chapter 7 bankruptcy forms for filing without an attorney · pdf filechapter 7 bankruptcy...
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Chapter 7 Bankruptcy Forms for
Filing Without an Attorney Address: United States Bankruptcy Court
126 U.S. Courthouse
517 East Wisconsin Avenue
Milwaukee, Wisconsin
53202-4581
Office Hours: 8:30a.m. to 4:30p.m., M-F
Main Office Phone Number: (414) 297-3291
Bankruptcy Help Desk: Staffed by volunteer attorneys on Thursday mornings from 9:00 a.m. to 10:30 a.m. The Help Desk Is in Room 153 at the above courthouse address.
Disclaimer: This packet of forms and related Information has been put togetherto·ossist individuals who ore considering filing ban/1ruptcy without an attorney. The Bankruptcy Court does not guarantee that this pocket contains all the forms or information you need to file bankruptcy. The information In this packet should not be a substitute for the advice of competent legal counsel. The staff of the Bankruptcy Court cannot provide /ego/ advice. Such advice may be obtoinedfram a competent attorney.----
TO: ALL PERSONS FILING BANKRUPTCY
A tmstee will be assigned in every Chapter 7 and 13 case. The name and address of the trustee will be given in the Notice of Banlauptcy Case Filing (also called the 341 Notice). That Notice will also give the date, time, and place of the "Section341 Meeting of Creditors." Attendance at this meeting is required of all debtors. The N.otice will be sent to the Debtor and all creditors listed on the mailing matrix within 7 to 1 0 business days.
A. No later than 7 davs before the Section 34 I Meeting of Creditors. vou are required to provide the trustee with copies of the following reguired documents (do not send originals. malce a copy for the tmstee):
1. Titles to all vehicles; 2. Recorded deeds and land contracts for all real estate; 3. Recorded mortgages for all renl estate; 4. The most recent real estate tax bill for nil real estate; 5. The preceding two (2) years signed federal and state income tax returns and all schedules
or transcripts of the returns. 6. Payment advices (e.g. pay stubs) or other evidence of payment received by the debtor
from any employer within 60 days befure filing the petition. 7. The name, address and telephone number of each holder of a Domestic Support
Obligation; and, 8. Any other documents requested by the trustee. 9. Tax returns and payments advices or other evidence of payment provided to the trustee
under paragraphs (a)(5) and (a)(6) above, shall not be filed with the court unless otherwise ordered,
B. At the Meeting of Creditors. you must produce the following:
1. Pictnre identification issued by a govemmental unlt (driver's license, county id card or the like), showing your name and picture identification.
2. Social Security card orrecent W-2 or 1099 showing your Social Security number.
C. In addition. you must provide to the trustee any additional documents the Trustee requests at least seven (7) davs before the meeting of Creditors:
If·any of these documents are not provided as requested, the case may have to be adjourned from the initial meeting date.
lf any of these matters are not applicable, please so indicate in your response. If you have any questions regarding the request, please contact the Trustee,
z
Warning Regarding Petition Prepnrers
Only an attorney is autl10rized to give you legal advice regarding a bankruptcy case or proceeding.
So-called "petition preparers" are not autl1orized to give debtors legal advice, Their role is strictly that of a typing service transcribing for a minimal fee tl1e information a client provides, For example, they cannot:
Malee suggestions regarding what papers are legally appropriate
Advise you regarding what is legally required when a form elicits infmmation :from you
Explain the meaning of a particular statutory provision or rule
Provide advice on the best procedure to accomplish a particular goal
Explain tlie result oftaldng or not taldng action in a case
Explain who should receive proper notice or service
Most of tl1e required forms in a bankruptcy case are available for free, and most are in pdffillable form so that they can be completed using a keyboard. If you do not have a computer, check at the Clerk's intake couoter regarding tbe availability of a computer you may use, free of charge, for the purpose of filling out the reqtrired forms.
Given !he availability on the internet of pdf-fill able forms, there is little or no reason for a debtor to pay a non-attorney "petition preparer" to obtain the forms. Properly completing those forms, however, may require advice ofcompetent legal counse~ a petition preparer may not give you such legal advice.
Waming to Petition Preparers: Section]] 0 of the Bankruptcy Code provides civil penalties for· persons, other than an allorney or an employee ofan.attomey, who negligently orfi·audzilent/y prepare bankruptcy petitions or any other document for filing by a debtor in connection with a banlrr:uptcy case. All petition preparers shall comply with the requitements of 11 U.S. C. § II 0. Failure to comply with § II 0 may result in civil enforcement action by the United States Trustee or subject the preparer to criminal prosecution under I8 U.S. C.§ 156,
Farm 200 (Chaptl!r7, Individual!
What forms do I need to file bankruptcy?*
A. To open a Chapter 7 bankruptcy case, you need to file these forms and deal with the filing fee today, If you are o business/corporation and want to file Chapter 7, you must hove on attorney.
D Voluntary Petition B 1 D Creditor Mailing Matrix 0 Exhibit D B 1D D Credit Counseling Certificate
Don't have your credit counseling certificate? D I took a credit counseling course, but do not have the certificate. (You have
14 days to submit it.) D I requested, but could not obtain the counseling, and I have an emergency
and need to file banltruptcy before I can take the course. (The judge may allow a 30 or45-day extension, depending on the explanation you provide.)
D I am not required to get credit counseling. {See instructions in Exhibit D) D Statement of Social Security Number Lccal Form 21 D $299 filingfee, or
Can'_t affa~d the filing fee? d You may be able to pay in instalirnemts B 3A D You maybe able to have your fee waived B 38
D Did a petition preparer help you? If so, you will need to file: D Notice to Debtor by Bankruptcy Petition Preparer B 19 D Disclosure of Compensation for a Bankruptcy Petition Preparer B 280
B. The following forms are also needed in your case. They are due in 14 days. If you do not submit them within 45 days, your case will be dismissed.
D Schedules · D Schedule A- Real Property D Schedule B- Personal Property D Schedule C- Property Claimed as Exempt D Schedule D- Creditors Holding Secured Claims D Schedule E- Creditors Holding Unsecured Priority Claims D Schedule F- Creditors Holding Unsecured Non priority Claims D Schedule G- Executory Contracts and Unexpired Leases D Schedule H- Co-debtors D Schedule 1- current Income D Schedule J -current Expenditures of individual Debtor(s) with Statement
of Monthly Net Income
D Statement of Financial Affairs D Statement of Current Monthly Income and Means Test Calculation
.C. These forms also need to be submitted within 14 days,
D summary of Schedules D Statistical Summary
B 6A B 6B B 6C 8 6D 86E 8 6F 866 86H 8 61 8 6J
B7
822A
B 6, page 1 B 6, page 2
* STOP! Have you filed Chapter 7 in the last8 years and received a discharge? If so, you must wait to file unti/8 years and 1 day after your last petition was filed.
4
m com · 1 F n C41JOJ IC!n ·arm 1upe:!
Vohmtnry Petition Nume of DebloJ(s): (nlis paf!e m11.rt be cump/t!IDri and filed flll!I'IU1' c:nst!,)
AIIJ'rlnr llnnltnmlc\' Cnses lilletl WIUtht l..ltsl B Vcnr.> (If more limn nvo. nttoch utlditionnl .sheet.) Lncnt!an Cusc Number: DnteFiled: Where Filed: J..acutlon C115e Number. DuteFiled; Where Filed:
l'cmlln 1 Dnnltrllpt~· Cusc Fll~d h~· nny S 1nusc, l'nrtuer, ur Mfillnll! nflhi!i Debtot• Ofmnrellum nne, nllm::h nddilionul sheet.) Nnme ofOehtor. Cme Number: Dote Fllctl:
DiSirict Relntionship: Jttdgc;
E:rhlbll A Exhlhh n {To bo completed If debtor is on individual
[fo bu complcle:tl Jftlubtor is required to file periodic rcpons (c.c., fmms IOK ond IOQ) wltnse debts nro primllri]y con.sumer debts,) \\1Ut the Sucurilie£ und Exclmnge Commission pursuant to SecJ.ion 13 or l5(d} of the Securitii!S 8tchnnge Act or 19J4 und is requi!Sting relief under ehnpter II,) 1, lhL! nuamcy for lhe petilloner nnmed in the foregoing petition, duclnrc that I
hove infonned !he pethloner lim\ [he or she] mny proceed undi!r chnplor7, II, 12, or 13 ortltle II, United Stutes Code, and hove expln\ned Ute rclicfomllnble under encb such thnpter. 1 further certify thnt I hove dalivorcd to the debtor the notice required hl' II U.S.C. § 342(b).
0 Eli.hlbit A is nltncber.l und 111nde n part ofthls petilion. X Signature of Attorney for Dcbtor(s) {Dote)
Exhibit c
Doe.'i the debtor own or hnve possession of nny property tlun poses or Is alleged to posen thrco\ of lmmln~:nt nnr.lltlentifioblll hnrm lo public henllh or snfety'}
0 Yes, and ExhlbitC is aunched ond mude n pnrtofthis pethion,
0 No.
Exblbll D
ffo be tompi!!U!d b)' CVCI)' individual debtor. Ifnjoint petition is nlcd, ench spouie must complete nnd ntlnth nsepnrnte Exhibit D.)
0 E·x.hiblt 0 completed nnd signed by the debtor is nunc bed nnd mntle n pnrt of litis petition.
If this Is a joint pc.tllion:
0 Exhibit D also completed nnd signed by the joint debtor is ntmchcd nnd mndc. n port ofthis petiliorL
Infnnnnllnn Rcgnrdlng lhll Debtor- Vcuuc
0 (Check nny nppticable bD:t.}
Debtor hns been domlnlh~d or hns had o ll!Sirlencc, prlncipnl place ofbtuim:ss, or principal nssets In this District for lBO days immcdlntcl}• pre~:eding the tlnle of lbis petition or for n longer port nfsueh 180 dnys thou in nny othllr District.
0 Them is 11 bankruptcy CllSC concaming: debtor's nffilintll, gnncrnl pnrtner, or pnrtm:rship pending iil this District.
0 Dlilitor is n dl!blor In o foreign proceeding ond hll!i its princlpnl pluce of business or pdncipnl nssets in the Unllllti Stoles in this District, or l1ns no prlnclpnl place ofbusirit:Ss or nssl!ts in the Unlt~:d Stnles but is n dert:ndnnt innn action or procectlinn [in o fcdcml or stntc court] In this Dis!rlct. or !he Interests oflh.c pnrlies will be scrvl!d In rcgortlto Uu~ n:licfsoughi in thir. District,
Ccrtlfi~!nlion b)' II Dei.Jtor Who Rcshlcsits 11 Tenon I urResldenllnl i'rnpcrty (Chct:i; u\1 ilpplicnblc bo:tes.)
0 Lnmllord hns njutlgm~:nt ognhlsttbe debtor for pD.Ssessiun of debtor's residcn~ (lfbox chile ked, complete the following.)
{Nome or Jnndlord tltnl obtnincdjudgmcnt)
(Address oflundlord)
0 Debtor cluimS thnl under npplicnble nonbnnl;rup!Cy Jnw, them n~ circumEtnnces under which the debtor\vould be permitted to cure Ute entire monetnry·defuuh thnt gnvc riSe to the judgment forpcssts!iion. ofier the judgment forpossi!SSion·wns entered, nnd
0 Debtor hD5 included wlll1lhis p!!lllion the deposit wltlt the court ofnny rent liml would become due dtiring the 30-dny·pcriod nflcr the filing ofU•c pelitiun.
0 Debtor ccnlfies Lbnl he/she hll!l serveD tltu Lnrn1Jord with this c:rtlficotion. (II U.S.C. § Jli2(1)),
5
B I (Offitiul Fom1) I {4/1 0) Pnge.J Voluntni'Y }lctitlon Numl! of Dcbtor(s}: (f/ti;r puxv 1111t.~l he compiCI/t!d a/ltl.!ift!d iJII!I'l!/J' ccuu.}
Slgnntures Slgnnture(s) ofUcblur{s} (lndlviduni/,Joinl) Slguntnru or11 Furclgn Rtprt!.!il!lttnlh•c
I dl!clnrc undl!r pnnnlty of peljury thnt the inrormntion prnvldi!Ll in this pnlithm is true I detlnre under pcnnll}' or pnrjmy lhnlthll informntion provided In this pctilion l5 nud correcL true and cDrrcct, thnt I nm the fo~ign representutive of u debtor in n foreign fif petitioner is nn lndividuui whose debts nrc primarily consumer debts and hns pmt:~:eding, nnd thnt I om uuthoriwd 111 11Je this petition. chosen to file under chnptcr 7J I om D\YllTC thnt 1 mil}' procm:d undru chnpter 7, II, I:!
{Chtck only unu box.) or 13 oflitll! II, United Stntcs Code, undcrstnnd d1Ll rcliefnvullnblc under cnclt suclt chnpter,nnd clmosc to proceed under chupter 7. D I request relief in uccordnnce with chapter \5 oft!tlc II, United Stoles Code. [If no oUonH!)' represents me nntlno bankruptcy petition prepnrer signs tlte polltion} I CllrtUicd copies of the documents required b)' II U.S.C. § 1515 nru nunched. hnvu obtninetlnnd rend the notice required b.Y II U.S. C. § .342{b}.
I request relief in nccordrmcu with lite clmptcr of title D Purslliln\to 11 U,S,C. § 1511,1 request relief in occordnnce with the
II, United Stntes Code, clmptcroftlllc II specllied in this petition. A cenitiecl copy orthc speclrietl in this petition. order grnnling rucognition of the foreign mnin proceeding i~ ounched.
X X Sigmuuro ofDcbtor (Sigmuure of Foreign Represr:ntntive}
X Signature of Joint Debtor (Printed Nome of Foreign Rcpr!$CI11Dllvc}
Telephone Number {if not represented by nllomey) Dote
Dote Slgunture or Attnn1el'"' Slunnlure ofNou-Aitorney Bnnltnlptcy Petitlnu Prepnrer
X I dl!l:lnrc under penni!.}• or peJjuty thnt: (I} l om n bnnliruptcy pelition prcpnrer us Slsnntureuf Allomcy for DebiDr(s) defined in 11 U,S,C, § 110; (2) I prepared lhls document for compcnsntlon nnd hove
Printed Nnme of Allomc~· for Oebtor{s) provided the debtor with n copy of this document nnd 1he notices and infommUon required under II U.S.C, §§ JIO[b), II OQ1), nnd 342(b); and, (3) If rules or guidelines hove bean promulgnted pursunnt to II U.S.C. !i 11 O{h) setting o
Finn Nome maximum fee. for services chnrg~oble by bankruptcy petition prepnn:rs, I hove given the debtor notice of the mnximum nmount before preparing llnl' dm:ument for filing for n debtor or nct!!!pUng ony fcc from the debtor, ns required in lhnl section. Official Fonn 19ls nUnched.
Address
Telephone Number Printed Nnme nnd tille, ifnn)•, ofBnnkruptcy Petition Prepnn:r
Dote Social-Security number {If the bnnltruptt:y pctillnn prcpnrcr Is not nn individual, stole the Socini·Sccurity number or the officer, principal.
'In n ctl5C in which jj 7D7{b)(<I)(D) nppll~, this signntw-t: also constitult:s u ICSpoll!ilble person or punnar of tln.! bnnkruptcy pt:tllian ·prcpnrer.) (Required cenificnticn thntlhe nuomey hns no btowlcdsc nficr nn lnquhy lhntthcinfonnntion by 11 u.s.c. § 110.) in the. schedules is im:orrc:cl
Signature of Debtor (Corponlllonll'nrlncrshlp)
I declare underpcnnlty ofpeljul}' lhot the information provided In this petition ls true Address nod correct, ond llmt. I have bean oul11orized to filn this petition on behalf or the X debtor.
The debtor requests the rellr:r in uccortlom:c-wlth the. choptcr of title II, United Stutes Code, specified in this pl!lltion.
Dall:
X Signoture of bnnltruptcy. petition prcpnn:r or officer, princlpnl, responsible person,
Signature or Authortzerllndlvitlunl or partner WhD!!u Soclni·Set:urhy number is proVided ubovc.
Printed Nnme Of AulhoriU.!d lndlvldunl Nnmes nod Boclnl·Sccurlly numbers of oil other indlvidunls who prepnrcd or nssistt:d in propnrlng thili docuintnl unle!l!llhe bllnkruplcl' petllion prupnrur is not nn
Tille oMuthnrized lndlviduol Jndlviduol,
Dntc If mere thnh one pers_on prepnrctl lliis document, ·Dttnch odd!Uonnl sheets conforming to the npproprlntc off' mini fonn fer cnch ptr.;on.
A bt111ATilplcy.pctftfon prepa~'s jaifllre to -complj• wills _ihe provi.sfolls of Iiiii.! J J a11P tile Federal Rules af Bonkillptcy Procedure Jllttl' rc.nslt in]llit!S or lmprisotlllU!lll or bath. 1 I .u.s. c.§ JJfJ: 111 U.S.C .9 l:i6.
Jmwt L, Mrullut.•li Clerk nfCtJliJ't
Uni/l!d States Bankruptcy Court Eastem Dlstrict of Wiscuns;u
Offi"• nf /he Clerk
REQUIREMENTS FOR FILING A
126 U.S. Cuul'thouse 517 E. Wi~·c:umiin rJve.
..ll:lilwnulir!e1 WI 53202-4581 414-297-3291
www. wieb.uscourts.gov
LIST OF CREDITORS, CREDITOR MATRIX, OR MASTER LIST (MATRIX)
In order to process matrices more efficiently, the Clerk requests that matrices are filed electronically either by using the File Your Creditor Matrix application which is available on the court's website, www.wieb.uscourts.gov or on the terminals in the public area of the Banlcruptcy Clerk's Office, or byE-Mail atwieb matrices(alwieb.uscourts.gov. Only in extenuating circumstances will a paper matrix be accepted for filing. It is not necessary to file a verification of the creditor matrix in this district.
I. Using the File Your Creditor Matrix application (www.wieb.uscourts.gov)
a. Type the names and addresses of all creditors. For example:
AT&T P 0Box575 Murray, UT 83557
ADT Security Services P 0 Box3490 Pittsburgh, PA 15450-7490
Sears, Roebuck & Company POBox3671 Des Moines, 1A 50322
b. Wlmtlfinished typing each creditor, click on Add Creditor.
c. Wllen finished adding all creditors, click on Submit List button.
d. You have an opportunity to review the list at the next window.
e. Click on either Back button to edit the list or the Submit button to accept the list.
i. Clicking on Submit will 'Send your matrix to a deputy clerk.
1
B ID {Offil:iul Form 1, Exhibit D}(l2/09)
UNITED STATES BANKRUPTCY COURT
In re·---~-,-------Debtor
Case No .. _-:-::--:-::---:-(iflmown)
EXHIBIT D- INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE 'WITH CREDIT COUNSELING REQUIREMENT
Warning: You must be able to check truthfully one of the five statements regarding credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy case, and the court can dismiss any case you do file. If that happens, you will lose wbatevcr filing fee you paid, and your creditors will be able to resume collection activities against you. If your case is dismissed and you file anotber bankruptcy case Inter, you rnny be required to pay a second filing fcc and you rnny have to take extra steps to stop creditors' collection activities.
Eve!J' individual debtor must file this Exhibit D. If a joint petition is filed, eaclz spouse must complete and file a separate Exhibit D. Check one ofthefrve statements below and allach any documents as directed.
0 1. Within the 180 days before tbc filing of my bankruptcy case, I received n briefing from a credit counseling agency ·approved by the United States trustee or bnnlcruptcy administrator that outlined the opportunities for available credit counseling and assisted me in performing a related budget analysis, and I have a certificate from the agency describing the services provided to me. Attaci1 a copy of the certificate and a copy of any debt repCIJqnent plan developed tln·ough the agency.
