CASE NAME:________________________ CASE NUMBER:__________________
 
 

BEGINNING BALANCE (ending balance from last month): $_______________
 

RECEIPTS:

1. Wages/Salary $______________

2. Gross Milk Proceeds $______________

3. Livestock Sales $______________

4. Crop Sales $______________

5. Government Payments $______________

6. Interest/Dividends $______________

7. Other Receipts (Specify) $______________

________________________

________________________
 

TOTAL RECEIPTS: (A)$______________
 

DISBURSEMENTS:

1. Wages/Salary Paid

a. Relatives $______________

b. Others $______________

2. Livestock Purchases $______________

3. Deductions from Milk Check $______________

4. Other Necessary Expenses $______________

5. Cash Withdrawn for Personal

Expenses* $______________
 

TOTAL DISBURSEMENTS (B)$______________
 

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

ENDING BALANCE (BEGINNING BALANCE PLUS NET RECEIPTS) $_______________
 

*Individual debtors may withdraw reasonable amounts of cash from the DIP account for personal expenses. The total amount of cash withdrawals during the month must be shown above. Individual items purchased with the cash need not be listed on page 3 unless the price of the item exceeded $100.00.
 

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

Bank:________________________________ Account#_________________________
 
 

SUBTOTAL $______________

MINUS TRANSFERS FROM OTHER ACCOUNTS $______________
 

TOTAL $_______________

(Transfer to Page 1, Line A)

Receipts may be identified by major categories. It is not necessary to list each transaction separately by name of customer or invoice number. You must, however, create a separate list for each bank account.
 
 

Bank: _____________________________________________
 

Acct. No.: _____________________________________________
 

Account Name: _____________________________________________
 

Location: _____________________________________________
 
 
 
 
 

Please list all disbursements made during the month on the attached sheet. You must create a separate list for each bank account. The date, check number, amount and brief description must be provided for each disbursement. Attach additional sheets if necessary. Also list any cash payments for personal expenses in excess of $100.00.
 
 
 
 
 

TOTAL DISBURSEMENTS $ _____________________
 

MINUS TRANSFERS TO OTHER ACCOUNTS $ _____________________
 
 
 

TOTAL MONTHLY DISBURSEMENTS $ _____________________

(This figure should be transferred to line B of the Summary Page)
 
 
 
 
 

DATE PAID	CHECK NO.	PAYEE	DESCRIPTION	AMOUNT

 
 
 

STATEMENT OF UNPAID BILLS (POST-PETITION)
 

List below any bill incurred after the filing of this case which has not yet been paid and which is more than 30 days old. Include any unpaid taxes.
 
 

STATUS OF POST PETITION PAYMENTS TO SECURED CREDITORS AND LESSORS
 

Name of Creditor Lessor

Date Regular Payment is Due

Amount of Regular Payment

Check # of Payment

Number of Payments * Delinquent

Amount of Payments Delinquent

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

*State reason for non-payment.
 
 

I, ________________________________________________________________

declare under penalty of perjury under the laws of the United States that I have read the foregoing Monthly Report on 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: