UNITED STATES BANKRUPTCY COURT

WESTERN DISTRICT OF VIRGINIA

In re enter Debtor name(s)	Case No. enter case #
Debtor(s)	Chapter select Chapter

APPLICATION TO PAY FILING FEE IN INSTALLMENTS - WESTERN DISTRICT OF VIRGINIA

In accordance with Fed. R. Bankr. P. 1006 and Local Bankruptcy Rule 1006-1, I apply for permission to pay the filing fee amounting to select Filing Fee in installments.

I am unable to pay the filing fee except in installments.

Until the filing fee is paid in full, I will not make any additional payment or transfer any additional property to an attorney or any other person for services in connection with this case.

I propose the following terms for the payment of the Filing Fee. (check applicable Chapter and fill in due dates):

☐	Chapter 7:

$111.00 upon filing of petition:	select date or enter SPACE

$112.00 on or before:	select date or enter SPACE (due 30 days after petition filed)

$112.00 on or before:	select date or enter SPACE (due 60 days after petition filed)

☐	Chapter 11:

$572.00 upon filing of petition:	select date or enter SPACE

$572.00 on or before:	select date or enter SPACE (due 30 days after petition filed)

$573.00 on or before:	select date or enter SPACE (due 60 days after petition filed)

☐	Chapter 12:

$91.00 upon filing of petition:	select date or enter SPACE

$92.00 on or before:	select date or enter SPACE (due 30 days after petition filed)

$92.00 on or before:	select date or enter SPACE (due 60 days after petition filed)

☐	Chapter 13:

$103.00 upon filing of petition:	select date or enter SPACE

$103.00 on or before:	select date or enter SPACE (due 30 days after petition filed)

$104.00 on or before:	select date or enter SPACE (due 60 days after petition filed)

If any installment due date falls on a day that the Court is closed, payment shall be made not later than the next business day.

I understand that the clerk shall issue an order of dismissal in any case where the initial installment payment required under FRBP 1006 and Local Bankruptcy Rule 1006-1 has not accompanied the filed petition or in any case where a subsequent installment payment has not been received by the due date and that my debts will not be discharged until my entire fee is paid.

I understand that, if my bankruptcy case is dismissed, my rights in other bankruptcy proceedings may be affected.

I understand that upon dismissal of the case, the remaining filing fee is nonetheless due and payable within l4 days following dismissal of the case and that subsequent applications to pay filing fees in installments will be denied until all prior filing fees are paid in full.

_________________________________	____________________________________________
Signature of Attorney Date	Signature of Debtor Date
(In a joint case, both spouses must sign.)
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Name of Attorney	Signature of Joint Debtor (if any) Date
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Address
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Telephone No.