0 2. Within the 180 days bef01·e the filing of my bankruptcy case, I received a briefing from a credit counseling agency approved by the United States trustee or banlcruptcy administi'Btor that outlined the opportunities for available credit counseling and assisted me in performing a related budget analysis, but I do not have a certificate from the agency describing the services provided to me. J'oumustfile a capy of a certificate from the agency describing the sen• ices pmvided to you and a copy of anydebt repCIJmrent plan developed through the agency no later than 14 dCIJ'S after your ban/a11ptcy case is filed
BID (Officilll Fcnn I, Elih. 0)(12/09)-Cunt. Pngc:!
0 3. 1 certify that I requested credit counseling services from an approved agency but was unable to obtain tl1e services during the seven days from UJe time 1 made my request, and the following exigent circumstances merit a temporary waiver of the credit counseling requirement so J can file my bankruptcy case now. [Summarize e..r:igenl ch·cums/ances here.]
If your certilication is satisfactory to the coort, you must still obtain the credit counseling briefing within the first 30 days after you file your bankruptcy petition and prompt!)' file a certificate from the agency that proYided the counseling, together with a copy of any debt m:magement plan developed through the agency. Failure to fulfill these requirements mny result in dismissal of your case. Any extension of the 30-day deadline can be granted only for en use nnd is limited ton maximum of 15 days. Your case may also be dismissed if the court is not satisfied with your reasons for filing your bankruptcy case 'vithout first receiving n credit counseling briefing.
0 4. I am not required to receive a credit counseling briefing because of: [Check ihe applicable statement.] [Must be accompanied by a motion for determination by the courL]
0 Incapacity. (Defined in 1 I U.S.C. § 109[h)[4) as impaired by reason of mental illness or mental deficiency so as to be .incapable of realizing and making rational decisions with respect to financial responsibilities.);
0 Disability. (Defined in J1 U.S.C. § 109(h)(4) as physically impaired to the extent of being unable, after reasonable effort, to participate in a credit counseling briefing in person, by telephone, or tlu·ough the Internet.);
0 Active military duty in a military combat zone.
0 5. The United States trustee or banlcruptcy administrator has determined that the credit counseling reqtJirement of 11 U.S.C. § I 09(h) does not apply in this district.
I certify under pennlty of perjury that the information provided nbove is true nud correct.
Signature ofDebtor: -----------
Date:-------
q
Locnl Fnmt11 Ue\': 1212007
UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT 01' WISCONSIN
lnre. ______________________ __
Dubtor
Case No.-------------------
Chnplllr
STATEMENT OF SOCIAL SECURITY NUMIIER(S)
I. Name of Debtor (Last, Firs~ Middle):-----------------------------
1 Debtor hns a Sociul Security Number and ll is ___ __
I Debtor does not have a Social Security Number but hns un lndividuul Taxpayer-ldentificalion Number (!TIN), and it is:----------------------
1 Debtor does not have either n Social Security Number or an Individual Tnxpayer-ldenlification Number (!TIN).
2. Name of Joint Debtor (Las~ First, Middle]:, _____________________________ _
I Joint Debtor has a Social Security Number and it is ____ __
I.JolnlDebtor does not have a Social Security Number but has an lndividunl Taxpayer-Identification Number (!TIN), and it is: -----------------------
LJoint Debtor does not have either a Social Security Number or an Individual Tm:payer-ldentilication Number (!TIN].
3. Name of Spoi!Se if not n Joint Debtor (LDS~ First, Middle]:-------------------------------
Address ____________________________ _
!:Spouse has a Social Security Number and it is ____ _
f:'iSpouse docs not hnve n Socinl Security Number but hns an Individual Tnxpayer-Jdentificatian Number (!TIN], and ll is:-----------------------
I spouse docs not hnve either a Social Security Number or an lndivlduul Taxpayer-Identificntion Number (!TIN).
I deolnre under penally of perjury that the foregoing is true and correct
X--~~~~~~-----~~ Signnture·ofDebtor Dnte
x-~~~~~~~~---Signnture of Join! Debtor Dnte
*Check the appropriate boxes abot'e and pl'Dl'ide the raqrtired informal! an. *Debtor must.pravide in[armatian[or non-filing spouse. "'[f Debtor, Jdlnt Debtor or Non-Filing Spouse has mare than one. Socia( Securib' Nrmiber, slate all. • Penalu'far making a false s/alemenl: Fine of up /o $250,000 or11p loS yeat\r in!Prisaumenl or both. 18 U.S. C. §§/52 and 3571.
/0
B JA {Dmclnl FonnJA) {12/07)
UNITED STATES BANKRUPTCY COURT
In re ---------;:--;-,..--------' Dcblol'
Cosc No,-------
Chnpler ____ _
APPLICATION TO PAY FILING FEE IN INSTALLMENTS
I. In uccordllJlce with Fed. R. Bunkr. fl. IDOfi, I opply for Jlcnnissicn to pll)' the filing fcc nmounting to$c__ ____ ln lnslnllments.
2 I nm unnbh: to pny llu: filing fcc except in lnstn\lmcnts.
J. Until Ute liUng fee is pnld in full, 1 will not mnkc nny uddllionnl p11}'111CIIl or tmnsfer nny oddillcnni)UO(lCrt)' to nn unorney or nny other person fnr services in connection with this Cll5C.
4. l pmpose lh~: following teml5 for the payment ofthe Filing Fee.•
$ Check one D With the filing cflhc petition, or D On or before
$ au or before
s on or before
$ on or before
The number oflnstnllmcnts proposcdshnll not exceed four {4), nnd tl1e linn! insmllmcntshn\1 be pnyrtblc notlnlcr llJun 120 doys after filing the petition. For cuusc shown, I he court mny extend Ute time of llll)' instnlhncnl, provided the Ins\ irulnllment is pnid not inter thnn I 80 d11ys nli.er filing U1e petition. Fed. R. Bnnkr. P. I006(b)(2).
5. I understood lhalifl fall to pay uny insulllment when due, my bankruptt:y case mn)' be dismissed and 1 rna}' not receive a d[schnrge of my tlebts.
Sigmttnrc of Attorney Dote Signature of Debtor Dnu: (In a joint cuse, boU1 spouses must sign.)
Name of Attamey Signature of Joint Deb lor (if nny) Date
DECLARATION AND SIGNATURE DFNDN·ATIDRNEY DANIGlUPTCV PETITION l'REPARER (Soo II U.S,C. § llO)
I dco\nre under pennlly ofpcijUT)' lhnC (1) I om n bankruptcy petition prcpnrer as defined in J I U.S.C. § 110; (2) 1 prepllfCd tlds document for compcnsotlon and hnvc. provided tltc dcbtorwllh n copy of this document ond lite notices and infcnnntion required under II U.S.C, §§ IIO{b), IID(h), and342(ll}; (~)if ntles or guidelines luwe been promulgntcd pursunnt.to II U.S.C. § J I D(h} settirig n maximum fee for services olmrgcnb\1! by bnnkruptcy pelltion prcpnrcrs, 1 It ave given the debtor notice oflho mnximum amount before preparing nny document for filing for n debtor or accepting nny fcc Trom the deb lor, ns required und~r that section~ and (4) I will not.Dcccpt any additional money or oUterpropcrt)ifrom lhe dehlor before the filing fee is pnld in full.
PrinLcd or Typed Nnmc nnd TlUc, ifnny, ofBnnkruptCj' Petition Prepnrer .Sooini~Security No. (Required by II U.S.C. § f1 0,) ljtha ba11kruptcy patltirmpraparo.r is not an Jndillldual, .rtate 1/lf! name, IIIla (ifnnJ~, address, and sacial-secut·Uy nmnberojJhc officer, prlualpal, resptlltsible. prtrJan, or partner who signs the dacJtmrmt:
Address
·~~~~~~~~~--------------Signature ofBunkruplc}' Petition Prcpnrcr Dille
Nnmes tmd SDt:inJ-Sccurity numbers of nll oUter individuniS \Yho prepnred or nssistt:tl in prcpurlng this document, unless the bunkruptcy pclitlnn prepnrcr is no! nn individual:
lfmore than r:meprwson prepanul this document, auuchaddltiana/ signed shee.ts carifomring tcnhe appropriate OffiCial Form for each person. A hankntptc:y perilion pre.parel' 's folilwc Ia comply with the pt•ovis/DIJS riftille I 1 and the Ferleral Rilles{]/ Bankruptr:J' Procedswe :may resu/titrflnes ur imprfsammmt or hath. 11 U.S.C, § 1 IOi IB U,S.C; § 156, ·
\(
D JB (Omcinl FnnnJB)(I2/07)
APPLICATION FOR WAIVER OFTiill CHAPTER 7 FILING FEE FOR INDIVIDUALS WHO CANNOT PAY THE FILING FEE
IN FULL OR IN INSTALLMENTS
The court fee for filing a case under chapter 7 ofthe Bankruptcy Code is $299.
lfyou cannot afford to pay the full fee at the time of filing, you may apply to pay the fee in installments. A form, which is available li"Din the bankruptcy clerk's office, must be completed to make tlmt application. If your application to pay in installments is approved, you will be permitted to file your petition, generally completing payment of the fee over the course of four to six months.
If you cannot afford to pay the fee either in full at the time of filing or in installments, you may request a waiver of the :filing fee by completing this application and :filing it with the Clerk of Court. A judge will decide whether you have to pay tl1e fee. By law, the judge may waive the fee onlv if your income is less than 150 percent of the official poverty line applicable to your family size and you are unable to pay the fee in installments. You may obtain information about the pove~ty guidelines at www.uscourts.uov or in the banlo·uptcy clerk's office.
Required information. Complete all items in the application, and attach requested schedules. Then sign the application on the last page. If you and your spouse are filing a joint bankruptcy petition, you botl1 must provide information as requested and sign the application.
/2-
D 38 (Qfficild Form JB) (12107) - ConL
UNITED STATES BANKRUPTCY COURT
In J'e: Case No. Deblor(s) (if7k-no-l-vn"") _____ _
APPLICATJON FOR WAIVER OF THE CHAPTER 7 FILING FEE FOR INDIVIDUALS WHO CANNOT PAY THE FlLING FEE TN FULL OR lN INSTALLMENTS
Pnrt A. Fmnlly Size nnd Income
I. Including yourself, your spouso, and dependenls you hnve Jisled orwllllist on Schedule 1 (Current Income of lndlvlduul Debtors[s)), how mllily people ure in your family? (Do not include your spouse if you are sepnrnted AND nre not filing a joint petition.) ___ _
2. Restate the following information that you provided, or will provide, on Line 16 of Schedule I. Altnch a completed copy of Schedule 1, if it is available.
Totnl Combined Montltl)' Income (Line 16 of Schedule 1]: $ -----3. State the monthly net income, if any, of dependents included In Question 1 above. Do not Include any
Income nlrendy reported in Item 2. If none, enter $0.
$. _____ _
4. Add Ute "Tolal Combined Monthly Income" reported in Question 2 to your dependents' monthly net income from Question 3.
'~'----------5. Do you expect the amount in Question 4 to Increase or decrease by more than 10% during the next 6
months? Yes No
If yes, explain.
Pnrt B. Monthly Expenses
6. EITHER (u] nttach u eomplclud copy of Schedule J [Schedule ofMontilly Expenses), and state your total monthly expenses reported on Line 18 of!hnt Schedule, DR (b) if you hove notyel completed Schedule JJ provide an estimnte of your tot11l monthly expenses.
$. _____ _
7. Do you expecl the amount in Question 6 to incrense or decrease by more than 10% during tlm next 6 months? Yes No lfyes, explnin-.-
Pnrt C. Renl nnd l1ersonnl Property
EITHER (1) attnch completed .copies of Schedule A (Reul Property) and Schedule B (Personal Property], OR (2] if you have not yet completed those schedules, answer the following questions.
8. State the amount of cnsil you hnve on hnnd. $ _____ _
9, State below any money you hnve In savings, chccldng, or' other accounts in a bank or other financlni institution.
Bonk ar Other Financial Jnslhutiun: Typo cf AccautiL5Uclt 11!i fiDYlngs, chccklnfL CD:
Amount
$
.s. ____ _
/3
B 38 (Official Fonn3B)(I2/07) -Com
I 0. Stat~ below lhe nssets owned by you. Do not lisl ordinary household ru1·nishings nnd clothing.
Address: Home Vnhu::S ______ _
Amount owed on mongngl$ nnd lhms: S -------
Ar.ltlress: Dt.ber tcnll!Stnu: Vnluc: s ______ _
Amount owed on mortgages and lhms: $-------
Molar vchich: ModclfYCllr. ______ _ Vnlu!!!S ______ _
Amottnl ower.J:S ______ _
Motor vehicle Mndui/Vcnr. ______ _ Vnluc;$ ______ _
Amount owed: s ______ _
Otlt!!t Dcscriptinuc_ _____ _ Vnluc:s ______ _
Amount owed: S -------
11. Stnte below any person,. business, organization, or governmental unit that owes you money nnd the nmount thai is owed.
Nome or Person, Bwlni!SS, or Orpnlzntion thnLOwes Ynu Manny
Pnrt D. Additionnl lnformn!lou.
Amount Owed
s ____ _ $ _____ _
12. Hnve you puid nn attorney nny money for services in connection with this·case, including the completion of this form, the bankruptcy petition, or schedules? Yes_ No_ If yes, how much have·you paid? s _______ _
13. Have you promised to pay or do you anticipate poying nn attorney in connection with your bnnluuptcy cD.Sc? Yes_No_ If yes, how much have you promised to pny or do you nnticlpnte paying? $ ---------
14. Have you pnld nnyone other t1111n nn nt!orney (such as a bnnlcruptcy petition ·prepnrer, paralegal, Lyplng service, or nnotller person) nny money "for services In connection witl1 Utis cnse, includiJlgthe completion of this iorm, the banlrruptcy petition, or schedules? Yes _No_ Jfyes, how much hove you paid? $--------
15. Hnve you promised to pay or do you anLiclpnte paying nnyonc. otlu~r thnn nil nttornc.y.(suoh as a bllrlkruplcy petition prepnrer, pnrnlegal, typing service, or nnotherperson) any money for services in connection wiU1 this coso, including tho oomplclion of this fOrm, the bankruptcy petition, or schedules? Yes No lf yes, how much hove you promised to pay or do you anticipate pay lng? $ ---------
16. Hns anyone paid an attorney or other-person or service. in connection with iliis elise, on your behalf? Yes No
lfyes, explain.
14
B 3B (Officinl Fonn JB) (12107) -Cont.
17. Have you previously filed for bankruptcy relief during the past eight years? Yes_No_
Cnse Number (if known]
Yenr filed Location of filing Did you obtain a discharge? [lflmown)
Yes No Don't know
Yes No Don11 know
I H. Please provide any other lnfonnatlon tl1at helps to explnin why you are unable to pay the filing fee in installmenls.
I 9. I (we) declnre under penalty ofpeljury thnt I (we) cannot currently afford to pny the filing fee in full or in instollmenls nnd Umt the foregoing information is true and carn:mL
Executed on: Dale Signature ofDebtor
Date Signature of Codebtor
DECLARATION AND SIGNATURE OJ' DANICRUPTC\' l'ETITIDN PREI'ARER !Soe 11 U.S.C. § 110)
I dcclnreundcrpenully ofpctiU!J' tim!; (I) I nm n bnnkruptcy petition prcpnrc.rns defined in I I U.S.C. § 110; {2) I prcpnrcd this documenl for compcn.s:ntion nnd luwe provldcU the dcblor wiU1 n copy oftl1is document nnd the notices nnd infonnnlion required under I l U.S.C. §H II O(b}, J I 001}. nnd 342(b); nnd (3) If rules or guidelines hnvc been promulgated pursunnlto II U.S. C.§ I I O{h) seUing n mrudmum fcc for services ~:ltnrgenble by bnnkrupt~:y petition prepnrers, I have given the debtor nctice.cflhll mnx.imum nmount before prcpnring nny documcnJ for filing for n debtor or neccpting Wl}' fee from the debtor, ns required under thnt section.
Printed or Typed Nwne nnd Title, If nny, of Bankruptcy Petition Prcpnrer Socini·Sccurity No. (Rcqulrod b)• II U,S,C. §I tO.)
if tho banlmtplr:)' pelf/ion pro parer Is nat an indMdJtal, state the name, title fl( anJ~, address, and soc:ial·.Iet:ttrfo• number of the officer, prfnclpa/, respanslble person or partuer wit a sfgnr the. dacumam.
Address
X S~ig=•n=n=w=re~o~f~B~nn~~==p~lcy~P~el~il"io=n•P~re=p=ruo==r------------- Dale
Nnmes ond Sooini~Sc~:urity numbers of nil oUter lmlividuols who.prcporcd or nssistcd·Jn propitrlng this document, unlt!Ss the bunlcruptcy pt:.tllinn prcpnrer is not on individual:
/[mare than one prwson prepared this document, at/ar:/1 addiliana/.signed sheets cat!farming to the appropriale Official Fot•mfot· aach pl!l<son. A brmkrupiCJ' pelftlon preparnl' 'sjall11re Ia comply with tim pravlsious of lit/a 11 artd rlw Federal Rt~les of Bankl'llplcy Procedw·c llltD' result in fines or imprlsanmrmt or both. ll U.S. C. § I JO: 18 U.S. C. § 156.
IS
BIY {Dfficlnll'orm 19)(12101)
United States Bankruptcy Comt
lnr•--------------~~------~ Debtor
Case No. -------------
Chapter ______ _
DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)
I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in II U.S.C. § I I 0; (2) I prepared the accompanying document(s) listed below for compensation and have provided the debtor with a copy of the document(s) and the attached notice as required by 11 U.S.C. §§ IIO(b), l!O(h), and 342(b); and (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § II O(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the mnximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required by that section.
Accompanying documents: Printed or Typed Name and Title, if any, of Bankruptcy Petition Prepnrer:
Social-Security No. of Bankruptcy Petition Preparer (Required by I I U.S.C. § 11 0):
If the banlc11rptcy petition preparer is not an individual, state ·the name, Iitle (if any), address, and social-security numbe1· of the officer, principal, responsible person, m· pal'tner who signs this document.
Address
X Sig;;;n"'a"'ru'"r"'e"o"'r"B:r.a"n"'lcr"'t"'lp"'t"'cy""'P""et"'lr"'Jo"'n,...I"''I"'·e"'p'"ar""er '"D"'a"'te,------------
Names and social-security numbers of all otiter individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is·not an individual:
Q'more.than one person prepared .this dormment, attach add/tiona/signed sheets cm!formingto the appropriate Offiriial Form for each person.
A bn•il<ruptcy petition prcpn•·c•·'s failure to comply with tlw provisions of title 11 und the Fcdcr:il Rules ol'Bnnl<ruptcy Procedure mny result in fines or imprisonment or both. 11 U.S.C. § 110; 18 u.s.c. § 156.
lb
819 (Ofiiclnl Fnnn 19) {1"1/07)- Cnnt. 2
NOTICE TO DEBTOR BY NON-ATTORNEY BANKRUPTCY PETJTION PREP ARER [Must be filed with any dacument(s) prupared by a banlauptcy petition preparer.]
Jam a bankruptcy petition preparer. I am not an attorney and may not practice law or give legal advice, Before preparing any document for filing as defined in § 11 D(a)(2) of the Bankruptcy Code or accepting any fees, I am required by law to provide you with this notice concerning bankruptcy petition preparers. Under the law,§ 110 oftheBankTuptcy Code (11 U.S.C. §I 10), I am forbidden to offer you any legal advice, including advice about any of the following:
whether to file a petition under the Bankruptcy Code (11 U.S.C. § 101 et seq.); whether commencing a case under chapter 7, 11, 12, or l3 is appropriate; wheU1er your debts will be eliminated or discharged in a case under the Bankruptcy Code; whether you will be able to retain your horne, car, or otl1er property after commencing a case under the Bankruptcy Code; the tax consequences of a case brought underthe Bankruptcy Code; the dischargeabilily of1llx claims; whether you may or should promise to repay debts to a creditor or enter into a reaffirmation agreement with a creditor to reaffirm a debt; how to characterize the natore of your Interests in property or your debts; or bank-ruptcy procedures and rights.
