailed examples and samples of a filled-out Official Form 122A-1, the Chapter 7 Statement of Your Current Monthly Income. Our guide provides clear, step-by-step illustrations for calculating your income for the bankruptcy means test, helping you understand and complete the form correctly.
Official Form 122A-1 Example – Single Filer Below Median Income
How this form was filled:
This sample of a filled Official Form 122A-1 shows the income calculation for a single individual filing for Chapter 7 bankruptcy. It demonstrates how to calculate current monthly income based on the prior six months, annualize it, and compare it to the state's median income for a household of one. In this example, the filer's income is below the median, meaning the presumption of abuse does not arise.
Information used to fill out the document:
- Debtor Name: Jane Marie Smith
- Filing Status: Filing single
- Case Filing Date: 01/15/2026
- State of Residence: California
- Household Size: 1
- Gross Monthly Wages, Salary, and Commissions: $4,000.00
- Other Monthly Income: $0.00
- Total Income for 6 Months (July 2025 - Dec 2025): $24,000.00
- Current Monthly Income (Line 11): $4,000.00
- Annualized Current Monthly Income (Line 12a): $48,000.00
- Applicable Median Family Income (for household of 1 in CA): $74,837.00
- Means Test Result (Part 2, Line 13): The presumption of abuse does not arise.
What this filled form sample shows:
- Demonstrates a straightforward means test calculation for a common scenario.
- Shows how to calculate the Current Monthly Income by averaging the previous six months' income.
- Illustrates the comparison of the debtor's annualized income against the state median income.
- Highlights the correct completion of Part 2, indicating that the presumption of abuse does not arise because income is below the median.
- Provides a clear sample for an individual filing for Chapter 7 bankruptcy.
Form specifications and details:
| Form Number: | Official Form 122A-1 |
| Form Title: | Chapter 7 Statement of Your Current Monthly Income |
| Use Case: | Single individual filer with income below the state median. |
| Filing Chapter: | Chapter 7 Bankruptcy |
Created: March 07, 2026 01:28 AM
