Form 106I — USA v. Harun (Dkt. 19.5)

Record facts

U.S. District Court for the Southern District of Georgia · No. 3:23-cr-00003-DHB-BKE · Doc. 19-5 · 2023-08-31 · Docket on CourtListener

Full text

Official Form 106I
Schedule I: Your Income
page 1
2IILFLDO)RUP 106I 
Schedule I: Your Income 
12/15
Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for 
supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your spouse. 
If you are separated and your spouse is not filing with you, do not include information about your spouse. If more space is needed, attach a 
separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question. 
Part 1:  
Describe Employment 
1. Fill in your employment
information.
If you have more than one job,
attach a separate page with
information about additional
employers.
Include part-time, seasonal, or
self-employed work.
Occupation may include student
or homemaker, if it applies.
Debtor 1 
Debtor 2 or non-filing spouse 
Employment status 
‰ Employed
‰ Not employed
‰ Employed
‰ Not employed
Occupation 
__________________________________ 
__________________________________ 
Employer’s name 
__________________________________ 
__________________________________ 
Employer’s address 
_______________________________________ 
Number Street 
_______________________________________ 
_______________________________________ 
_______________________________________ 
City 
State 
ZIP Code
________________________________________ 
Number 
Street 
________________________________________ 
________________________________________ 
________________________________________ 
City 
State 
ZIP Code
How long employed there?
_______
_______
Part 2:  
Give Details About Monthly Income 
Estimate monthly income as of the date you file this form. If you have nothing to report for any line, write $0 in the space. Include your non-filing 
spouse unless you are separated. 
If you or your non-filing spouse have more than one employer, combine the information for all employers for that person on the lines
below. If you need more space, attach a separate sheet to this form.
For Debtor 1 
For Debtor 2 or 
non-filing spouse 
2. List monthly gross wages, salary, and commissions (before all payroll
deductions). If not paid monthly, calculate what the monthly wage would be.
2.
$___________
$____________
3. Estimate and list monthly overtime pay.
3. + $___________ 
+ $____________
4. Calculate gross income. Add line 2 + line 3.
4.
$__________
$____________
Debtor 1 
  ____________________________________________________________________ 
First Name 
Middle Name 
Last Name
Debtor 2 
____________________________________________________________________ 
(Spouse, if filing)
First Name 
Middle Name 
Last Name
United States Bankruptcy Court for the: __________ District of ___________
Case number ___________________________________________ 
 (If known) 
Fill in this information to identify your case: 
Check if this is: 
‰ An amended filing
‰ A supplement showing postpetition chapter 13
income as of the following date:
________________
MM  /  DD /  YYYY 
__________ District of __________
Case 3:23-cr-00003-DHB-BKE     Document 19-5     Filed 08/31/23     Page 1 of 2

Debtor 1 
_______________________________________________________ 
Case number (if known)_____________________________________  
First Name 
Middle Name 
Last Name
2IILFLDO)RUP,
Schedule I: Your Income
page 2
For Debtor 1
For Debtor 2 or 
non-filing spouse
Copy line 4 here ............................................................................................... Î 4.
$___________
$_____________
5. List all payroll deductions:
5a. Tax, Medicare, and Social Security deductions 
5a.
$____________
$_____________
5b. Mandatory contributions for retirement plans 
5b.
$____________
$_____________
5c. Voluntary contributions for retirement plans 
5c.
$____________
$_____________
5d. Required repayments of retirement fund loans 
5d.
$____________
$_____________
5e. Insurance 
5e.
$____________
$_____________
 
5f. Domestic support obligations 
5f.
$____________
$_____________
 
5g. Union dues
5g.
$____________
$_____________
5h. Other deductions. Specify: __________________________________ 
5h. + $____________
+ $_____________
6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h.  6.
$____________
$_____________
7. Calculate total monthly take-home pay. Subtract line 6 from line 4.
7.
$____________
$_____________
8. List all other income regularly received:
8a. Net income from rental property and from operating a business,
profession, or farm 
Attach a statement for each property and business showing gross 
receipts, ordinary and necessary business expenses, and the total 
monthly net income.  
8a.
$____________
$_____________ 
8b. Interest and dividends 
8b.
$____________
$_____________ 
8c. Family support payments that you, a non-filing spouse, or a dependent 
regularly receive 
Include alimony, spousal support, child support, maintenance, divorce 
settlement, and property settlement. 
8c.
$____________
$_____________ 
8d. Unemployment compensation  
8d.
$____________
$_____________ 
8e. Social Security  
8e. 
$____________
$_____________ 
8f. Other government assistance that you regularly receive 
Include cash assistance and the value (if known) of any non-cash assistance 
that you receive, such as food stamps (benefits under the Supplemental 
Nutrition Assistance Program) or housing subsidies. 
Specify: ___________________________________________________ 
8f. 
$____________
$_____________ 
8g. Pension or retirement income
8g.
$____________
$_____________ 
8h. Other monthly income. Specify: _______________________________ 
8h. + $____________
+ $_____________
9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h.
9.
$____________
$_____________ 
10.Calculate monthly income. Add line 7 + line 9.
Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse.
10.
$___________ +
$_____________ = $_____________
11. State all other regular contributions to the expenses that you list in Schedule J.
Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and other
friends or relatives.
Do not include any amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J.
Specify: _______________________________________________________________________________
11. +
$_____________
12. Add the amount in the last column of line 10 to the amount in line 11. The result is the combined monthly income.
Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies
12.
$_____________
Combined 
monthly income 
13.Do you expect an increase or decrease within the year after you file this form?
‰ No.
‰ Yes. Explain:
Case 3:23-cr-00003-DHB-BKE     Document 19-5     Filed 08/31/23     Page 2 of 2

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