[The notice may pra11ide additional examples of legal advice that a bankruptcy petition preparer is not authorized to give.]
In addition, under 11 U.S.C. § l!O(h), the Supreme Court or the Judicial Conference of the United States may promulgate rules or guidelines setting a maJtimurn allowable fee chargeable by a bankruptcy petition preparer. As required by law, I have notified you of this maximum allowable fee, if any, before preparing any document for filing or accepting any fee from you.
Signature of Debtor Date Joint Debtor (ifany) Dale
[h1 a joint case, bath spouses must sign.]
11
B2BO (Fonn 280) (10/05)
United States Bankruptcy Court
______ District Of _____ _
Jnre ______ ~~~-------Dcblor c .. c No,--------
Chapler _____ __
DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREFARER
[l'lli.rform milS/ be filed with tim pelillan if a bankr11ptcy petit/on preparer prepares tile petition. 11 U.S. C. § 11 0(11)(2).]
!. Under II U.S.C. § 11 O(h), 1 dcc!nrc under penally ofpetiury Utall am not an allomcy or employee ofnn allomey, that! prepared or coused to be prepared one or more documents for filing by Lhcnbove-nnmcd clebtor(s) in connection with this bankntptcy cose, nnd thnt cornpemllltlon pnld to me within one year before the filing of the bnnltruplcy petition, or agreed to be pu\d to me, for services rendered on behalf of the dcbtor(s) in contemplntion of or In connection with the bankruptcy cnse is tiS follows:
For document pl'cpnration services I have agreed to accepl............................... $c__ ______ _
Prior to the filing of this stntement I hove receh,cd............................................. $ ________ _
Bnlnnce Due......................................................................................................... $'------------
2, I have prepared or caused to be prepnred the following documents (Itemize):
and provided the following services (Itemize):
3. The source of the compenSation paid to me was: D Debtor D Othet• (specify)
4. The source of compensation to be pnid to me is: D Deblor D Other (specil)')
5. The foregoing Is a complete. stntcmcnt ofnny agreement or arrangement for payment lD me for preparation of.lhc petition iiled by the debtor(s) In !his bankrupltly cnse,
6. To my knowledge no other person has prepared for comperisation a document fol' ftJing In connection wiU1 this baTiltruptcy cnse except as listed below:
NAME
Signature
Printed nnmennd Litle, ll'nny, of Bankruptcy Petition Jlrcporer
Address:. ___________ _
SOClAL SECURITY NUMBER
Social Security number ofbnnkrupltly petition prepnrcr (lflhe bankruptcy petition prcpnrer 1s not an Jndivldunl, state the Social Security number oft.he officer1 principnl, responsible person or partner oflhc bankruptcy petition prepnrer.) (Required by lJ U;S.C. § I 10.)
Date
A ba/1/a'UjJ/CJI pe.lition pre.parel"'sfaihwe to comply with the pravisiDJrs of title 11 -t;Jnd.the.Fedi!rdl Rilles qJBankruptcyPracedw·eJJlOJlresuft in fines or imprisonment or both. 11 U.S. C.§ IJD; 18 U.S, C.§ 156.
19'
D6 Cm•cr (l'nrm 6 Cover) (12/07)
FORM 6. SCHEDULES
Summary of Schedules Statistical Summary of Certain Liabilities and Related Data (28 U.S.C. § 159)
Schedule A- Real Property Schedule B- Personal Property Schedule C- Property Claimed as Exempt ScheduleD - Creditors Holding Secured Claims Schedule E- Creditors Holding Unsecured Priority Claims Schedule F- Creditors Holding Unsecured Nonpriority Claims Schedule G -Executory Contracts and Unexpired Leases Schedule H - Codebtors Schedule I -Current Income oflndividual Debtor(s) Schedule J- Current Expenditures of Individual Debtors(s)
Unsworn Declaration Under Penalty ofPerjury
GENERAL INSTRUCTIONS: The first page of the debtor's schedules and the first page of any amendments thereto must contain a caption as InForm 16B. Subsequent pages should be identified with the debtor's name and case number. If UJe schedules are filed with the petition, the case number should be left blank.
Schedules D, E, and F have been designed for the listing of each claim only once. Even when a claim .is secured only in pnrt or entitled to priority only in pnr~ it still sbould be listed only once. A claim Which is secured in whole or in part should he listed on ScheduleD only, and a claim which is entitled to priority in whole or in part should be listed on Schedule E only, Do not list the same claim twice. If a credftor has more than one claim, such as claims arising from separate transactions, each claim should be scheduled separately,
Review the specific ins!JUctions for·each schedule before completing the schedule.
1'1
06A (Officinl Fonn 6A) (12J07J
ln~--------~~~------------------D~:btut•
Cm;~: Nu. ------...,o:-:-----c----------(lflmo\\'11}
SCHEDULE A- REAL PROPERTY
ENcept us directed below, list nil renl pmp!!rty in which the d!!btor husuny Jcgnl, cquituble, or fmure interest, including n!J property owned usn cull!nnnl, community property, or in which the debtor hns n life estntc. Include nny property in which the debtor bolds rights and powers exorcianble for ~1c debtor's own bcm:fiL lftln: dt!btor is married, state whether the husband, wife, both, or the mnrilul community own tl1e property by plncing nn "H," "W," "1," or ucn In lhc column lubeled "Husband, Wife, Joint, or Community.'' If the dabtor holds no Interest in renl property, write 01Nonc" under "Dt!Scription nod Locniion ofProp~:rty."
Do nol hlchu1e intei'CSls In CJil.!cutoJ·y contrncts nnd 1lllt!.'tpircd lenses on lids schedule. Lisllhem in SclJoi.lulc G- Executory Cnnti'OclSund Unexpired Lc.nscs.
1 r nn entity clnirns to have nlil:n or hold o secured interest in nny propcrt)' 1 stnte lhc amount nflht! st.-cured cluim. Sec Schedule D. I fno enllty claims to hold n secured Interest in the property, wrile "None" in the column lnbeletl "Amount of Secured C\uim."
If the dcbJor is lUl lndh•idunl or Jr n ju lnt petition is Jiied, slnle the nmounl of nny eliemplion c.Jnimed in the property only in Schcdull! C - Property Clnimed ns Exempt.
DESCIUI'TION AND LOCATION OF
PROPERT\' NATURE DJi DEBTOR'S
INTEREST IN PROPERTY
CtJltRENTVALUE OFDEDTOR'S INTEREST IN
PROPERTY, WJIDOUT OEDUCI'ING AN\' SECURED CLAIM OR EXEMPTION
AMOUNT OF SECURED
CLAIM
zo
U fiB {Official Fom161l) (12107}
In ru ____ -;,--,-,--------------Dubtur
Cuse No.---=::----:---;---(Ifltnnwn)
SCHEDULE B- PERSONAL PROPERTY
E;s;ccpt ns directed bclaw,lislnll personnl property oftlu: dcblorofwhntcvcr kind. Iflhc debtor hos no property in one or more orU~t: cmegories, piDcc nn "x" in thu nppt·oprlote position in the column Jnbclcd "None.." Ifoddilionul space is needed in nny cntegory, nunch 11 sepnrutc sheet properly idcntl ried wHh the cnse nome, cuse number, nnd the number oftln: category. lflhe debtor is married, stole whether thchusbnnr.l, wife, bolh~ or the muritnl communily awn the property bj' plncing an "H," "W,""J," or "C" in the calumnlnbeled uHusbnnd, Wife, Joint, or Communlt:y.~' IfU1e dcbtor is un Jndlvidunl oro joint petition is filed, stntc the Dmou.nt of nny axcmplians claimed only in Sclu:dule C- Properly Clnimcd ns Exempl.
Do not list Interests in executory contn~cts nnd uncxpircl1l1!U5CS on this schedule. List them In Sdtl!dnlc G • Exccutnt'Y Ctmlrn~ts nnd Unexpired Lenses.
lflhc propcrty Is being hold fonhc debtor by someone else., siDLe that person's nama and nddrcs~ under "Description and Location ofPrnpcrly." If the property is being held for u minor child, simpl)' stale the child's iniliols and the nome nnd address ofr..hc child's pnrenlor gunrdinn, such ns "A.B., n minor child, by John Do~ gunrdinn." Do not disclose the child's nome. See, II U.S.C. §I 12nnd Fed. R.. Bnnkr. P. 1007(m}.
T\'PE OF PROPEfiTI'
I. Cnsh on.ltnnd.
2. Checking, savings or other finnncinl nceounts, ccrtllicrlles of deposit or shares In bunks,snvings nnd lonn, thrift. building nnd lonn, nnd homestead n9socintious, or c:rcd\L unions, brcla:rage houses, or eoopemtivcs.
3. Securi~y doponlts with public utilIties, telephone companies, lnndlords, nnd oth~rs.
4. Household noods nnd furnishings, includmg nudlo, video, nnd complllcr cquipmcnl
S. Bon~:s; ph:lun:s nnd at11er nrt objects; nmiques; sLUmp; coin, record.lnpe, t!Ompncl disc, nod other collections orcollctliblcs.
6, Wearing oppnrcl.
7. Furs ond jcwchy.
S. Fln:nrmsnnd sports, photo· graphic, nnd other hobby equipment.
9. lnu:nml!i in lnsurom:e policies. Nome lnsnrnncc company ofcnch policy nnd hnmlw liUtrend~:r or refund vuluc ofcnch.
10. Annuilil!i. llcmize nnd nome ench i.~:su~r.
11. lntercsts in on edm:nUoniRA us defined in 26 U.S.C. § 530(b)(l) c.rundor n qunlificd Sinte tuition pion us delinetlln 2fi U.S.C. § 529(b)[l), Give pnrticulnrs. (File sepnrntely the rccord(s) arnny nucl1 intc~l(a~ 11 U.S. C. !i
N 0 N E
DESCRll'TION AND LOCATION OFPROPERTI'
CURRENT VALUE OF DEBTOR'S INTEREST IN PROPERTY, WJTH~ OUT DEDUCTING AN\'
SECURED CLAJ?oi'l OREzXEM11TION
2--/
B 6B {Dfficinl Form 6D} (12107)- CnnL
lnr•--------~~~--------------------' DcUtnr
CIISL! No.-------,=--.,-----(lrltnown)
SCHEDULEB-PERSONALPROPERTY (Continuation Sheet)
T\'JlE OF PROPER'n'
12.lnterosts In UtA, EiUSA,Kc:ngh, or other pension or profit shoring pions. Gh•e pnrllculnr:;.
IJ. Stock und interests in inr:orporull:d nnd unincorpomtcd businesses, Itemize.
14. Interests in pnnncrshlps or joint Vt:JJtures. Itemize.
15. Government ll11d corpornte bonds nnd other ncgotinblc nud nonmgotloble instntmcnts.
1 fi. Accounts rcceivnble,
17.Aiimon)', mninlt!nnm:e, support, nod propcr1y selllemcnts tn wlJicl11he debtor is or TTlllY be enlilled. Give pnr11culors.
1 B. OU1cr liquidDted debts owed lD debtor including tnx refunds. Give pnrticulors.
19. Equitable or fuwn: lntcr~ts, life. cstntes, nnd rights or powers cxc:n::lsnblo rortllc hcncrit.oflhe debtor ottu:r limn thosclistedinSchetlulcA- Real Propeny.
20. Conlingentoml noncontingcnt lntnrestsln cslnle oro dcccdnnt, de nth lrenent plnn, lire lnsumnee policy, or lnt!iL
21, Olhcrconllngent nnd unliquideted clnlms ofevl!fY nature, Including ln.'i. rer1mds, I:Ollntnrclnimn oflhe dcblor,and rinhts to scJoffclnhns. Oivt: cstimaled valu~areuulL
N 0 N E
'·.,·
DESCRII'TION 1\ND LOCATION OF PRO PERT\'
.. _;: . .-: -~;
... : : ·.· >- :-
'·' ' . . ~ ·.-,
.. :·
.. ;
CUilRENTVALUEOF DEDTDR1S INTEREST IN PltDPEfiT\1, WITII
OUT DEDUCTING AN\' SECURED CLAlM on EXEMI'TION
2Z
B fiB (Official Fonn GB) (12/07)- Cont.
lnn ________ ~~~-------------------------Debtor
Cnso Nn, ------=;----;---(HluiUwn}
SCHEDULEB-PERSONALPROPERTY
T\'PE OF PRDPERT\'
22. l'nu:nts, copyrlg]m, nnd otlu:r inulllcctunl propcny, Give panlculurs.
2.3. Licenses, frnnchlses, nnd oUter geneml lntnngiblcs. Give pnrtlculn1'5.
24. Customer lim or oUter compllntions containing personally ldentifioble Information (ns Ucfiner.l in II U.S.C. § 101 (41A)) pro vi dell to I he deb Lor by inrllvldunls in connection wltlt obwinlng n product orncrvice from the debtor primarily forptrsonnl, family, or household purposes,
25. Automobiles, tttlcks, trnllers, and otheneidcles nnd necessaries.
26. Boats, motors, nnd necessaries.
27. Aircrnfi nnd accessories.
28. Office equipment, furnishings, nnd supplies.
29, Machine!)', rtxtu~, equipment, nnd supplies used in liusiness.
30.1nvcntory.
3J.Anlmnls.
32. 'crops- growing or hnrvesi.Cd. Give particulnrs.
33. Funning equipment and ltnplcments.
34. Form supplies, clu:miculs, nnd feed.
35. Dtl11~rpc!Snnnl pmperty·ofony lcind not nlrendy lisl!!d. lteinlzc.
N 0 N E
': :-~"'.
(Conlinunlian Shtl!l)
DESCRIPTION AND LOCATION OF PROFERT\'
.--,:. . - .. '
. ··.··:
CUIUtENTVALUEOF D~BTOR'S INTEREST IN PRDI'ERT\', WI'I'IIOUT DEDUCTING ANY
. -~-. •:
SECURED CLAIM OR EXEMPTION
. :,__. .::.
.-. · .
------'cominuulion slrects-nllnchcd TnlOI>- $ (Include amounts rrum nn.Y ctmUnuntion L.:-------------------' sht!Cts nttnched, Repon·totnl nlsn.on
Summary pfSchcdulcs.}
B 60 {Offitiul Fonn fiO) (12107)
In"------;;--;-:---------' Debtor
Cnsc No·--------,=--,------(lfltnown)
SCHEDULE.D- CREDITORS HOLDING SECURED CLAIMS
Slntc the nnme, mnillng uddress, including zip code, nnd Ins! four digits of nil)' nccounl number of nil cntitic..'i holding claims secured by property ofU1e debtor ns oflhe dote of filing ofthe pelilion. The complete necourll number ofnn)' ncc:ount the debtor hns with the. credilllr is useful lo the lntstce nnd the crcdilornnd mny be provided If U1c deblor chooses Ia do so. List creditors holding nll types of secured interests such ns judgmenl liens, gnmlshmcnts, slntutory liens, mortguges, deeds oflnlsl, nnd other sccurill' interests.
List creditors in nlplmbctlcnl onler to the c);:tent prnctlcnble. Ifu minor child is the creditor, stnte the child's initinls nnd lhe nome nnd uddress ofU1e child'spurcnt or gunrdinn, such ilS "A.B., n minor child, by John DoeJ gunrdinn.'' Do not disclose the ch.lld's nome, See, 11 U.S.C. §112 nnd Fed. IL Bonkr. P. 1007(m}. Irnllsccurcd creditors will not fit on Ibis page. use l11c continuation s\u:et provided.
If nny entity oUuw tlmn a spouse in a joint case mny be jointly linblc on n clnim, pluce on "X" in the columnlobeled "Codebtor," include Ute enLity on the npproprinlc schedule ofcredilors, ond complete Schedule H- Codebtors. IfnjoinL petition Is filed, stntc whcUtcr lht! husbnncl, wire, boUt of them, or tlu:: mnritnl community moy be linblo on nuch claim by plnclng nn "H," "W,'"uJ," or "C'' in the column lnbulcd "Husbnnd, Wife, Joint, or Community."
If the clnim is contingent, plnce ntl "A"' in the column lnbeled "ContingenL" JfU1e clnim is unliqulclnted, plnce nn "X" in Lhc co·lumn lob~:led "Unllquidntcd." lflh~: claim is disput~:d, ploce an''X''In lhe colunu1 Jnbelcd "Disputed." {You mny need to place nn "X" in more U1nn onr; of Lln~sc Llm:c columns.)
Total Lhc columns labeled "Amount ofCinim WiU1oUt Deducting Value ofCollnl.ernl" nod "Unsecured Portion, If Any~· in U1e boxes labeled '"Tollll(s)~ on the last sheet ofU1c completed schedule. Report the tolnl from lbe column Jabeletl"AmounlofCinim WiUJoul Deducting Vnlue or Collnternl" nlso on the Summary of Schedules nnd, iflhc debtor is nn indlvldunJ with primnrily consumer debts, report the totnl from the column lnbeled "Unsecured Portion, If Any11 on the Slntislicnl Summnry of Certain Linbililics nnd Relnted Onto.
D Check lhis box if debtor hilS no creditors holding secured clnims to report on this Schedule D.
CREDITOR'S NAME AND "' 1\>IA!LING ADD!lESS ~ 1:: " - ~ t: INCLUDING ZIP CODE AND
0 :<o !;; "'!i5 AN ACCOUNT NUMilER "' z ~
(See Jnslruct/an.r Abava) Q <-$ 0 o:O-" u oo"'=O
Cl u =
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO,
contlnuntion sheets --EIIIII~hcd
DATE CLAIM WAS INCURRED,
NATU!lE OF LIEN, AND
DESCRIPTION AND VALliE OF
PllOPERTI' SUBJECT TO LIEN
VALUE$
VALUES
VALUE$ Sub1ntnl ,.. (Total orthis pngc)
Tntnl ~ (Use orli)' on lost pogc}
!<: Cl
"' ':;: Cl
"' "' (.!> e 5 z ~
;:, .,. 0' "' ~
Q 0 u
Ali'IOUNT OF CLAIM WITHOUT
DEDUCTING VALUE OF COLLATERAL
$
$
(Report nlsn on Sunnmuy or ScheduleS.)
UNSECURED PORTION, IF
AN\'
$
$
(Irnppllonblc. report olso nn Stntislh:nl Summary arCennin Linbillties nnd ne:lntcd Dnln.J
z_4-
B 60 (Dffit:inl Form CiD) {I:U07)-ConL
!nrc _______ ~~~--------------~ DobtuJ•
Cnse No.----------;=---,,---------(iflmown)
CREDn'OR'S NAME AND MAlLJNG ADDRESS
INCLUDING ZIP CODE AND AN ACCOUNT
NUMBER (See Ju.rtnrt!ltans lfholle.}
ACCOUNT NO,
ACCOUNT NO,
ACCOUNT NO,
ACCOUNT NO.
ACCOUNT NO.
SCHEDULED - CREDITORS HOLDING SECURED CLAil\1S (Continuation Sheel)
.,; DA.1'E CLAIM WAS ~
c AMOUNT OF CLAIM != .:i': "' 0: INCURRED, NATUilE '< c WITUOUT
0 ~o- "' i;; ci' -~ OFLIEN,AND " § ~ DEDUCTING VALUE DESCRIPTION AND 10 OF COLLATERAL "' z!<.,
\;; ~ ..
