Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 4
Other Necessary
Expenses
In addition to the expense deductions listed above, you are allowed your monthly expenses for the
following IRS categories.
6. Taxes: The total monthly amount that you actually pay for federal, state and local taxes, such as income taxes,
self-employment taxes, social security taxes, and Medicare taxes. You may include the monthly amount withheld
from your pay for these taxes. However, if you expect to receive a tax refund, you must divide the expected
refund by 12 and subtract that number from the total monthly amount that is withheld to pay for taxes.
Do not include real estate, sales, or use taxes.
$_______
7. Involuntary deductions: The total monthly payroll deductions that your job requires, such as retirement contributions,
union dues, and uniform costs.
Do not include amounts that are not required by your job, such as voluntary 401(k) contributions or payroll savings.
$_______
8. Life insurance: The total monthly premiums that you pay for your own term life insurance. If two married people are filing
together, include payments that you make for your spouse’s term life insurance.
Do not include premiums for life insurance on your dependents, for a non-filing spouse’s life insurance, or for any form of
life insurance other than term.
$_______
9. Court-ordered payments: The total monthly amount that you pay as required by the order of a court or administrative
agency, such as spousal or child support payments.
Do not include payments on past due obligations for spousal or child support. You will list these obligations in line 35.
$_______
0. Education: The total monthly amount that you pay for education that is either required:
as a condition for your job, or
for your physically or mentally challenged dependent child if no public education is available for similar services.
$_______
1. Childcare: The total monthly amount that you pay for childcare, such as babysitting, daycare, nursery, and preschool.
Do not include payments for any elementary or secondary school education.
$_______
2. Additional health care expenses, excluding insurance costs: The monthly amount that you pay for health care that is
required for the health and welfare of you or your dependents and that is not reimbursed by insurance or paid by a health
savings account. Include only the amount that is more than the total entered in line 7.
Payments for health insurance or health savings accounts should be listed only in line 25.
$_______
3. Optional telephones and telephone services: The total monthly amount that you pay for telecommunication services
for you and your dependents, such as pagers, call waiting, caller identification, special long distance, or business cell
phone service, to the extent necessary for your health and welfare or that of your dependents or for the production of
income, if it is not reimbursed by your employer.
Do not include payments for basic home telephone, internet or cell phone service. Do not include self-employment
ex
enses
such as those re
orted on line 5 of Fo
m 122C-1
or an
amount
ou
reviousl
deducted.
+ $________
4. Add all of the expenses allowed under the IRS expense allowances.
Add lines 6 throu
h 23.
$________
Additional Expense
Deductions
These are additional deductions allowed by the Means Test.
Note: Do not include any expense allowances listed in lines 6-24.
5. Health insurance, disability insurance, and health savings account expenses. The monthly expenses for health
insurance, disability insurance, and health savings accounts that are reasonably necessary for yourself, your spouse, or
your dependents.
Health insurance
$__________
Disability insurance
$__________
Health savings account
+ $__________
Total
$__________
Copy total here .....................................................................
$________
Do y
ou actually spend this total amount?
No. How much do you actually spend?
Yes
$__________
26. Continuing contributions to the care of household or family members. The actual monthly expenses that you will
continue to pay for the reasonable and necessary care and support of an elderly, chronically ill, or disabled member of
your household or member of your immediate family who is unable to pay for such expenses. These expenses ma
y
include contributions to an account of a qualified ABLE program. 26 U.S.C. § 529A(b).
$_______
27. Protection against family violence. The reasonably necessary monthly expenses that you incur to maintain the safety of
you and your family under the Family Violence Prevention and Services Act or other federal laws that apply.
By law, the court must keep the nature of these exp
enses confidential.
$_______