CASE NAME:______________________ CASE NO.:____________________
 
 

STATEMENT OF CASH
 

BEGINNING BALANCE (ending balance from last month) $______________
 

ADD INCOME:

Salary $_______________

Other Income (Specify):

_______________________ $_______________

_______________________ $_______________

________________________ $_______________
 

TOTAL INCOME (A) $_______________
 

LESS EXPENSES:

Mortgage $_______________

Other Expenses (itemize

amounts in excess of $500) $_______________

__________________________ $_______________

__________________________ $_______________

__________________________ $_______________
 

TOTAL EXPENSES (B) $_______________
 

NET RECEIPTS (Line (A) less Line (B)) $_______________
 

ENDING BALANCE (BEGINNING BALANCE PLUS NET RECEIPTS $_______________
 
 
 

NOTE: Attach a copy of the most recent bank statement and a reconciliation for each account.
 
 

1. Have you incurred any debts since the

filing of the petition that remain unpaid? YES ( ) NO ( )
 

If so, provide the necessary information in the space provided.
 
 

DATE DUE

PAYEE

DESCRIPTION

AMOUNT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

2. What tax forms are you required to file? ____________________
 

_____________________________________________________________
 

3. Are you required to make estimated

payments (1040 ES)? YES ( ) NO ( )
 

4. Are your post-petition real estate taxes

paid through all current billings? YES ( ) NO ( )
 

5. Is your insurance in effect? YES ( ) NO ( )
 

If no, when did coverage expire? ______________

Policy number:_________________

Company:___________________
 

6. Summarize both court and non-court activities during this month that have affected the progress of your case.

___________________________________________________________
 

___________________________________________________________
 

___________________________________________________________
 
 
 
 
 

7. Discuss when you anticipate filing a plan of reorganization and disclosure statement.
 

_____________________________________________________________
 

______________________________________________________________
 

______________________________________________________________
 
 
 

8. List issues to be resolved during the administration of this case.
 

_____________________________________________________________
 

______________________________________________________________
 

______________________________________________________________
 
 

I, _______________________________________________________ declare under penalty of perjury under the laws of the United States that I have read the foregoing Monthly Report of the Debtor, and that the figures, statements, disbursements itemizations, and account balances as listed, are true and correct as of the date of this report to the best of my knowledge, information and belief.
 

Copies of this report have been forwarded to the U.S. Bankruptcy Court and the Internal Revenue Service.
 

____________________________________

Signature
 

Print name, capacity and phone number

of person signing this Declaration:
 

____________________________________

Name
 

____________________________________

Title
 

____________________________________

Phone #
 
 
 
 
 
 
 

Dated:___________________