" ., __
VALUE OF PROPERTI' Cl !!! 0 "O"' ::; u ,~o SUDJECf'fO LIEN 0 c 5 u u s
VALUES
VALUES
VALUES
VALUES
VALUES
UNSECURED PORTION, IF
i\N\'
Sheet no. ____ of ____ euntinunlion Subtntnl (sj~ $ $ sheets nunc.lu!d to Scbcthilc or Cn:diloG Holding Secured
(Totnl(li:) ofthlspnge)
Claims 'fotnl(s) ~
(Usc only on Ins\ pnge) $ $
{Report nlso on (lfnppllcnbl!!, Summnl}' or Si:hedU]cs,) rcporl!D]SO on
Stnlis:ticnl Somm111y ofCertnln ·Linbllitresnntl ;.RcJntl!ll Dnln.)
2
B 6E (Omcinl Fonn DE) {0<111 U)
lore ________ ~~----------------~ Debtor
Cnsc No··------=----:---(!1 lmDll'll)
SCHEDULE E- CREDITORS HOLDING UNSECURED PRIORITY CLAIMS
A complete Jist of claims entitled to priority, listed SCJUU1Jtely by type. of priority, is to be set forU1 on Ute sl1eeL'i provided. Only holdm of unsecured claims .cntilled to priority should be listed in this schedule. In the boxes provided on Ute oUnchctl slu:cts, stole tl1c nnmc, moiling. nddress, including zip code. und Just four digits of the account number, ifuny, ofuU t:~~titles holding priority claims ngninsl tltc debtor or the property ofthe debtor, ru; DfUtc date of the filing of Ute pctHion. Usc n separate continuntion sheet for cnch type of priority nnd Iobel ench Witll Ute type of priority.
The c.omplclc oceount number ofnny nccount the debtor hns wltb Ute crcdilor is useful to the lnlsLee nnd the creditor nnd mny be providcrl if lhe deblor chooses to do so, lfn minor child is 11 creditor. stole the. child's initinls nnd the nnmc nnd nddress of the child's pnrcnt or gunrditm, such ns 11A.B .. n minor child, by John Doe, gunnlinn.11 Do not disclose Ute child's nome. Sea, I I U.S.C. §112 nod Fed. R. Bnnkr. P. 1007{m).
Jfnny entity other than n spouse in njoinl case moy be jointly 1\nllle on n claim, pluce on "X" in lhe column lnbcled "Codebtor," include. the entity on tl!c upproprhlle schedule of creditors, oml complete Schedule H-Codebtors. If njolnt petition Is filed, stntc wheUu:r the husband, wife, both oflhcm, or the mnrltnl communil)' mny be liable on cuch clnim by placing 1m ''H," ''v.1," "J, 11 or "C" in the column lnbeled "Husband, Win; Joinl. or Community." If the claim is conlingcnt, pi nee un "X" in !he colwnn labeled "ContingenL11 If Ute clnim is unliqujdnled, plnce tm "X" in the column lnbcled 11Unllquidmcd." lfU1e cluim is disputed, plncc on "X" in the column labeled "Dispuled.11 (You mny need to p!nce on "X" in more thnn one ofU1esc three columns.)
Report the total of claims listed on ench sheet in the box labeled 11Subtotnls" on ench sheeL Report 1l1e totnl of all claims listed on U1is Schedule E in the bolo" lnbeled "Tolol,.. on the lost sheet of the completed schedule. Report this toto! ulso on the Summnry of Schedules.
Report lhe total of nmounls entitled Ia priority listed on tmch sheet in lhe box lnbeled 11Subtotnls11 on cnch sheeL Report the totnl of nil amounts enUUed to priority listed on this Schedule E in the box labeled "Tolnls" on U1e last sheet oflhe completed schedule. Indh•idunl deblors with primnn1y consumer debts report this Lollll also on the Slntislicnl Summmy of Certain Liabilities nnd Related Dntn.
Report the toto! of amounts not entitled to priority tis led on each sheet in the box Jnbelcd "Sublotnls" on ench sheeL Report rhe totnl of ull nrnounts not entilled to priority listed on this Schedule E In the box Jnbclcd '"Totnts~, on the lnsl sheet ofthe completed sehedule. lndividun! dcbLOrs with primorily consumer debts report this tclnl also on the StoUstlcol Surnmnry of Certain Linbilltlcs and Related Dntu.
D Check this box if debtor hns no creditors .holding· unsecured priority claims to rCporl on this Schedule. E.
TYPES OF PRJ ORITY CLAIMS (Chec)l the npproprinle box(es) below 1r clnims in thnl cnlegcry ore listed an Ute nuncllcd sh~IS.)
0 Domestic. Support Obligntions
Clnims for domestic support U10L nre owed to orrcoovcrnble by.n spouse, former spouse, tlr"chlld oflho debtor. or lhe pnren!., legol gunitllnn, or responsible relntlve of such n child, or n govemmentnl unll to whom such n domestic support clnlm hos been osslgned to the extent provided in 1l u.s. c. § 507(a)(l).
D Extl!n.&lons of ercditln nn lovolunlnry cnse
Clnims arising in the ordinary course ofll1e debtor's business or financial affairs nfier the commcncomcnt of the case but before lhe curlier oflhe appoinll110nl orn trustee or the order rorreller. II u:s.c. § 507(n)(3).
0 Wngcs, snJnrics,·nnd commissions
Wngcs, snloi'ies, nnd commissions, Including vnontion~ sevcrancr.:, ond sick leuve poy·owing lO·cmployecii nnd commissions owing to qualifying indeptmdent soles represeotnUvcs.up to $1 1",725"' per person cnmed within I 80 tlnys .irnmei:lintely preceding "the filing-ofthe orlginnl petition, or Ute ccssntion ·of bi!Sincss,. whichever occurred firs~ to the· extent provided ln n U.S.C, 9 507(Ii)( 4). 0 Conlributions to employee· benelil plnns
"Money owed to employee benefit pions for serviceu rl!flderctl within- 180 dnys immediately preceding the filing ofUn: originnl peUUon, or the ct!Ssnlion ofb.usiness, whichever occumid first, to the extent provided in lJ U.S.C, § 507{n)(5).
·-.~o AmoJUJl subject Ia adjirstme.nt on41Dl/J3, and avery' lhreeJrears lhereajle.I'With respect to cases conmrem::ed on or aficr the datc.afac!JrlS/mr.mt.
B 6E (Ofliciul Fnnn 6E) (OM! 0)- Com
In r•---------:::-:---------Dcblor
D Ccrtnin fnrmers nnd ftsbcrnum
Cn!iC N•·-----,.,--:---(IJ known)
Cluims ofcerlnin formers nnd flshemlcn, up to $5,775• per fnm1er or flShcnnnn, nguinst the debtor, ns provjded in 1 I U.S.C, § 507(n}(6}.
D Deposits by indivitlunls
Claims ofindividunls up to $2,600* for deposits for the purchase, lcusc, ornmtnl of prop crt)' or services for personal, fnmlly, or household usc, U1al were nol delivered or provlded. l l U,S,C. § 507(n)(7).
D Taxes nod Certain OUtct· Debts Owed tu Go\•emntcntnl Units
Tm:es, cus10ms duties, nnd penalties owing to fcdcrnl, slnlc. nnd local govemmcnlnl units ns sel forth in I I U.S.C. § .507{n)(B).
D Commitments to Mninlnin the Cnpitnl ofnn lnsurcr.l Depositor')' Institution
Clnims bused on commitments to U1c FDJC, RTC. Director ofU1e Office ofThrifl Supcrvislon, Comptroller of the Currency, or Bonrd of Governors oflhe Federal Resen•e System, or their predecessors or successor5, to muintnin the cupitnl of nn insured depository inst.illlUcn. 11 U.S.C. § 507 (n)(9).
0 Cluims for Dl!lltb or Pursonnllnjur)• While Debtor Was lnloxlcnled
Clnims for deaUJ or personal Injury resulting from lhe. cperut.ion -of u molor vehicle or vessel willie the debtor wns intoxlcnted from using nlcohol, n drug, or nnotl1cr subslonce. II U.S.C. 9 507(n)( I 0),
"' Amounts are subjecllo adjllslme.nt on 4101113, mrd eveiJ' t!wee. years thercaflen!•ilh respect to cases comtmmced an or afier the dale af adj11slment.
continunlion Sheets attncher.l
21
B 6E (Omcinl Fomt 6E) (0~/1 0}- ConL
In t·c ------::-:-.,----------Debtor
Cnse No·----=:----:------(iflmown)
SCHEDULE E- CREDITORS HOLDING UNSECURED PRIORITY CLAIMS
CRIJ11TOR'S NAME., MAILING ADDIIESS
INCLUDING ZIP CODE, AND ACCOUNT NUMBER
(Sec lmumrt/011$ rtlsot•e.}
Account No.
Account No.
Account No.
AccoUllt No,
Sh~t no._ nr _ cmi~nuntio11 sla:eu Dllnr.hcd to Sclrcdul~ ora~tlilnnr llnldi11g Priurhy Clnin~S
{Continuntion Sheel)
TJ•pe of Priority ror Clnims Listed on This Sheet
DATE CLAIM WAS INCURRED AND
CONSIDERATION FOR CLAIM
Subtmnls>- S fl'otnls oftltis pnge)
Totnl> {Use only on lll!llpngeoflhe complotcrl Schedule E. Report nlso on·thc SummnrY ofSchctlulcs.)
Totnls>(Use only on lnst poge oftlic complet!!d Schedule E. If npplienblc, rep on Iii so on the Stntisticnl Summary ofCennln Llnbilltics nrul Relntcd Dntn.)
AMOUNT OF
CLAIJ\'I
s
AMOUNT ENTITLED
1'0 PIUORIT\'
AMOUNT NOT
ENTITLED TO
PIUORIT\'1 IF ANY
2-5
D 6F (Omcinl Fam1 UF) {12/07)
Jn re ________ n::=:::--------' Debtor
Cnsc No.-----.,.-==;;,-----(iflulown)
SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAllVIS
Stntc the nmne, moiling uddress, including zip cod~:, nnd lost fourdigits ofnny nccountnumbcr, ofull entitles holding unsecured clnimswithout priority ngninst the debtor or the property of the debtor, ns of the dote ofliling ofLhe petition. The eumplcte nccount numberofuny uceount the debtor hns with the creditor is U!icfulto the trustee nnd the crctlhor nnd mny be provided iflhc debtor chooses lO do so. lfu minor child is a crcdilor, stnle the child's initinls nnd the nnme nnd nddress oflhc thfld's purenl or gunrdinn. such ns 11A.B., n minor child, by John Dm; gunrdiun." Do notdisclosc the child's nome. See, 11 U.S.C. §112 nod Fed. R. Bnnkr. P. 1007(m). Do not include clnims listed in Schedules D und E. Irnll creditors will nat fit an Utis pnge, usc U1e continuation sheet provided.
Ifnny entity oU1er thnn a spouse In njolnt cuse mny be jointly liable on n clnim, place nn ":h"' In the column Jnbcled "Codebtor~,, include the. cntily on the npproprinlt! schedule of creditors, nnd compieie Schedule H ~ Codeblors. Ifn joint petition is filed, state wheUu~r tl1c husband, wlie, both of them, or the marital community may be liable on ench clnim by plnclng nn "H,""W." "J," or''C"In the column lnbeled "flusbnnd, Wifu, Joint, or Community."'
If the clnhn Is contlngcnl, pluce on 11X" in the column labeled 01ContingenL" lfllu!clnim is unliquidntcd, place nn •'X'' in the column lnbeled "Unliquidated," If the clnlm is disputed, plncc nn "X'' in the column labeled "Disputed." (You mny n~:cd to place nn 11X" in more tbnn one of these. three columns.)
Report the totnl of nil clnims listed on this soh~:dule in the bo1-! labeled "Tolnl" on the ID.!It sheet of the completed schedule. Reporl this totnl nlsn on the Summary ofSchctluh.:s nnd, If the debtor is no incllvldunl with primnrily consumerdcblsf report lhis 1otul nlso on the Stnlisllcnl Summnry of Certain Linbililies nnd Rclulcd Dotn..
h tl' 0 C cck 115 box ffdcbtor hns no creditors holding unsecured cloims to rc.parton this Schedule F.
ui CREDITOR'S NAME, "' ~ DATE CLAIM WAS
ffi Q AMOUNT OF
MAU..!NO ADDRESS ~ .. ~~ INCURRED AND "' CLAlM Q .o '< INCLUDING ZIP CODE, Q • CONS!DERA T!DN FOR Q
(-
~~~ ~ Q ~ ANDACCDUNTNUMBER "' CLAIM. "' OJO~ 5 tSee lnstrut:Jfan.r abOI'L'.} Q
UJ~o IF CLAlM IS SUBJECT TO (- 0' 0. 0 ;:J u z ::; UJ u SETOFF, SO STATE. 0 i5 :I; u 5
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
Subtntnl>- s
__ conlinuntinn shecl5 nUnched Tntnl>-(Usc only on inst pngc.ofiho cnmpleted.Schcdulc F.)
s
{Reportnlsn on Summary cfScheduJcs·nnd,1fopplicnble, on the Stnlistlcnl Swnmnl)' ofCertnin LTn'bilities-ntid Rclnlcd Doll!,)
B fiF (Officlul Funn 6PJ ( 12/07}- Con!,
lnr•-------------=~----------------~ Debtor
CnscNu. ______ ~~----~-----------(lflrnown)
SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS (Contlnuntian Shet!t)
uf CREDITOR'S NAME, ~ !::: ~ DATE CLAIM WAS 1- 0 AMOUNT OF MAILING ADDRESS 0 "".6 ~ INCURRED AND m ~ 0 CLAIM
1- "' INCLUDING ZIP CODE, "' ~C:- CONSIDERA TIGN FOR t:J < !:i "' ~ 0
AND ACCGUNTNUMBER 0 ..,;~d: CLAIM. ;3 p. OJO.a "' (Sec instructions nbcve.} 0 .,~o IF CLAIM IS SUBJECT TO Cl 5 u §j u ::J SETOFF, SO STATE. u 5
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
Sh~ct no. ____ of____ ccntlnuntlon shccts·nllnched Subtotnl>- $ to Schedule of Creditors Holding Unsecured Nonprlorizy Cloims
Total>- s (Us~ only cliln.st pnge orthc cumplu\cd Schedule F.)
CRcpon nino on Summary ofSchcdule.s und.lfnppliclible onlhc Slll.tlsticnl SummnJY ofCcrtnin L!nbtll~lcs nnd llelnted Onlll..)
B 5F (Dffit:iul Fom1 fiF) {12107)- Cont.
In J'c ______ --:;---;--:---------Dcbtor
Cnsc No.-------:;::-:----:------(iflmuwn)
SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS (ConLinuntion Shc.t.:t)
ui CREDITOR'S NAME, "' !!:"'j':: DATE CLAIM WAS
~ 0 AMOUNT OF MAJLING ADDRESS 0 "'-o- INCURRED AND ~ g CLAIM
f.- " z INCLUDING ZIP CODE, Ill ~ r-: ::I CONSIDERATION FDR 0 <
Ul <~::;( ~ 0 AND ACCOUNT NUMBER 0 CLAIM. 5 c.
(See lnstrw:tlons ubovc.J 0 Jll0:;: ~ "' u rn~o IF CLAIM IS SUBJECT TO 0' Ci ::I u 0 :::; :c SETOFF, SO STATE, u
~ ACCOUNT "NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
Sheet no. __ or __ continuntion sheets nttuthcd SubiO!ol>- $ to Schedule orCredilors Holding Unsecured Nonpriority Claims
Totnl)o- $ (Usc only on lnst puge orthc completed Schetlule F.)
{Report also on Summnry orSclu:dulcr. nnd,_ifnpptlenble.oli U1cStntlstlcnl Sommmy ofCcrtnln LioblliUcs n11d RC!ntet.l Dntn.)
31
B 6F(Officin1 Form UF) {12/07)- Coni.
lnrc ____________ ~~------------------Debtor
Cnsc No.--------=-----,-----------(if!Uiown)
SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS (Cantinunticn Sheel)
u.f CREDITOR'S NAME, rt: !::rt:i: DATE CLAIM WAS 1- " AMOUNT OF MAILING ADDRESS 0 ;l::o- rNCURRED AND Gi til
~ CLAIM
1- o~·5 '< INCLUDrNG ZIP CODE, "' CONSIDERATION I' DR t:l til ~IS~ ~ " AND ACCOUNT NUMBER " CLAIM. - 0..
0 ~~0 :::> "' !Sf!'.: instructions nbo\'e.) IF CLAIM IS SUBJECT TO Cl 5 u :::> u 0 ::; :!: SETOFF, SO STATE. u 5
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
Sheet no. ____ or ____ conlinuntlon slumiS ouocbed Sublolol~ s to Schcdulc.ofCredllors Holding Unsecured Nonpriorll)' Clnims
Tolnl> $ (U!!e only on ln!il puge oflhc complcu:d Schedule F.)
(Report also on SummnT}' of SchedUles nnd, lfnpp.llcnble on thcSlntislieiil Summazy ofCcrtnfn Uribililies ond neloted Datn.)
B 6F {Official Fnm1 fif) (12/07)- Com,
lnr•------------~~-----------------Dcbtor
CnseNo. ______ ~~----~-----------(lfltnown)
SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRlORlTY CLAIMS
CREDlTOR'SNAME, MAILING ADDRESS
INCLUDING ZIP CODE, AND ACCOUNT NUMBER
(Sec lnslruclion!l nlmve.}
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
ACCOUNT NO.
Shecl no. ____ of ____ cantlnunlinn sheeu; oltnohed to Schedule orCrcdilot!i Holding Un::;ecurcd Nonprioricy Claims
(CanlinuoLion Sheet)
DATE CLAIM WAS INCURRED AND
CONSIDERATION FOR CLAIM.
IF CLAIM IS SUBJECT TO SETOFF, SO STATE,
Subtotal>- 5i
AMOUNT OF CLAIM
Total> $ (Use only on hml pngc or the cumphucd Schedule F.)
{Report nlan nn5ummnry or:Schl!dulcs nnd, lr oppllcnble Ill\ the Stntisticnl SummiU}' DrCcnnin LinbfliLieS ii!id Related Dolo,}
'-------'
37
U 60 (Officinl Form 6G) (1 '1107)
lnr•--------~~------------------Del:Jtor
CnscNo .. __________________ __
(Irlmown)
SCHEDULE G -EXECUTORY CONTRACTS AND UNEXPillED LEASES
Describe nil f!1;ecutcry contrncts ornny noture und ull unc11:pircd lcnsc.c; ofrcnl or pcr.;onnl property. Include ony timeshure. lnl011!Sls. Stntc nuturc or debtor's interest in contnlcl, i.e~ "Purchnsert'' 11Agtmt,Y' etc. Stull! whether debtor is the lessor or lessee ofn tense, Provide the nnmcs nnd complete mailing nddruse..<t a roll other parties to cuch lcnsc orcontmct described. Jr u miner child is D pnrty to one ofl11c lenses or contmcts, stnle lhe child'slnitinls nnd the nnmc nnd uddress of the child's purcnt or guunllnn, such ns 11A.B.l 11 minor child, by John Doc, gunrdiun.11 Do not disclose the child's nnmc. See. I 1 U.S.C. §1 12 nnd Fed. R. Bonkr. P. 1007(m).
D Check this box if debtor hnsno [!Xeoutor,y conlrncl!i or unexpired le115cs,
NAME AND MAILING ADDRESS, DESCRIPTION OF CONTRACT OR LEASE 1\ND INCLUDING Zll' CODE, NATURE OF DEBTOR'S INTEREST. STATE
OF OTI!ER I'ARTIES TO LEASE OR CONTRACT. WHETHER LEASE IS FOR NONIIESIDENTIAL REAL PROPERTI'. STATE CONTRACT
NUMBER OF ANl' GOVERNnoJENT CONTRACT.
B fiH [Omclnl Fann 6H) (12107)
Iu rc _____ --::--,-----------Debtor
Cnso No.-----:::;:----;----(iflrnown)
SCHEDULE H- CODEBTORS
Provitle the infommlion t"t!qucsted concerning nny person or entity, other lhnn n spouse in njoinl cnsl!, thnt is nlso linblc on nuy debts lisl.l!d by tim debtor in Ou:sclu:dules of creditors. Include nil guurnntors nml co--signers. If Ute debtor resides or resided inn community property stnte, commonwcnlth, or territory (including Alnskn, Arizonn, Cnlifontln, ldnho. Louisiana, Ncvudn, New McKico, Puerto Rico, Tcxns, Wnshington, m· Wisconsin) within the cight..ycnrpcriod immediately preceding U1c commcnmmumt ofthc cuse, identify U1c nome orthc debtor's spouse und ofnn)' fom1cr spouse who resides or resided wllh the debtor in the cmnmunily propert:)• stntc, commonwcnllb, or llmilol)'. Include nil nnmes used by lht: nonclebtor spousa during Uu~ eight yenrs immcdintel}' preceding the commcncelnt:nl ofU1is cnse. If n minor child is u codebtor or u creditor, stole Lhc chllcl's initials und lhe nnmc ond udclrcss ofthe child's pnrent or gunrdinn, such n!i "A.B., o minor child, b)' John Dot:., guurdinn." Do not disclose the child's name. Soo, II U.S.C. jill nnd Fcd.IL Bnnkr. P.l007[m).
D Check this box if debtor has no codebtors.
NAME AND ADDRESS OF CODEBTOR NAME AND ADDRESS OF CREDITOR
: .. : : '
......
, ... ·.
···c
BGI (Officlnl Fo•·m 61) (12/07)
lnre ________ =-~-------------------Dehlor
Cnsc No. --------::c;.,----:---(ifltnnwn)
SCHEDULE I- CURRENT INCOME OF INDIVIDUAL DEBTOR(S)
·n1e column lnbeled "Spouse" must be comph:led In n\1 cnses Jiled by joint debtors ond by every mnrriml debtor, whether or not n joint pcLilion Is Oled, unless the spousus nn: sepnrnted nnd ujoinl petition Is not filed. Do not stole the nnme ofnny minor child. The nvernge monU1ly income culculn!ed on this fonn mny dlffur from the cumml month!)• income culculnted on Fonn 22A, 21B, or 22C.
Debior's Mnrhnl DEPENDENTS OF DEBTOR AND SPOUSE Stnlus:
RELATIONSH!P(S)!
EmJ!loyment: DEBTOR Occupntion
Nome 01 employer
""" '""" Address of Employer
INCOME: (E!itimnte ofovernge or pmjected monthly income nt time CDSC filed)
1. Monthly gross wnges, snlory, nnd commissions (PrornLe if not pnid monthly)
2 Esllmnle mcnlhly ovnrt.imc
3. SUBTOTAL
4. LESS PAYROLL DEDUCTIONS n. Pnymll toxes nnd social securit)' b. Insumnce c. Union dues d. Other (Specify)!---------------
5. SUBTOTAL OF PAYROLL DEDUCTIONS
6. TOTALNETMONTHLYTAKEHOMEPAY
7. Regulor income from opernlion ofbusiness or profession or fnnn {AUnCh detniled slntcmenf)
H. lnccme from renJ property 9. lnteresl-nnd dJ,•ldcnd!i 10. Alimony. moinumnnce or support pnymcnts pnynblc tn the debtor for
lhe debtor'S U!IC or tl'!nt of dependents lfslcd nbove 11. Socinl sccu1ily or govemmenl ussistnncc
(Spet:il'y):.-::---:-:-----------12. 'Pension or retirement income 13. Othermonlhl)' income
(Spcclli')·'--------------
14. SUBTOTALOFLINES7THROUGH 13
AGE(S):
SPOUSE
DEBTOR SPOUSE
$ $
$ $
$ $
$ s $ $ $ $ $ $
I : $
$
$ $
$ $
$ $
$ $
$ $
$ $
$ $
s
I : $ 15. AVERAGEMONTHLYJNCOME(Addnmounl5onlines6nnd14) ~======---~=====:......-------J $ 16. COME!NED AVERAGE MONTHLY INCOME: (Combine column
totals from line 15) {Rcpnrtuhm on Sumituuy ofSchcdultiS ondJ ifupplicnble, on StnUstionl Summary ofCcrtnin Linbllftles nnd Related Dutn)
17. Describe any increase or dccrense in incbmc n:nsonnbly nnlicipnted to ·occur within lhe yent following the filing of lhls dooumenl:
BGJ (Officinl Form 6.1) (12/07)
In r•---------------Delltur
Cnse Nn·-----,=-------(lfknown)
SCHEDULE J- CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S)
Complete this schedule by t!Sthnntint: tlu: O\'l!rnfil!otpmjectetl month!}• e>:punst!S of the lleblornn~ the debtor's family at time cuse nh:d. Prornte nny pnyments mode bi~ \\'l!tkl}•, quurterly, somi-nnnunll~·. orumnmll}' to show monthly rote. The nvcrngc monthly expenses cnlculntcd on this fonn mu~· differ from the deductions from income olio wed on Fnnn22A or22C.
0 Check this bol:'if n joint pctitiou is Iilctl ond debtor's spouse mni!Jinlns u sepurute household. Complete n scpnrntc schedule of !Pipcnditures lnbclcd "Spouse,"
J. Rent ar home mongngc puymcnl {include lotronu:tl for mobile home)
n. An!rcnl estate tul:cs incJuded7 Yes No
b. Is property insumnce included? Yes___ No __ _
2. Utllities: n. Electricity nnd heating rue!
b. Water nnd sewer
c. Tc\cplu:mc d.Oiher _______________________ _
J. Home malntCllnm:e (n:pnlrn nnd upl;ccp)
4. Fond
5. Clothing
6. Lnundo• nnd dry clenning
7. Medit.nl nnd dentnlcxpc.nses
E. Tnmspartntinn {not including cnr pnymeots)
9. Rccrcntlnn, clubs nod entcnninmcot, nuwspnpers, mngnzincs, etc.
IO.Ciuuitnble contributions
ll.lnsumm:c (not deducted from wogi!S or Included in home morlgog.e pnymants)
u. Homeowner's cr renter's
b. Life
c.Henl!h
d. Auto
~olli~·-----------------------------------1:!. Tuxes (not deducted from wngas or includOO in home mongngc payments} (Spocl~·)l ______________________________ _
13. ln!ltalhncnt payments: (ln chnpLer 11, 12, nod 13 cll!i~S, do net llst pnyments LD be included in the plan)
n.Auto b. Other _____________________ _
c. Other ______________________ _
14. Albnnny, mnintcnnnc:c, nnd support pnidto clhers
15. Payments for suppcrt of oddilionnl dependents not living nt your homn
I 6. Regular c~pernu:s from cpcmtion nfbwlni!Ss, profes:don, or fann (nttnch dWJiled sLDicmimt} 17.ather ________________________ _
lB. AVERAGE MONTHLY EXPENSES (Tolnllincs 1-17. Rcpon also on Summnzy cfSohcdlilcs nnd, ifnppiiCDble, on the Slntlslicnl Summnt}' orccnuin Liabilities ond Rclntcd Onto.)
19. Descn'be nny increase or dccren.su In c:ipuntiiWrt:!l rensonnbly nnticipntcd 10 occur within the ycnr.following the filing of! his dccumcnl:
2U. STATEMENT OF MONTHLY NET INCOME
n. A~cJ1!ge·monUtiJ•.Incomc from Lina IS ofSchcdlllc I
b. Average monthly· expenses rrom Line IB·nbo·vc
c. Monthly net income (n. minus b.)
5
s s s s s s s s s s s s
s s $
s s
s
s s s s $
$
s
$
$
s $
B6 Dl:clarntinn (Offidnl Form r, • Dc:tlnmlion) (12/07)
In re _____ --,;:;:c::c-------Uehlnr
Cnlt! No. ------ooc----,---{lf ltnuwn)
DECLARATION CONCERNING DEBTOR'S SCHEDULES
DECLARATION UND~R .PENALTY OF P~IUURY BY INDIVIDUAL. DEBTOR
1 declare umh:r penalty ofpcrjury lhall hove rcnd I he furegoing summary nntl sc\tcdulcs, consisting nf __ 5hccl5, und lhnt thuy ure true nnd cnrreclto th!! bi!St or Ill}' knowledge, info011n1lon, nnd lmllcf.
Dote ___________ _ Signnturc: _________ =:---------Dchlnr
DDie __________ _ Slgnnlurc: _____ ---.===:-;,=,--------
(Joint Otblnr, if11ny)
[lfjoln\l:ll!ie, b11\h sp1111.51!5 must sign.)
DECLARATION AND SIGNATURE OF' NON·ATI'ORNE'i' DANJffiUJITC).' PETmON PREPARER {Sci! 11 U.S.C. § 110)
1 tleclnre under penni!}' ofpudury thnt: (I) I nm u lumktuptcy petition prtlpnn:r ns dclil!fll in II U.S. C.§ 110; (2) 1 pn:pD.red this dm:umenl fnr enmpcnsnlinn nnd hove psovlded tin: deh!or with n coPY of this dncumt:nt nnd the nuliccs nrul fnformnlinn required under I I U.S.C. §§ IIO(b}, IIO(h) nnd 342(b); nrul, (3) If rules or guhlclines hnve. llcen pmmulgutl!tl pummnllo II U.S. C. !i l!O(h) setting n mAA'imum fee fnrscrvices clllllYet~bh: b)• bnnbup1C}'pelillnn preporcrs, lltnve !liven the debtor nctieeofthe maximum omount befcn: preparing nny document fcrfiUug for n debtor or accepting nny fee from the de.btnr. ns requlre.tllly thn1 s=:tlon.
Prinu:r.l orT}'Jierl Nnmconr.l Title, ifniiJ', ofBnnluuptcy Petition Pn:pnrer
Socinl SI:Cutil}' Nn. (Required bJ• I 1 U.S, C.§ 1 10.)
([tin: bmtkntpii!J' plllilirm prvpurrwt.f lltll au 1/lrliv/duuL .l/Die I hi! numc, lllfn (if uuJ'), adtln!.~ nllti .rm:iu/,n:cur/lj• numberafllle a,D/f!tli prlllt!lpnl, ~mLdblu per.~rm, nr p.llrmur 1tfltJ .rig/IS //1/:r dtlC/111/J!(I/,
Address
" S;;lf!!U'::::~Iu=m~o~riia;;n=n;::l:ru:::;pl=ny~.;;P,~I;;Iti;:o=n-;;P~.c=·pn=r=n=r -------- Dntc
Nnm~ nnd Sotinl Securit)' numbers aruJJ ctlu:rinr.li\'idunls who pn:pnn:tl orni!iiS\cd In preparing \his document, tmlt!Ss the hnnkrupley pctltion 11rcpnrer is not nn indivldtint:
lj'mure 1/run Ill II! p!!t:rtm.proparod lhlsdar:umelll, u//m:/1 mldu/mruf styned slmvts cot!{tmlllllg In the upproprlme Offir:Ja/ Fnn11Jur cmch parson.
A bnnlmtp/r::J'Prlllllutl prrpu~r'.tfnlfu/11-tn cmupiJ• 1r/tll /ll~prurhlu/U of/It/ I! l'lotlll t/rr: Fcrkrrl/ nulc.rq{Uankruplt:JI Prm:edrm~ ll~•n!Sitlt llljine.r rwrmprl.!umur.n/ wbul/1. J 1 U.S.C,.f IJU: 18 u.s.c. f JJ(i.
DECLIIllATION UNDER PENALTY OF PERJUIU' ON BEHALF OF A COIU'OllATION OR PARTNERSH!l'
1, the !the. president or other officer or on nuthmitl:d ugcnt of the colJlornllon oro tnember or on nulhorizcd ngcntnfllu: pnnnorshlp j orthc [ccrporntlon or pnnnershlp] nnmr::d ns dnbtor ln·this ease, dcclnre tmdr::r pr::nnlty of pr::rjury thnt I hnY~t rwd the forr::golng sunumu)' nndscbcdules_ cnnsisllng of __ .!llu:cts (7'Dtal.r/Jamt otr S/111111/ttiJ' page pfus 1). and thnt thny ore true nnd correct tn ibc best nf rriy l:rtowlcdgc, lnfonJlllllon, ontl belief.
.Dote _____________ _ Signnturc: ______________________ _
JPrlnt nr type nnme nflnrliv1dunl slgnlng on behnlror debtor.]
[Aft indll'idua/.Iigrlfl1g on bahu!fofo partnerJftljt or r:arporatinll must lndle!lltl! po:r/r/rm or r!!ltttlr:mshfp to dab tor.]
Pr!llult}'}ormaltillg afa/sc.Jta/lmrtml arcrmun/Ingpropl!rlY: Flnc. of up to $500,000 or imprisonment for up to 5 ycnrs or both. IU U.S. C.§§ 152 nnd 3571.
E 7 (Omcinl Fonn 7) (04110)
UNITED STATES BANICRUPTCY COURT
1n re: D~:btnr
CnscNo. ___ ..,.,==--------(1fhnmvl1)
STATEMENTOFFINANCIALAFFAIRS
This stntemcntls to be completed by evety debtor. Spouses filing njoint petition mny file n single stntemcnt on which the infonnntion for both spouses is com~lned. If the cose is filed under chapter 12 or chnpler 13, n married debtor must furnish infonnnlion for both spouses whether arnot a joint petition is filed: unless Ute spouses nre separnted and ujoint petition is no! filed, An indlviduEI} debtorengnged in business ns n sol!! proprietor, partner. fnmll)' former, or self-employed professional, should provide Lim infannntion requested on tltbi stnlemcnl concerning nil such activities ns well ns U1e individuuJ's personul nffnirs. To indicntepoymcnls, lrnnsfers nnd the like lC minor cbildrc:n, slutc the child's initinls and the nnmc w1d address ofU1e child's parent or gunrdinn, such ns "A.B., n minor chil~ by John Doe, guurdhm." Do not disclose the child's nome. Set; 11 U.S.C, §I 12nnd Fcd.R. Bunkr. P.I007(m).
Qut!Slicns 1 - 18 nrc to be completed by nil debtors. Debtors thnlnre or hove been in business, us defined below, nlso must complete Questions 19-25. If the nnswc.r to nn npp1icnble question Is ' 1Nonc, 11 mnrlt the bol: lnbc.lcd 11Nonc.. 11 lf ndditionnl space is needed for the answer to on)' question. use and nllnch n sepnmte sheet proper!)' jdtmtiiied witltlhe cose nnme. cnse number (lflcnown), nnd the number of the question.
DEFINITIONS
"in business." A debtor is "in busin~:SS" for the pui'Jlose ofthis form if t11e debtor is 11 corpornUon or partnership. An indivldunl debtor is "in business" for the purpose of this form if the debtor'is or hns been, within sh:. years immediutei}' preceding .the filing oflbis bankruptcy cnse, any of the following: nn officer, director, mnnnglng cxecuUve. or owner of 5 percent or more of the voting or equity see.urilies of n corporntion; n partner, other than n limited partner, of a purtncrship; n sol!: pmprie.Lor or self-employed full~limc orpnrt-Limc. An Individual debler Dlso mny be "in businessT' for the purpose of this form lflhe debtor engages in u Lrndc, business, or otln:r uclivit)•, other thun ns nn c.lnployee. 10 supplement income from the debtor?s primDry employmenL
"Inside/'." The term ''insider" includes but is not Iimiled to: relatives of the debtor. genernl partners of the debtor llnd lheirrelaUVes; corporations of which the debtor Is nn officer, dlre.ctnr, or person in conLrol; officers. direclors,nnd uny owner of 5 percent or more of the voting or eqully sccurilies of o corpornle debtor i:md their relatives; nmllatcs of the debtor and insiders of such nffilinl.es; nny mnnnging ugent or the debtor. 11 U.S. C • .li 101.
1. Income from employment or opernllon ofbu!oiness
Nune: State the grossnmount of income the debtor hus received from employment, trade, or profession, or .from opernllon of D lhe debtor's business, including parLMLime activities either ns on employee or in indepcndei\Ltrnde orbusinllSS, fmm the
beginning of this a~lendur year to the dole this case 'WDS commenced. SLO\e.olso the; groSs ilmotmls received during the two ycnrs lmmedintcly preceding this cnhmtluryear. [A ·dcbtor.thut mnintains, or hns maintnine~ finnnciul records on Un: bnsis of·11 fiscnl mlhcr Lhnn 11 culendnrycnr may report fiscni ycnr Income. ldentifY the beginning nnd i:ndlng tlntes of the debtor.'s iisonl yeur,) 1fnjolnlpetilion.is filed, stnla Income for ench spouse scpamtcly. (Married debtOrs Jiling under chllptcr 12 or ohnpWr 13 must stntc income of both spouses \Vhe.lhcr or uot u joint palition is Iiled, unless the spouses nre scpnmtcthmd njoint petition is nol'filed,)
AMOUNT SOURCE
2
2. Income oUter tlum from employment or O(ll!l'l\linn of busini!S!i
Nnllll Stntc the nmounl of income received by Uu~ debtor othcrlltnn from cmploymcn~ lrodc, profession, opcrntion of the D debtor's business during the two ycnt·s immediotcly preceding the commencement of this cnsc. Give purliculnrs. lfn
joint petition is filed, stoh: Income for coch spouse scpamtcly. (Murriod debtors filing under chnplcr 12 or ahopter l3 must stole income forench SJmusc whc!hcr or not njoinl petition is filed, unless tlte spouses ore seporuted nnd o joint pelilion is not fiJt!rl.)
AMOUNT SOURCE
3. Pn)•ments to crcdilors
Complete a. or b., as npproprlata, am/ c.
D n. individual or jai11t deblor{s) wilh prlmarib• consumer debts: List nil pnyments on loons, insullJmenl purchases of . goods or services, Wld ether dcbiS to nny creditor mode wiU1in 90 dti)'S immedinu:ly preceding the commencemenl of this cnse unli!SS the nggrcgnte vnlue of nil property thnl constitutes oris niTccted by such transfer is less Ulan $600, !ndicnte wiU1 nn asterisk (•) nny payments Lhnt were mode to D credilor on account of n domestic support cbligntion or ns pnrl ofnn nlu:mnlive repayment schedule under n pion by nn nppmwd nonprofit budgeting nod credit counseling agency, (Mnrried debtors filing undar chnplar 12 or chapter 13 must include pnyment.s b}' either or both spouses whether arnot njolnt petition is filed, unless the spouses nrc sepnrnt.ed nod njoint pcthion is not liled.)
Nam:
NAME AND ADDRESS OF CREDITOR DATES OF PAYMENTS
AMOUNT PAID
AMOUNT STILL OWING
0 b. Debtor whose de.bt:r ore nat primarily canSJtl/11!1' debts: List ead1 payment or otflel' Iran:rfor to any c:redilor made \vi thin 90 dnys immediately preceding the commcncem~mt of the case unless !be aggregate value of nil property thnl constitutes or is nfTected by such trnnsfor is less thnn $5,850', If Uu: dcbtoris nn individual, indicnte with"nn nslerislt {•) nny pnymcnts thnt wei'!! mode-to a creditor on nccounl of n domi!Slic support oblignlion or ns parl of nn li ltemntive repnymcntsclu~dule under o plnn·by nn approved nonprofit budgeting nod credit counseling agency. (Married dcblors filing under clu~pter 12 or chapter 13 must include pnyrncnts nnd other trnnsfers by either or both spouses ·whether or nnl njoint petition is filed~ unless the spouses nrc scpnrnlcd nnd njolnt peliUonis nol filed.)
NAME AND ADDRESS OF CI1.ED1TOR OATES OF PAYMENTS/ T11.ANSFEI1.S
AMOUNT :PAID 011. VALUE OF TI1.ANSFEI1.S
AMOUNT STILL OWING
·Amount subject to udjuslmf!llt on 4101113, Cl/ld evCIJ' tlweeyuw.r Jhereujlerwllh re.!PHCI ta cases cammf!lice.d an or qfier lhe dale afut!fustment.
3
Nm~
D c. 1'111 dctblol's: List nll pnyments mode within one ycnr immedintcl)' preceding the commcncemunt of Litis case to or for lhe benefil of creditors who ore or were. insiders. (Married debtors filing under chapter IJ or chapter 13 must include payments by either or bath spouses whetller or not ujolnt pelilion is filed, unless llu~ spouses ure sepnmLCd und njoinl pcthion Is not fil!!t.l.)
NAME AND ADDRESS OF CREDITOR DATE OF AND RELA T1 ONSHII' TO DEBTOR PAYMENT
AMOUNT PAID
4. Suits mul udmlnistrnth•c proccetllngs, executions, gnrnislmumts nnd nttnehments
AMOUNT STILL OWING
Ncne n. List all suits nnd ndminisLrntive proceedings lo which U1c debtor is or was o pony within one yenr immcdloLely 0 precoding the filing of this bnnkruptcy cnse. (Mnnicd debtors filing under chapter 12 or choplcr 13 must include
Jnfonnntion eonccmiog either or botb spouses whelher or not n joint petition is ·filed. unless the spouses nre sepnruled nnd a joint pelition is not filed.)
CAPTION OF SUIT AND CASE NUMBER NATURE OFPROCEEDING
COURT OR AGENCY AND LOCATION
STATUS OR DISPOSITION
Nan:: b. Describe nil property H111t hns been nttnched, garnished or seized under any legnl or equltoble process wilhin one 0 yenr immedintely preceding Lhc commencement ofUtls case. (Married debtors filing under chapter 11 or chapter 13
musLinolude infonnntion concerning property of either or both spouses whether or not njoint pellLian is filed, uri less lhe spouses nrc·scpnmlcd end njainL peliUon is not filed.)
NAME AND ADDRESS OF PERSON FOR WHOSE BENEFIT PROPERTY WAS SEIZED
5. Repossessions, forct:losurcs nlid rritums
DATE OF SEIZURE
DESCRIPTION AND VALUE OF PROPERTY
Nan:: List nil pfopcrtj• thnl hns bmm repossessed by n credhor, sold nt n foreclosure sale, tnmsfetred Utrough o deed in lieu 0 of foreclosure: or returned tn the seller, wilhin one senr immedlntely preceding.U1e commencemenl oflhis·cnse.
(Mnrried debtors filing under chapter 12 or cbnptt!r 13 must inelud6lnfannnlion concerning ·prop6rty·afelther or both ·spouses wbeU1eror not I! joint petition i,s filed, unless the spouses·nrc separated nnd njoint·petitlon is not nt~;d.}
NAME AND ADDRESS OF CREDITOR OR.SELLER
DATE OF REPOSSESSION, FORECLOSURE SALE, mANSPER OR RETURN
DESCRIPTION AND VALUE OF PROPERTY
4/
4
G. Assignll!cnts nntl rccch•cJ•shiJ15
Nouc u. Dt!liaribt: uny ossignment ofprcpcrl)' for the benefit ofcrctlilors mode within 120 dnys immcdintc\y precetlitlg the D commcnccmcnl oftbis cnsc. (Mnrrictl debtors filing under clmpter 12 or chnpter 13 must inclutlt: uny nssignmcnt by
cilhar or both spouses whether or notnjoinl pclition is filed, unless the spouses nrc scpnrntetl nnd njoint petition is not filed.)
NAME AND ADDRESS OF ASSIGNEE
DATE OF ASSIGNMENT
TERMS OF ASSIGNMENT OR SETTLEMENT
Nunc b. List nil property which hus been in Ute hnm:ls ofn cuslotllnn, rcueivcr, or court-nppolnt.ed officlul within one yeur D immcdintely pre~tling U1c commcncemenl or Ll!ls anse. (Mnrricd deblOrs filing. under chnpter 12 or chnplcr 13 must
include infonnntion concerning property of cllher or both spouses whether or not njoint petition Is med, uolcss the spouses nrc scpnrntcd nnd njcinl petition is not Iilcd.)
NAME AND ADDRESS OF CUSTODIAN
7. Gifts
NAME AND LOCATION OF COURT CASE TlTLE & NUMBER
DATE OF ORDER
DESCnJPTION AND VALUE Of PROPERTY
Na~e List nil gifts or chnrltnblc. contribulions mode within one )'cur immediately preceding the commencement of lhis CllSC
0 t:hccpt orclinnry nnrl usual gins to fnmill' members nggregnting Jess llmn S20D·in value per Individual family memb~:r nnd chnritnble ctln1ributions nggrcgnting less than $100 per recipient. (Monied debtcrs filing under chapter 12 or chapter 13 must include gifts or conlribulions by either or boUt spa us~ whether arnot njaintpcUlion is filed, unless U11: spouses nrc scpnrnted and njoint petition is nol filed,)
NAME AND ADDRESS OF PERSON OR ORGANIZATION
B. LOS!ii!S
RELATIONSillP TO DEBTOR, IF ANY
DATE OF GIFT
DESCRIPTION AND VALUE OF GIFT
Non: List ulllosses from firc, then, other onsunlty or gambling within one yenr hnmediotely preceding the commencement D orthis cnse or since the. c.omn.umccmCnt ofUtis cnse, (Married debtors filil1gundcr chnpter 12 or·chDpler 13 musl
.include .losses by either or both spouses whf!Uu:r or nol njoinl pctltlon is filed, unless the spouses ore sepnrntcd nnd n joinl pclilion is not filed.)
DESCIUPTION AND VALUE OF PROPnRTY
DESCnJPTION OF CIRCUMSTANCES AND, IF LOSS WAS COVERED IN WHOLE OR IN PART BY INSURANCE, GIVE PARTICULARS
DATE DFLOSS
!1. Puynumls rclnlcd to debt counseling or lmnlcruptcy
None List nil paymcnls mode or property lrnnsfcrred by or on bchnlf or the debtor to uny persons, including nltorneys. for D consultolion concerning debt consolidntion, relief under U1e bnnkruptcy low or prepnmtion ofn peULion in bnnlmlplcy
within une ycnr immcdintcly preceding the commcncemcnl oflhis onsc.
Ncn~
NAME AND ADDRESS OFFAYEE
10. Other u·nnsfcrli
DATEOFI'AYMENT, NAME OF PAYER IF OTI-IER THAN DEBTOR
AMOUNT OF MONEY OR DESCRJPTION AND VALUE OF PROPERTY
5
0 n, List oll other property, olher lhnn properly Lrnnsferred in the ordinnry course oflhe business or finnncinl uffnir5 of the tlcbtcr, tmnsnmcd e1U1er nbsolutel)• or D5 security within hvo ycnrs immedintnly preceding tl1e commencement of this case. (M'unied debtors filing under chapter 12 or chapter 13 must includ~: trnnsfcrs by ciUu~r or both spouses whether or nol njoinl petition is filed, unless the spouses nm sepornl.cd nnd njoinL petition is not filed.}
Nlllle:
NAME AND ADDRESS OF TRANSFEREE, RELATIONSHIP TO DEBTOR
DATE
DESCRJBE PROPERTY TRANSFERRED AND VALUE RECEIVED
D b. List nil property tronsferred by tit!!. debtor within ten ycurs immedinlely preceding the commencement of this case lo n !inlf·sellh.:d trust or similnr device of which the debtor is n bencficiury.
NAME OF TRUST OR OTHER DEVICE
11, Close!] finunclnl nccounts
DATE(S) OF TRANSFER(S)
AMOUNT OF MONEY DR DESCRJPTION AND VALUE OF PROPERTY OR DEBTOR'S INTEREST IN PROPERTY
None: List nil fimmciul accounts mtd instruments held in the nnme of the debtOr or for Ute benefit of llu: debtor whic.h were 0 closed, sold, or othenvlsc tmnsferrcd within one ycnr immcdinlcly preceding the commenccnn:nt of Lhis ansa. Include
chcclcing, snvlngs, or oUter finnncinl nee aunts, cerlificntes of dcposl~ .or other.instrumcnl!i; shares nnd share accounts held in bunks, credil unions, pension funds, coopcrolives, assooiolions, bm1tcrnge houses nnd oUter finnnclal lnslilullons, (Monied debtors lillng under chapter 11 or chnpler j3 must include lnfcnnntlon concemirig accounts or Instruments held by or for either or both spouses whether or nolnjolnt pClition js filed, un"Jess the spouses nre scpnrnh:d nnd njolnl pelition Is not filed.)
NAME AND ADDRESS 01' INSTITUTJON
TYPE OF ACCOUNT, LAST FOUR DIGITS OF ACCOUNTNUMBE!l, AND AMOUNT OF FINAL BALANCE
.AMOUNT AND DATE OF SALE OR CLOSING
43
12. Snfc dcpos\1 buxi!S
None. List each sufc deposit or other box or deposilor:\' in which U1e dabtor bns or hurl securities, cnsh, or other vn\uables 0 wilhin one ycur immctlioLcly preceding the commencomenl ofthls cliSt!, {Monied debtors filing under chnpter 12 or
chapter 13 must include boxes or depositories ofeilher or bolh spouses whe~ll!r or not njoinl petition is filed, unless the spouses ore st:pnmted nod ojoint petition Is not riled.)
NAME AND ADDRESS OF BANK Oil OTHER DEPOSITORY
13. Sctofrs
NAMES AND ADDRESSES OF THOSE WlTI-1 ACCESS TO BOX OR DEPOSITORY
DESCIUPTIDN OF CONTENTS
DATE OF TRANSFER DR SURRENDER, IF ANY
6
Nam: List nil setoffs mod~: by nny credhor, including 11 bnnk, ngninsL n debt or depo!.'il of lhe debtor within 90 du3'S preceding 0 the commencement ofUJis case. (Milllicd debtors li1ing under chapter 12 or chnptcr 13 must include infonnnlion
concerning eiUu:ror both spouses whelber or not njoinl petition is filed, unless the spouses are s~:pnrnled and a joint petition is not filed.)
NAME AND ADDRESS OF CREDITOR
14. ]'ropcrty held for nnotluw person
DATE OF SETOFF
AMOUNT OF SETOFF
Nnnt List nil property owned by nnotller person that the debtor holds or controls. D
Ncnt
NAME AND ADDRESS OF OWNER
15 • .P1·Ior nddri!SS of debtor
DESCRIPTION AND VALUE OF PROPERTY LOCATION OF PROPERTY
D If debtor has moved wiUiin U1rcc yt!llrs lmmcdinlely preceding the commcm:c:menL oflhis cnse, list nll·premises which tha debtor occupll!d during that period and vtscnlcd prior Lo Uta commcnccmcnLofthis case. lfnjoint petilion is. nlod, report nlso nny sepurntc address of eilhcr-spouse.
ADDRESS .NAME USED DATES OF OCCUPANCY
0
7
Hi, Spouses nnll Former SpoU!ii!S
I r the debtor resides or resided in u commnnily properl)' slut~; commonwcn1th, or territory (including Alnslm, Arizonn, Cnllfomlu, lduho, Loulsinnn, Nevndn, New Mexico, Puerto Rico, Tc>:ns, Wushlngton, or Wisconsin} within eight ycnrs immcdiutcly preceding the commencement orthc cnsc, identify lhc nnmc of the debtor's spouse ond of 1111)' fanner spouse who rc.sld!!S or resided with Uu! debtor in the community property stole.
NAME
17, En,•irunmcuhll JnfnrmnUon.
For the purpose of this que.slion, the following dofiniLions apply:
"En\•ironmentnl Low'' means nny fcdernl, stale, or locnl statute or regulntion rcgulnling pollution, contnminnlion, rcleu.'ics ofhuznrdous or toxic subsumccs, wnstes ormDicrlnllnto the oir, land, soil, surface water, groundwntcr, or other medium, including, but not limited to, statutes or regulations regulating the cleanup oflhese substnnccs, wnstcs. ormntcrlnl.
1'Shc11 mcons nny locoUon, facility, or property ns defined under nny Environmental Lnw, whether or not presently or fonnerly owned or opcn:n.ed by !be debLDr, including, but nolllmlted to, disposal shes.
11Hnznrdous Mntcrialn means anything d~:fined usn hazardous WllSI1:, hnznrdous substances toxic substance, hnznrdous mnterinl, poUutnnt.. or contnminnnl or simi! or term under nn Em•ironmenLnl Luw.
Ncnc n. List !he nmne nnd address of every site for which the debtor hns received notice in writing by n govemmentnl 0 unit UuiLiLmn)' be liable orpotentinJJy liublc under or in vlolntion ofnn Environmentul Low. Indicate the
govemmentul unil, the dale of ll1e nolice, nnd, if1mown, the Environmental Law:
SITE NAME AND ADDRESS
NAME AND ADDRESS OF GOVERNMENTAL UNIT
DATE OF NOTICE
ENVIRONMENTAL LAW
N1111C" b. Listlhe name nnd address ofevcrj site Jbr which U1c debLorprovided nolice ton governmcntnl unil of.n relellSC 0 ofHnznrdous Mnterlnl. lndicnte-UJe governmentul unit to which the notioo WllS scnl nntl the clntn of the notice,
SITE NAME ANDADORESS
NAME AND ADDRESS OF GOVERNMENTAL UNIT
DATE OF NOTICE
ENVIRONMENTAL LAW
Nc11ll c. List all judicial or ndmlnlst.rnlivc procm~dings, including setllements or orders, under-any Environme11laiLnw with D rcspectlo which the debtor is or was npnrl)'· lndlcnte the name und nddress of the governmental unit thnl is or wns u parl)'
to the procl!eding, .and the doclmt n_umbcr.
NAMEANO ADDRESS DOCKET NUMBER OF GOVERNMENTAL UNiT
18, Nnture, lncntion.nnd nnmc of business
STATUS .OR DISFOSITION
NonJ: n, Qt/Je debtor Is an lndividrmf, list-the nnmes, nddrcsses, lnxpayer-.:idtmtiiicntion numbers, nature of Ute businesses, D nod beginning nnd ending clntes of nil businessos in which the debtorwns nn a nicer, director2 partner: or.mnnaging
8
executive of n corpomtlon, pnrl.uer inn pnrtmmhip, solu proprietor, or wns self-employed in u lllldt; profession, or other uclivily eiU1cr full- or port-lime within six ycm·s immodinlely prccecllng tl1e commencemcnl of this cnse, or in which the debtor owned 5 percent or more of the voting. or equity securities wilhin .:;ix yl!lars bnmedinteh• preceding the commencomenl oflhis case.
lftlta dcbror is o panncrs!Jip, list the m1mcs, addresses, toxpnyer-identlfh:ntlon numbers, nature of the businesses, und beginning nnd ending dutcs ofnll businesses in which the dnbtor wus u pnrlm:r or owned 5 p~:rcent or more of U1e voting or equity securilies, wiUdn six yeurs immedintely preceding the commencement of this case.
lfthe dcbtm· is o corporal fall, list tho names, addresses, LDXpuyer·ldcnlificntion numbers, nnturc oflhe businessi!S, nnd beginning nnd ending dates of nil busim:.sscs in which the debtor was n pnrlncr or owned 5 percent or more of Ute voting or equity securities wilbin slx yenrs immediately preceding tlte commencement of this ens e.
LAST FOUR DIGITS BEGINNING AND
NAME OF SOCJAL-SECURJ1Y OR OTHER INDIVIDUAL TAXPAYER-J.D. NO. (!TIN)/ COMPLETE EIN
ADDRESS NATURE OF BUSINESS ENDING DATES
Nom: b. ldentif)• nny business listed in response to subdivision n., above, Lhnt is "single nsselronl cstnte" llS
0 defined in II U.S.C. § I D I.
NAME ADDRESS
The following questions nre to be completed by ever)' debtor thnt is u corpornllon or partnership ond by nny indlvidunl debtor who. is or has been, within six l'l!nrs immedln.lely preceding Ute commencement of this case, nny oftlu: following: 11n officer, director, mnnn.glng axeculive: or owner of more tlt11I15 percent orthe voting or equity securities ofn corporntion: n partner, oUu:r thnn n limited pnrtner, ofn partnership, n sole proprietor~ or st:lf-employcd inn t.rDdc, profession1 orolher activi1)•1
either full- cr pnrt-timc.
(An indhtfdual ar job!/ t:kbtorshonld complete.thlsporlilm of the statemrml ou~r if the debtor is CJI' ha:r bmm in business, as defined abqve, within six years immedlale/y preCeding Jhe.comnrencenreltl afthis case. tl debtorll'ho has nat been ·in business within those si:r JleOI'S should go directly ta the signature page.)
19. Boolts1 records nnd finnncinJ slnlcments
Non!!. a. LlsL nll boolckeepern tmd nccountnnts who wiUtin two ycnrs immcdinlcly preceding the filing ofthis D bunlauplcy Cnsc kcpl or supervised lhe !tee ping of books of account ·and records of the debtor.
NAME AND ADDRESS DAT.ES SERVICES RENDERED
Naut b. Lisl nil firms or indivldunls who within two J'CDrs immedinlcl)• preceding lhc fillng oflhis bnnlcruptcy 0 cnse hove audited Uu~ books of nccounl nntl records, or pre pored n finnncinl stnlcm~.utt of the deblor.
NAME ADDRESS DATES SERVICES RENDERED
4-b
Nnn.: c. List oil Jinns or individuols who ol the time of Ute commencement of litis cnse were in possession of the 0 boolts of nccounl nntf records of the debtor. lfnny oflhc books ofnccounlnntl rei!Ords ure not nvnilnble, c"plnin.
NAME ADD !tESS
Nnn~ d. List ull finnnclnllnsthutions, orcditnrs nnd other pnrties, including mel'cnntilc nnd trnde ngencics, Lo whom u 0 finnncinlslntcmenl wns issued by lhe debtor within two ycors immediately preceding tltc cammcnccmcnl of Ibis cos c.
NAME AND ADDRESS DATE ISSUED
20. Inventories
Nam: n. List the dotes oflhc lnsl two inventories lnl>en of your property, the nmm: oftlu: person who supervised !he 0 tnking of ca.ch invenltH)', und the dollnr amount nnd basis of ench invcnlDIJ',
DATE OF INVENTORY INVENTORY SUPERVISOR
DOLLAR AMOUNT OF INVENTORY {Specify cosl, mnrkcl or oUter bnsis)
None b. List the name and oddress of the person having posses.'iion of the records ofench of the in\•enlories reported 0 in n., oboye,
DATE OF INVENTORY
21. Current Pnrtncrs, Officers, Directors and Shnrcholdcrs
NAME AND ADDRESSES OF CUSTODIAN OF INVENTORY RECORDS
Nnnr. n. If the deblor is n pnrtnersltip~ llsll11e nnture ond percentnge of partnership interest nf ench member oftlte D pnrlnornhip.
NAME AND ADDRESS NATURE OF INTEREST PERCENTAGE OF INTEREST
Nann b. lrtltc debtor is n corporution,list nil officers ond di.rec\ors oftl11~ corpomtion, nnd cooh stockholder who 0 dirccUl' or indirectly awns, Controls, or holds 5 percent or more of the voti~g or equ.lty securities of the·
corpomUon.
NAME AND ADDRESS TITLE NATU!tE ANQ PERCENTAGE
OF STOCK OWNERSHIP
9
41
10
22. Former purlners, nfficcrs, dirccturs mul slmrchnldcrs
Nanc a, If the deblor is n partnership, Jisl each member who wilhclrew from lhe pnrtncrship will lin tme ycur intmedintcly 0 preceding the commencement of lhis Clli!C.,
NAME ADDRESS DATE OFWJTHDilAWAL.
Na11c b. lflhe d~:btor is o corpornlion, llsl all omcers or directors whos~: rclutlonship wllh the corpomllon lenninntcd D wllhln one )'CDr lmmedintcly preceding the commcnc~:menl of this cnse.
NAME AND ADDRESS TITLE DATE OF TERMINATION
23. Witlulnnmls frnm n partnership or distribu1ions by n corporntion
Nanc If the debtor is n pnrtnership or corporulion,lisl all wil11drnwals or distributions credited or given to nn insider, D including compensation in ony form, bonuses, !onus, stock redemptions, oplions t:Xen:ised and nny other perquisite
during one yenr hnmediotcly preceding tha commem:emenl of this crum.
NAME & ADDRESS OF RECIPIENT, RELATIONSHIP TO DEBTOR
24, Tnx Consolldlltion G1•oup.
DATE AND pURPOSE 0 F \\~THORA WAL
AMOUNT OF MONEY OR DESCIUPTION AND VALUE OF PROPERTY
None lf the debtor is n corporollon, list lhc nome. and foderollw:pnycr-idenlificntion number ofth~ parent ·corporntion of nny D consolidated group fo1·Lnx purposes of which lh~: debtor hns been n member nl any tim a within six yenrs
immcdlotely preceding the commencement ofU11: ctl!ic,
NAME OF PARENT CORPOilATION TAXPAYER-IDENTIFICATION NUMBER (E!N)
25, Pension Funds.
None If Ute dcbtoris·nol on individllnt, list the nnmc nnd fcdcmllnxpnyerwidcmllficnllon number ofnn.Y pension .fund to D which the debtor, ns an employer. hns been responsible for contributing nl nny:limc wiUtln sixyenrs immediolely
preceding ~lc commencement of Ute ·cll!lc,
NAME OFPENS!ON FUND TAXI' AYER-IDENT!FICA TION NUMBER (EIN)
.. ,.. ... " ...
II
[If r:amp/eted by llll imlil•iductl or JndMdtlo/ and spa1tse]
I declare undcrpennll)' nfpc~ury Umt1 hove rend Ute nnswern oonlnlncd in the foregoing statement of flnnnciul uffnirs nnd nny tltlnchmcnts thereto nnd thnt they ore true nnd corrccL
Dote
Dole
Signnture of Debtor
SignaLUre of Joint Debtor (ifnny)
{/fcnmpluf~l 011 Jn~lmlft!fu purmnr.rlnp ur cnrporttl/an]
I dcelnre undcr pennlly orpeljmy lhntl hnve. ~lithe nnswara canloincd in the foregoing stntcmenl offinoncfnlniTnlrs ond ony nunchmcnt!i lhtn:lo IUid tim! th~· nrc true nnd cnnectto tin: b=.st ofm}' knowledge, informntlon nud belief.
Dole --------------------- Signntuu:
Prinl Nnmenml Tille
[An individunl signing on bclmtrorn pnOllc!:!ihlp or co~pomtlan must lndlcntc position or rdntinnship to dchtor.J
_tontinuution shccl!i nttnchOO
~1mf{J'.[ur nmkiiiJ: nfobeslalrmumt: Fine rzi11p tu SJ(JIJ,UOO or llllprl.lanm:rU.(ornp fr.I.S.}'I!Il'r.t, or hulls. 18 U.S.C §f IJ2 Ullll3S1J
DECLARATION AND SIGNATURE OF NON~ATTORNEY DANiffiUPTC\' PETITION"I'REPAnER (See t I U.S.C. §liD)
I d~:~~lnrc under pllllnhy ofpeljury Llmt: (I) I run n bnnkruptcy p~lition prepnn:r ns. dclincd in 11 U.S.t. § 110; (2} I pn:pnrcd lhis ducntllcnt for com]ttnsntlon·nnd lmvc provided the debtor with 11 cops of this document nnd the notices nnd lnfonnntlon required under II U,S.C. §§ II O(b), 11 D(h), nnd J~J(b}; nnd, (3) ifrult..!l or_gufdc\lnes hove b!:!!n prumil\glllcd pur.;unnt Jo II U.S.C. § llO(h) selllngn milXimum fcc forserviw chmycnblc bS lmnl..-ruptcy petition prcpnrur.;, I hnve giV!=fl the debtor nnlicc of the mrudmum nmount before prcpntina nny rlocum~ml forfilinu fnrn dcbtorornc~cpt\ng on}' fee frum !he debtor, os: requircd by-tlmtsettiun.
Prin!ed or Typed Nome nud Tlt\c,lfuny, ofBilllkrup1cy Pttilfon Preplltcr Soclni.Sccurlty 'No. (Rcqulrful hy II U.S. C. f 110.}
!film bunkruplcJ' pt!f/llwr pr11pnrc.r isltnl em Jnd/vldtiU/, slnlt! lire nwmt, If/It! (f{unJ~, addf'J!SS, rmrlsadul~.fl!ctiNU'IIIJ/1/bl!r eft he ajfil:er, prmclpul, n::rpnnd/Jie per:uur, nr purtttl!l' w/lo slgllo~·t/li,\' tlnt:UIIICitl.
J\ddtl!ll
5ib'11Diun: or.Bnnl.ruptcy Pclllton 11n:porer Dnte
Nnm~ nnd Socini·SI!Cllrfty num!Jers ofnll other Jndlvldunls who pn:pnral ornssisted In ptllpnring lllis document un\t:lls lhc bnnl;mptcy pt:lltlou pre)tllrcr[9 not un inillvldunl:
If marc dum one: penon propnn:d this dncuincnt, nllnch.nddhlannl 11igncd shecls confonnlnglo 1l1e npprnprinlc Officlnl Ftmn fol'cmch purson
A bnJJioTllplcJ' petition prepnriY''sfullure to compb1 wfllt t/Je prot•ldatJs n[Jf/11! J J mul/lre Fetlunl Rules o[Dnlllcntplt:,t• PrnceEllire illllJ' ri!Srifr ir1 jiflt!'i or Jmptlsortml!nt or bnrlt, JB US. c. §/56.
41
B l:!A (Offidnl Fonn22A} (Chnpter7} (12/1(]}
lnre ________ ~~~~---------Dcbtor(s)
According to the information required to be entered on this statement (chec!t one box ns directed in Port I, III, or VI of this statement):
Case Number.--=;--,--;--(If known)
0TJtc presumption nrisus. 0Tbc presumption docs not nrise. 0Thc presumption is tempornrily innppllcnblc.
CHAPTER 7 STATEMENT OF CURRENT MONTHLY INCOME AND MEANS-TEST CALCULATION
In nddition to Schedules I and J, this statement must be completed by every lndividuni chapter 7 debtor. If none oftl1e exclusions in Part I opp!ics,joint debtors may complete one statement only. lfnny oftl1e exc!nsions in Port I applies, joint debtors should complete separate statements If they believe this is required by§ 707(b)(2J(C).
Part I. MILITARY AND NON-CONSUMER DEBTORS -
Dlsnbled Vete•·nns.Ifyou are a disabled veteran described in tl1e Deciorntion in this Part lA, (I) cheek tl1c box at tl1e beginning of the Declnrntion, (2) check the box for "The presumption does not arise,. at the top of this stntement3 and (3) complete the verification in Part Vll[. Do not complete any of the remaining parts of this statement.
lA 0 Declnratlon of Disnbled Veternn. By checking this box, I dcclnre under penalty of pedury that I om n disabled veternn (as defined in 38 U.S.C. § 374 I (I)) whose indebtedness occurred primarily during n period in which I wns on active duty (as defined in 10 U.S.C. § IOI(d)(1)) or while I was performing o homeland defense activity (as defined in 32 U.S.C. §901(1)).
Non~consumcr Dabtors, Jfyour debts are not primarily consumer debts, check the box below nnd complete the
18 verification in Part VIU. Do not complete nny of the remaining parts of this statement
0 Declnrntion ofnonMconsumcr debts. By checldng this box, I declare that my debts are not primarily consumer debts.
: Reservists nod Nntionnl Gunrd Members; nctivc duty or homehmd defense activity. Members of a reserve component · of the Armed Forces and members oflhe Notional Guard who were called to nctive duty (as defined in 10 U.S. C.
§ IOl{d)(l)) ofter September I I, 2001, fur a period of at least 90 days, or who have perfurmed homeland defense activity (as defined in 32. U.S.C. § 901 (I)) for a period ofntleost 90 days, are excluded from all forms ofmenns testing during the time of active duty or homeland defense activity and for 540 days thereafter (the "e<clusion period'1. If you quality for
' ; this tempomry exclusion, (1) check the ~ppropriate boxes nnd complete nny required information in 1he Declnrntion of .. _: Reservists and Notional Gunrd Members below, (2) check the box for "The presnmption is temporarily lnapplicnble" at the
top ofthis statement. and (3) complele the verification in Pnrt VIJL During your exclusion period you nrc not reqUired
·" to complete. the bnlnnce of this form) but you must complete the fonn no Intel" ·thnn 1.4 dnys after the date on which ...
your cxc.lusion period cndsl unl~ss the time for filing a motion I"aisingthe mcnns test presumption expires in your : c.nsc before your exclusion period ends.
·rc·~ 0 Dcclrtrntion of Reservists.nnd Nntionnl GunrdMcmbers. By cbecldng this box nnd mnking the npproprlnte entries · below,l declare tltatl am eligible for a tcmporary·exclusion from means testing because, ns n member ofn reserve
component of the Armed Forces or the National Guard
·- IL 0 I was called to nctive duty after September .1 i, 2001, fur n period ofnt least 90 days and - 0 1 remain on active duty /or/ ... '
'•'-" 0 I was released from active duty on . which is less than 540 daysbeforo
-:;;i' this bankruptcy cnse was filed;
OR .'. •,; . .. . · ·•, h. 0 I am performing homeland defense nctivity fur a period of ntleast 90 .dnys/or/
0 l performed boraelnnd defense activity for a period of ot ienst90 days, terminating on which is less than 540 days before this bnnlcruptcy case was filed.
B l2A (Officlnl Fonn22A) {Cimnlcr7J (12/10) 2
Part II. CALCULATION OF MONTHLY INCOME FOR§ 707(b)(7) EXCLUSION
Mnritnl/filing stnh1s. Check the box that applies and complete the bnlnnce of this pnrt of this statement ns directed. n. D Unmarried. Complete only Column A (uDcbtor's Incomcn) for Lines 3·11.
b. 0 Marri~:cl, not filingjointly2 with declarntlon ofsepnrnte households, By checking lhis box., debtor declares under penalty ofpeJjury: "My spouse nod J are legnlly separntod under npplicable non-bnnlcruptcy lnw or my spouse nod I
2 nre living apart other thnn for the purpose of evading the requirements of§ 707(b)(2)[A) oftl1e Bnnlcruptcy Code." Complete only Column A (uDebtor's lncomc11
) ror Lines 3-11.
c. 0 Married, not lilingjoin!ly, without tl1e declaration ofsepnmte households setout in Line 2.b above. Complete bath . Column A ("Debtor's Income") nnd Column B ("Spouse's Income") for Lines 3·11.
d. D Married, filingjointly, Complete both Column A ("Debtor'slncomen) nnd Column B ("Spouse's Income") for Lines 3-11.
All figures must reflect' overage monthly income received from all sources. derived during ColumnA Column B the slxcnlendnr month• prior to filing the banlrruptcy case, ending on the lnsl day of tl1e Debtor's Spouse's month before the filing. ffthe amount of monthly income varied during the six months, you Income Income must divide the six-montl1 total by six, nnd enter the result on the appropriate line.
3 Gross wages, saiDIJ', tips, bonusi!S, overtime, commissions. $ $
Income from the operation of n business, proressiou or fnnn. Sublrnct Line b from Linen and·enter the difference in lhe appropriate colurnn(s) ofLine 4. If you operate more than one business~ profession or form, enter aggregate numbers nod provide details on an nttnchrnent.
·. Do not enter n number less than zero. Do not include nny pnrt of the Pusint!.!s expenses
4 entered on Line b ns n deduction in PnrtV.
a . Gross receipts $ . . ·
b. Ordinary and necessary business expenses $
•.. ,. C, Business income Subtract Line b from Line a $ s Rent nnd otber renl property income. Subtract Line b from Line a nod enter the difference in the appropriate column(s) of Line 5. Do not enter a number less thnn zero. Do not include nny pm't of llle operating ex:pcnsl!!l £lntcred on Line b ns n d£lduction in Pnrt V.
's a. Gross receipts $
b. Ordinary and necessary operatlng expenses $
c. Rent W1d other real property income Subtmct Line b from Line a $ $
. t; :', lnterestt dividends and royalties. $ $
'.7. : Pension nnd retirement" income. $ $
~~~,it Any mnounts paid by nnother person or entity, on n regular bnsis~ "ror tile household
. expenses of tl1c debtor or the debtor's dependents, including child support paid for Utnt purpose. Do not include alimony or separate maintenance payments or nmounts.pnid by your spouse if Column B is completed. .Each regular payment should be reportod in only one column; if a payment Is listed in Column A, do not reportthatpnyment in Column B, $ $
:,\ Unemployment compensntlon. Enter the nmount in the appropriate column(s) ofLine 9. HoweVer~ If you contend that unemployment compensation received by you or your spouse was a benefit under the Social Security Act, do not list the amount of such oornp~:~nsation in
" Column.A orB, but instead state the nmount·in the space below:
Unemployment compensntion claimed to I be a benefit under the Socinl Security Act Debtor$ I Spouse$ $ $
61
13 ""'A (Officilll Fonn 22A) {Chllntcr7} (1:!/10)
Jncomc from nil other som·ccs. Specify source and nmount. If necessary~ listndditionnl .sources on n separate pnge, Do not include nllmony or scpnrntc mninteunnce puyments pnid by you I' spouse if Column B is completed, but include nil oU1c1' pnymcnts of nlimony or scpnmte mnintennnec. Do not include any benefits received under the Social
10 Security Act or payments received ns n victim of a wnr crime, crime against humanity. or ns n victim of intemntional or domestic terrorism.
ll
I :: I I : I Total and enter on Line I 0
Subtotal of Current Monthly Income for§ 707(~)(7). Add Lines 3 Lhru 10 In Column A, and, if Column B Is completed, add Lines 3 U1rough 10 in Column B. Enter the lotnl(s).
Totnl Current Monthly Income for§ 707(b)(7). If Column B hns been completed, add 12 Line 1l, Column A to Line 11, Column B, and enter Lhe total. If Column B has not been
completed, enter the amount from Line 11, Column A .
$ $
$ $
$
. . • ····•· ' ' ·•• ·· .. : ·•Partm. APPLI(CATION OF§ 7o7(b)(7{EXbLQSIQJ'oTc ' >' ;· '' ...•. ·.·.·.·. '. u Annunlized Current MonU1ly Income fo1· § 707(b)(7). Multiply the amount from Line 12 by U1e number
12 and enter the result. $
14.
Applicn~lc median fnmily income. Enter the median fnmily income for the applicable state and household size. (This information is available by family size nt www.usdol.gov/usU or :from the clerk of the bankruptcy court.)
n. Enter debtors state of residence: b. Enter debtor's household size:
Applicntion of Section 707(b)(7). Check the applicable box and proceed as directed.
$
·15 0 The nmount on Line 13 is less thnn or cqunl to the nmount on Line 14. Check the box for "Tile presumption does not arise" at thctop ofpnge 1 oflhis statement, nnd complete PartVJII; do notcomplctePnrts IV, V, VI or VII.
· · 0 The nmount on Line 13 is more tlmn the amount on Line 14. Coniplele the rem11iriingparts ofthis statement.
Complete Parts IV, V, VI, nnd VII of this statement only if required. (Sec Line 15.)
~·: ·iK:..: Enter the .. nmount from Line 12. $
, .:· .. ,<~ Mnritnl adjustment. If you checkedtl10 box at Line 2.c, enter on Line 17 the total of any income listed in . ·• <.i Line II, ColumnB that was NOT paid on n regular basis for the household expenses of!he.debtorortl1e
' .. ;.:··•; debtor's dependenls. Specliy in the lines below !he basis for excluding the Column B Income (such as ··. j .. f' ::<J payment tiftbe spouse's tnx llablllty.or the spouse's support of persons other than the debtor or.the debtor's · .· '.. dependents}nnd the amount of income devoted to ench purpose, lfnecessal)', list additional adjustments on " n scparnte page. If you did not check box at Line 2.c, enter zero .
. : I !: I I : I : ·' .. \i:\ Total and enter onLine 17. $ . '~-· . ,. ·tiS ·:·; Current monthly income for § 707(b)(2). Subtract Line 17 from Llne 16 and enter. U1e result $
l
B "J"JA COfficiul Form ""::A) rchnpler 7) ( 12/10) 4
Part V. CALCULATION OF DEDUCTIONS FROM INCOME
Subpart A: Deductions under Standards of the Internal Revenue Service (IRS)
Nntionnl Stnndnrds: food, cJothiug nnd other items. Enter in Line 19A ihe 11Totnl" amount from IRS National Stnndard.s far Food, Clothing and Other llems fortlte applicable number of persons. [This
19A infonnation is avnilnble nt www.usdoi.gov/us!l or from the clerk of the bunkruph:y court.) The applicable number of persons is the number that would currently be aiiowed ns exemptions on your federnllncome tnx return, plus the number of any additional dependenl5 whom you support. $
Nnllonnl Standards: henlth care. Enter in Lineal below the amount from IRS National Standards for Out-of-Pocket Health Care for persons under 65 years ofnge, and in Line n2 theiRS Nationnl Standnrd.s fur Out· of-Poclcet Henlth Cnre for persons 65 yenrs of ngc or older. (This information is available at www.usdoi.aovlustl or from tlte clerk of the bankmptcy courl) Enter in Line bl the applicable number of persons who nrc under65 years ofnge. and enter In Line b2 the npplicnble number of persons who arc 65 years of age or older. {The applicable number of persons in each age calegory is the number in that category that would currently be allowed as exemptions on your federal income tax: return, plus the number ofnny additional dependents whom you support) Multiply Lineal by Line bl to obtain a total amount for persons
19B under 65, and enter the result in Line cl. Multiply Line a2 by Line b2 to obtain n total amount for persons 65 and older, and enter the result in Line c2. Add Lines cl and c2 to obtain a total health care amount, and enter the result in Line 198.
Persons under 65 ycnrs of nge Persons 65 ycnrs of ngc or older
a!. Allowance per person n2. Allowance per person
bi. Number of persons b2. Number of persons
cl. Subtotal c2. Subtotal $
Locnl Stnndnrds: housing nod utllltles; nonwmortgngc expcnsi!S, Enterihe amount of the IRS Housing and Utilities Standards; non-mortgage expenses for the applicable county and family size. {This Information is
2DA available at www.usdoi.nov/ustl or from the clerk of the bankruptcy court). The applicable family size ... · consists of the number that would currently be nllowed as exemptions on your federal income tax return, plus
the number ofnny ndditiomll dependents whom you support $
'·.· Locnl Stondnrds: housing nod utilities; mortgngefl'ent expense. Enter, in Line a below, the nmount of the IRS Housing and Utilities Standards; mortgage/rent expense for your county and family size {this
' : Information is nvallable atwww.usdoj.gov/ust/ or from the clerk oftlte bankruptcy court) (the applicable family size consists ofthe number that would currently be allowed as exc~ptions on your federal income tax return, plus tho number of ~ny additional dependenl5 whom you support); enter.on Line b the total ofthe
<2tiJ3'' A vcrnge Monthly Payments for any debts secured by your home, as stated In Line 42; sub !met Line b from Line a and enter the result in Line 20B. Do not enter nn nmountlcss thnn zero.
' ,' a. IRS Housing and Utilities Standards; mortgage/rental expense $
I id b. Average Monthly Payment for any debts secured by your home,
If nny, os stated in Line 42 s c. Net mortgage/rental expense Subtract Line b ·from Line a. $
I;;;) Local Stnndnrds: bousing and utilities; adjustment If you contend that the process set out in Lines 20A und 20B does not nccumtely compute the allowance to which you nre entitled under the TRS Housing and
I : Utilities Standards, enter any additional amount to which you contend you nre entitled, and stnte tlte blisiS'for :: your contention in the space below:
: , __ $
rD~2=lA~fOrffi~IC~Io~I~F~orm~'='~A~lf~C=h~DDnl~l''~r~7l~f~I2~/~IO~J--------------------------------------------------~----,---------,·5 Local Stnndurds: trnusportntion.; vehicle opcrntion/public trnnsportntion expense. You nrc entitled to nn expense nllownncc In this c:ntegory regardless of whether you pny the expenses of operating n vehicle and regardless of whether you usc public trnnsportntion.
Check the number of vehicles for which you pny the operating eKpenses or for which lhe operating expenses are included as n contribution to your household expenses in Line 8.
22A D 0 D I 02armare. lfyou checked 0, enter on Line 22A the "Public Trnnsportntionn amount fi·om IRS Local StllJldnrds: Trnnsportntion. If you chet:ked 1 or 2 or more, enter onLine 22A the uopernting Costs" amount from IRS Lacnl Stnndnrds: Trnnspartntian far the npplicnble nwnber of vehicles in the npplicnble Metrapnlitnn Statistlcnl Area or Census Region. (These amounts are nvnilnble at www.usdoLeov/ustl or from the clerk of the bnnlcruptcy court.) · $
Locnl Stnndnrds: trnnsportntion; ndditionol public trnnsportntion expense. If you pay the operating expenses for a vehicle and nlso use public tronsportatlon, nnd you contend tho.t'you nrc entitled to nn
228 additional deduction for your public trnnsportntion expenses, enter on Line 21B the "Public Transportation" amount from IRS Local Standnrds: Trnnsportntion. (This amount is nvnilnble ol www.usdoLtmv/ustl or from tl1e cleric of the bnnkruptcy court) $
Locnl Stnndnrds: trnnsportntion ownershipnensc expense; Vehicle 1. Check U1e number of vehicles for which you clolm an ownership/iense expense. (You may not claim nn ownership/lease e}l.-pense for more thnn
: twa vehicles.) D I D 2 or mare. Enter, In Line a below, the "Ownership Costsfl for "One Cnr" from the IRS Locnl Standards: Tmnspcrtation (nvnilnble ntwww.usdal.oav/uslf or from the clerk afthe bnnltruptcy court); enter in Line b the tatnl of !he
23 Average Monthly Payments far any debts secured by Vehicle 1, ns stntcd in Line 42; subtract Line b from . Line n nnd enter the result In Line 23. Do not enter nn nmount less thnn zero.
n. IRS Transpartntian Stnndnrds, Ownership Costs $
b. Avernge Monthly Pnyment far nny debts secured by Vehicle I, ns stated in Line 42 $
.c. Net awncrship/lense expense far Vehicle I SublrnctLine b from Line a.
· :-.~ Locnl Stnndnl'ds: transportation ownersbip/lensc expense; Vehicle 2. Complete tWsLine only if you · · :_: : .. : checked the 112 or more" Box in Line 23.
-.·>) Enter. In Line a below. the "Ownership Costsu for 110ne CW'11 from the IRS Locnl Standards: Transportation (nvallnble atwww.usdaj.gov/usU or from the clerk of the bankruptcy court); enter in Line b the tatnl af1he
, : ·" Average Monthly Pnyments far nny debts secured byVehlole 2, ns stated in Line 42; sublrnotLiae b from · _;_~24' .,~-~ Line a and enter the result in Line 24. Do not enter nn nmount.less thnit zc1·o.
: { i-"---+l_R_S_T_r_a_ns_,_p_a_rt_nu_· a_n_s_t..:.n..:.nd..:.n..:.r..:.ds::.•..:.D_w ... n_e ... rs_h_,lp_C __ as_ts __________ --11-$----------------------l
b. Average Mantl1ly Pnyment far nny debts secured by Vehicle 2, ' .. :: l---+ns.....,st_n ... te_d..:.i..:.n_L..:.in..:.c_4_2 ___________________________ +$--------------------l
· ::· i.•' c. Net ownership/lease "''pense far V chicle 2 Sublract Line b from Line n.
· ·'· -: Other Necessary Expenses: tnxcs. Enter the total average monthly exp~nse thatyou nctunlly incur .for rill . ·jS_:·~.! federal, stnte11Ild.locnl taxes, ether thEm real estate nnd sales taxes, such as income tnxes, self-employment
·:: taxes, social-security tnxes~ nod Medicare tnxes.Do not include real estnte or snlcs tnxcs.
Other Necessary Expenses:· involuntary deductions for employment Enter the tolti.l avernge monthly payroll deductions that ore n:guired for your employment, such as retirement contributions, union dues, and
$
$
: ·;: uniform costs. Do not include discretionary amounts, sucb.ns voluntnry 401(h:) contributions. $
I
";,ji,[cj 0. ther Necessary Expenses: life insurance.- Enter total average monthly premiums that you nctunlly pay for teon life insurance for yourself .. Do not include premiums foi· insurance on your dependents, for whole
I,.::: life or·ror nnv other fonn.ofinsurnncc. $
.:·:~t:);~:~~ O~cr Ncccssnry Expenses: cOUrt-ordered payments. Enter the total monthly amount that you are · 28_:::;: tequired tO 'pay pursuantto the order of a court or administrative ngency 1 such ns spousal or child support : ~--.;::;:. payments. Do not include payments on pnst due obligations included in Line 44. $
29
30
.3! .
32
Other Necessary Expenses: cducntion for employment or ror n physicnlly or mentnlly challenged chiltl, Enter lhe totnl overage monthly amount thnt- you actunlly expend far education that is n condition of employment and for education thnt is required for a physically or mentally challenged dependent child for whom no public education providing similar services is nvoilabte.
Other Necessary Expcns!!S: childcnrc. Enter the lata! nvernge monthly amount thnt you octunlly expend on childcare---such ns baby~sitting, dny c:nre, nursery and prescl10ol. Do not include other cducntionnl pnyments.
Other Nceessnry Expenses: health enre. Enter the total average monthly amount lhatyou actunlly expend on health care Umt is required for the health and welfare of yourself or your dependents, thnt is not reimbursed by insurance or pnid by n health savings nccounf1 and that is in excess of the amount entered in Line l9B. Do not include pnymcnts for hcnlth insurnncc or ltenlth snvings accounts listed 1n LJnc 34.
Other Necessary Expenses: tclccommunicntion scnriccs. Enter the total average monthly amount thnt you actunlly pny for telecammunicntion services ather than your basic home telephone nnd cell phone servicesuch ns pngers, call waiting, cnller id, special long distance, or Internet service--to the el\ient necessary for
henlth and welfare or that Do not include nny deducted.
$
$
$
$
33 Totnl Expenses AUowed under IRS $
34
Subpn:rt.B::. Addililmal Liy:ing E:{pense D'edm:tions Note: Do not incl~de any expenses_ tliat you .h· ""'" Holn.nn T
Henlth lnsurnncc, Disability lusurnnec, nnd Henlth Savings Account Expenses. List the monthly expenses in the categories set out in lines a-o below that ore rensonobly necessnry for yoursel~ your spouse, or your dependents.
Account
Tolnl and enter on Line 34
If you do noi"nctunlly expend this totnl amount, state your actual total avemge monthly expenditures in the spnce below: $
Continued contributions to the enre ofiJousehold or fnmlly members. Enter the total average actual monthly expenses that you will continue to pay for the reasonable and necessary care and support Of lin elderly, chronically il~ or disabled member of your household or member of your immediate fumily who is unable to for such $
Protection ngninst fnmily violence. Enter the total average reasonably necessary monthly expenses that you actually incurred to mnlntaln tl1e safety of your family under the Family Violence Prevention nnd Services
· Act or otl1er applicable federollnw. The nature of these expenses is required to be lcept confidentlnl by the court. '$
energy costs. Enter tlu~ total average monthly amoun~ in excess Ofthe·nllowance specified by lRS Standards for Housing and Utilities. that you nctuolly expend for home energy costs. You must
provide your cnse trustee with documentntion of your nc.tun] expenses, nnd )'ou must demonstrate thnt tl1e ndditionnl nmount clnhncd is rcn~onnble nnd necessary. $
Education expenses for dcpcndciit children less thnn 18. Enter the totnl avemge monthly expenses that you actually incur, not to exceed $147.92* per child, for atlendance-nt.a private or public elementary or secondary school by your dependent children less than 18 years QfQge. You must provide your cnse trustee with documentntion Of your nc.tunl nnd must explnin \Yby U1e nmount.elnimed is rcnsonnblc nnd nod for in the IRS Stnndnrds.
*Am aunt subject ta ac!/ustmenl 01r4101113, and eveljt//rreeyears tlleJ't!aj}i!rwltlr respect.1a ca:res commenced on.ar.aflor the date afacfjustmrml.
ss
B ·n/\ (Offi ' IF ,"lA){CI t 7)(1"'/10) u:m •tmn __ mn c.r - 7
Addltionnl rood nnd clothing expense. Enter the totnl average monthly nmounl by which your food nnd clothing expenses exceed the combined nllowances for food and clothing (apparel and services) in tl1e IRS
39 National Standards, not to exceed 5% of those combined nllownnces. (This inforiUntion is nvallablc at www.usdoi-l!ov/ustl or from the clerk of the bnnlcruptcy court) You must demonstrate thnt the ndditionnl amount clnimed is rensonnblc nud nccessnry. $
40 Continued chnritnble contributions. Enter the amount thnt you will continue to contribute in the form of cash or financial instruments to a chorltnble organization us defined in 26 U.S.C. § 170(c)(l)-(2). $
41 Totnl Additional Expense Deductions under§ 707(b). Enter the total of Lines 34 tlll'ough 40
$
Subpart C: Deductions for Del:itPiiym~nt; ·. ' ···>-. . ~ ....
Future payments on secured c.lnims. For each of your debts that is secured by nn interest in property that you own, list the name of tl1e creditor, identicy the property securing the debt, state the Average Monthly Pnyment, and check whether the payment includes taxes or insurnncc. The Average Monthly Payment is U1e totnl o[nll amounts scheduled as contractually due to ench Secured Creditorln the 60 months following the· filing of the bankruptcy case, divided by 60. Ifnecessnry, list ndditlonal entries on n sepornte page. Enter the total of the Avernge Monthly Payments on Line 42.
Name of Property Securing the Debt Average Does payment '.42 Creditor Monthly include taxes
Payment or insumnce?
n. $ Dyes Dno
b. $ Dyes D no
c. $ Dyes Dno
Totnl: Add Lines a, b nnd c. $
· · Other pnyments on secured clnlms.lf.nny of debts listed in Line 42 are secured by your primary ·. residence, n motor vehicle. or other property necessary for your support or the support of your dependents. · you may include in your deduction 1/60ti1 of any amount (the "cureamounr') that you must poy the creditor
. · In nddlticn to the payments listed in Line 42. in crderto maintain possession ·of the properly. The cure
. ';-:·· : nmount would include any sums in default that .must be paid in order to avoid repossession or foreclo·surc .
·: List nnd totnl any such amounts in the following chart. If necessary, list addltionnl entries on a separate
. . ~3.· age .
Name of Property Securing the Debt l/60th of the Cure Amount Credilor .
n, $
.. i ' b. $
c. $
.. < Total: Add Lines a. b and.o $
. 0/ Pnymcots on prepetition priority claims. Enter the total amoun~ diVided by 60, of all priority claims, such as priority tax, chnd support nnd nlimony claims, fur which you were liable at the time of your banlcrupiC)' :;· . filing. Do ncit include C.UI1'cnt.obligntlonsJ such ns those set out in I.;inc 28, $
8 .,,A (Official Fonn '11,\) (Chanter?) (12/IOl
45
Chapter 13 ndministrntivc expenses. If you nre eligible to file n c115e underchnpter 13, complele the following chart, multiply the amount in line n by the amount in line b, and enter the resulting ndministrallve expense. ..
b.
c.
Projected average monU1ly chapter 13 plnn payment.
Current multiplier for your district as detennined unde1· schedules issued by the Executive Office for Uniled States Trustees. (This informntlon is nvnilnble at www.usdoj .oov/usl/ or from tbe cle•·k ofthe bankruptcy
$
courl) x
Average monthly administrative expense of chapter 13 case Total: Multiply Lines nand b
46 Total Deductions for Debt Pnyment. Enter tl1e totnl of Lines 42 through 45.
· Subpart D: Total Deductions from Iricome ··
47 Totnl of nil deductions nllowcd under§ 707(b)(2). Enter tbe total of Lines 33, 41, and 46.
48 Enter the amount from Line 18 (Current monthly income for§ 707(b)(2))
.49 ·. Enter the nmount from Line 47 (Totnl of nil deductions nllowed under§ 707(b)(2))
50 Monthly disposnble income under § 707(b)(2). Subtract Line 49 from Line 48 and eater the result
51 _ 60-month dlsposnblc income under§ 707(b)(2). Multiply the amount In Line 50 by the number 60 nnd
$
$
$
enter the result $
Tnitinl pre.!lumption detenninntion. Check the applicable box and proceed ns directed.
. .. ::
-· D Tbc nmount on Llne 51 is less tlmn $7,025•. Check the box for"The presumption does not nrise" ntthe top ofpoge 1 of this stntement! and complete the verification in Part Vlll. Do not complete the remainder of Part VI.
D The nmount set forth on Line 51 is more thnn $11,725*. Check the box for 11The presumption Brises" at the top of page 1 of this statement! nnd complete the verification in Part VITI, You ·may also complete Part VII. Do not complete the remainder ofPnrt VI.
0 The nmount on Line 51 is at lcnst $7~025*, but not more tbnn $11,725*. Complcle the remainder ofPnrtVJ (Lines 53 through 55),
'53_· .. 1
·:. , : ::·,:·· Enter tbc nmount of your totnl non~priority unsecured debt $
·'54_;,:' Threshold debt payment amount. Multiply the amount in Line 53 by the number 0.25 and enter tlm restill. $
1 \ >(':-' Secondary presumption determination. Check the applicable box and proceed as directed. 1:J}):·} 0 The amount on Line 51 is less than the amount on Line 54. Check tho bo>:for "The presumption does not arise" nt .c :: J::< ihetop of page I of this stntemen~ nnd complete tl1e verification in Part Vlll.
1'!,~'- ~',,: 0 Tltc nmount on Line: 51 is cqunl to or greater thnn the omount on Line 54. Checkthe box for "The presumption
ariscsfl at the top of page 1 of lhis staiement! and complete the verification in Part Vlfl. You.mny also complete Part VII.
'L:~~~:L)·:; .Other Expenses. List nnd descnDe any monthly expenses, not otherWise stated in this form, that ate reqUired for1he health -'>'>::;; and welfare of you and your family and thnt you contend should be an addltiooal deduction from your current monthly ·:;;;:.\~:-::; income. under·§ 707(b)(2)(A)(ii)(I), If necessary, list additional sources-on a scporate_page. All figures should reflect your -'~··:t }-_~ average monthly expense for each item. Total-the expenses,
'<f<i a. Expense Description Monthly Amount
$ b. $ c. $
Total: Add Lines a, b and c
* Aniounl!.· ore csubjer:l.lo·acfjusunent an 4/0J/13,·and every tltreeyears llummflerwithrespec:l Jo·cascs commenced on or qfler Jlle rfate ofacfjustment.
B 21A (Dfliclnl Form !2A) (Cilnptcr7) (12110} 9
Part VITI: VERIFICATION
1 decJnre under penalty of petjury thnt the informntlon provided in this statement is true nnd com~ct. (!fthis Is a joint case, both debtm"· IIIIlS/ slg/1.)
57 Date: Signature:
(DI!btar)
Date: Signature: (Joint Debtor, If am~
SB
B6 SmnmDiy (Offidnl Fonn U- SumnWI)') (12/07)
United States Banhuptcy Comt
Jnre ______________ ~~~----------Deblor
Cose No.-------------
Chapter _______ _
SUMMARY OF SCHEDULES lmlicnte ns to euoh schedule whelber that schedule is nllached and slate the number ofpogcs in cnch. Report the totuls from Schedules A, B, D, E, F. I, und J in Ute boxes provided, Add Ute amounts from Schedules A untl B to dctennino the totnlnmount oftltc debtor's ussels. Add lh!! nmounts of nil claims from Schedules D, E, nnd F to determine tlte Lotnl nmount of the debtor'sliobilitics. Indlvlduul debtors ulso must complete the "SlnlisUcnl Summary ofCcrtuin Liobillti~:S nml Rclnted Dnln" if they file. n cnse under ohnpter 7. II, or 1.3.
NAME OF SCHEDULE
A- Renl Prop~:ny
B- Pcrsonni'Prnpcrt.y
C- Property Clnim&l ns Bct:mpt
D- Creditors Holding Secured Clnims
E- Creditors Holding Unsecured Priority ClniJTl!i {Tclnl orc:tnims on
F- Creditors Holding Unsecured Nonpriority Clnims
G- Executory Conlmcls nnd Unexpired Leases
H- Cod~blors
1- Current Income or lndividunl Dcbtor(s}
TOTAL
ATTACHED [l'ES/NO) NO. OF SltEETS
D 6 Summnn• {Official Fom16 • Summnr;,•} (12/07}
United States Banlauptcy Comt
In rc -------::,-;-----Debtor
Cnse No. _______ _
Chnpler ____ _
STATISTICAL SUMMARY OF CERTAIN LIABILITIES AND RELATED DATA [28 U.S. C.§ 159)
I fyou arc on individual debtor whose debts ore primarily consumer debts, ns defined in § 101 (B) cf U1c Bnnkruplcy Code {II U.S.C. § 101 (8)), filing n cusc undt!rchaptcr 7. II or 13, you must rep on nil infonnnlion requcsted below.
tJ Check U1is box if you nrc un individual debtor whosc debts oro NOT primarily consumer debts. You nrc. not required to report nny infonnution hen:.
This Information is for stntisticnl purposes only nnder 28 U.S. C.§ 159.
Sununnrize the following ll'PCS of linbilltics, ns rcportcU in the Scbcdulcs, nnd lotnl them.
Type cfLinbllity
Domestic Support Obligations (from Schedule E)
ToKes ond Ccrtnin Other Debts Owed to Go\•emmentnl Units (from Schedule E)
Claims for Death or Personal Injury While Debtor Wns Intoxicated (from Schedule E) (wheUn:r disputed or undisputed)
Stud~:nt Loon Obiigntions {from Sc:Jn:t.lule F)
Domestic Supper~ Seporulion Agreement, nnd Divorce Decree Obligations Nol Reported on Schcduhs E
Obligulions lo Pension or Profit-Shming, nntl Other Similitr Oblignllons (from Schedule F)
TOTAL
Stnte the fullowlnf!:
Avernge lncomc (from Schedule 1, Line I 6}
Av<:rngc Expenses (from Schedule J, Line 18)
Current Monthly Income {from Fonn 22A Line 12; OR, Form 228 Line 11; OR, Fonn 22C Line 20 )
I. Toiol from ScheduleD, "UNSECURED PDRT!ON,IF ANY" column
2 Toinl from Schedule E. "AMOUNT ENTITLED TO PlUDRITY'' column.
3, Tninllrom Schedule E, "AMOUNTNDT ENTITLED TO PIUOIUTY, If ANY" column
lJ. Totnl from Schedule F
5. Total ofnon-prlorll)' unsecured debl (sum of l, 3, and 4)
Amount
$
s
s
s $
$
$
$
$
$