}bk1{Form 6.Suary ofScheduls}bk{

United States Bankruptcy Court

Eastern District of Virginia

In re

,

Debtor

Case No.

Chapter

 15-13148

13

Mossammat R. Khatun

B6 Summary (Official Form 6 - Summary) (12/14)

Indicate as to each schedule whether that schedule is attached and state the number of pages in each. Report the totals from Schedules A,

B, D, E, F, I, and J in the boxes provided. Add the amounts from Schedules A and B to determine the total amount of the debtor’s assets.

Add the amounts of all claims from Schedules D, E, and F to determine the total amount of the debtor’s liabilities. Individual debtors must

also complete the "Statistical Summary of Certain Liabilities and Related Data" if they file a case under chapter 7, 11, or 13.

SUMMARY OF SCHEDULES

ATTACHED NO. OF NAME OF SCHEDULE ASSETS LIABILITIES OTHER

(YES/NO) SHEETS

A - Real Property

B - Personal Property

C - Property Claimed as Exempt

D - Creditors Holding Secured Claims

E - Creditors Holding Unsecured

Priority Claims

F - Creditors Holding Unsecured

Nonpriority Claims

G - Executory Contracts and

Unexpired Leases

H - Codebtors

I - Current Income of Individual

Debtor(s)

J - Current Expenditures of Individual

Debtor(s)

Total Number of Sheets of ALL Schedules

Total Assets

Total Liabilities

(Total of Claims on Schedule E)

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Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

1 305,000.00

3 9,200.00

1

1 397,000.00

1 0.00

2 2,447.00

1

1

2 4,596.00

2 3,099.00

15

314,200.00

399,447.00

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 1 of 33
}bk1{Form 6.Staiscl Sumaryof CetainLbles andRlte Da}bk{

United States Bankruptcy Court

Eastern District of Virginia

In re

,

Debtor

Case No.

Chapter

 15-13148

13

Mossammat R. Khatun

B 6 Summary (Official Form 6 - Summary) (12/14)

STATISTICAL SUMMARY OF CERTAIN LIABILITIES AND RELATED DATA (28 U.S.C. § 159)

If you are an individual debtor whose debts are primarily consumer debts, as defined in § 101(8) of the Bankruptcy Code (11 U.S.C.§ 101(8)), filing

a case under chapter 7, 11 or 13, you must report all information requested below.

Check this box if you are an individual debtor whose debts are NOT primarily consumer debts. You are not required to 

report any information here.

This information is for statistical purposes only under 28 U.S.C. § 159.

 Summarize the following types of liabilities, as reported in the Schedules, and total them.

Type of Liability Amount

Domestic Support Obligations (from Schedule E)

Taxes and Certain Other Debts Owed to Governmental Units 

(from Schedule E)

Claims for Death or Personal Injury While Debtor Was Intoxicated

(from Schedule E) (whether disputed or undisputed)

Student Loan Obligations (from Schedule F)

Domestic Support, Separation Agreement, and Divorce Decree

Obligations Not Reported on Schedule E

Obligations to Pension or Profit-Sharing, and Other Similar Obligations

(from Schedule F)

TOTAL

State the following:

Average Income (from Schedule I, Line 12)

Average Expenses (from Schedule J, Line 22)

Current Monthly Income (from Form 22A-1 Line 11; OR,

Form 22B Line 14; OR, Form 22C-1 Line 14 )

State the following:

1. Total from Schedule D, "UNSECURED PORTION, IF ANY"

column

2. Total from Schedule E, "AMOUNT ENTITLED TO PRIORITY"

column

3. Total from Schedule E, "AMOUNT NOT ENTITLED TO

PRIORITY, IF ANY" column

4. Total from Schedule F

5. Total of non-priority unsecured debt (sum of 1, 3, and 4)

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0.00

0.00

0.00

0.00

0.00

0.00

0.00

4,596.00

3,099.00

1,250.00

92,000.00

0.00

0.00

2,447.00

94,447.00

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 2 of 33
}bk1{Schedul A-ReaPropty}bk{

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

B6A (Official Form 6A) (12/07)

Except as directed below, list all real property in which the debtor has any legal, equitable, or future interest, including all property owned as a

cotenant, community property, or in which the debtor has a life estate. Include any property in which the debtor holds rights and powers exercisable for

the debtor's own benefit. If the debtor is married, state whether husband, wife, both, or the marital community own the property by placing an "H," "W,"

"J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the debtor holds no interest in real property, write "None" under

"Description and Location of Property."

Do not include interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and

Unexpired Leases.

If an entity claims to have a lien or hold a secured interest in any property, state the amount of the secured claim. See Schedule D. If no entity

claims to hold a secured interest in the property, write "None" in the column labeled "Amount of Secured Claim." If the debtor is an individual or

if a joint petition is filed, state the amount of any exemption claimed in the property only in Schedule C - Property Claimed as Exempt.

Description and Location of Property Nature of Debtor's

Interest in Property

Husband,

Wife,

Joint, or

Community

Current Value of

Debtor's Interest in

Property, without

Deducting any Secured

Claim or Exemption

Amount of

Secured Claim

continuation sheets attached to the Schedule of Real Property

SCHEDULE A - REAL PROPERTY

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0

SFH at

5226 Fillmore Ave

Alexandria, VA 22311

Fee simple - 305,000.00 397,000.00

Sub-Total > (Total of this page) 305,000.00

Total >

(Report also on Summary of Schedules)

305,000.00

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 3 of 33
}bk1{Schedul B-Personal Prpety}bk{

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

B6B (Official Form 6B) (12/07)

Except as directed below, list all personal property of the debtor of whatever kind. If the debtor has no property in one or more of the categories, place

an "x" in the appropriate position in the column labeled "None." If additional space is needed in any category, attach a separate sheet properly identified

with the case name, case number, and the number of the category. If the debtor is married, state whether husband, wife, both, or the marital community

own the property by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the debtor is an individual or a joint

petition is filed, state the amount of any exemptions claimed only in Schedule C - Property Claimed as Exempt.

Do not list interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and

Unexpired Leases.

If the property is being held for the debtor by someone else, state that person's name and address under "Description and Location of Property."

If the property is being held for a minor child, simply state the child's initials and the name and address of the child's parent or guardian, such as

"A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

Type of Property

N

O

N

E

Description and Location of Property

Husband,

Wife,

Joint, or

Community

Current Value of

Debtor's Interest in Property,

without Deducting any

Secured Claim or Exemption

continuation sheets attached to the Schedule of Personal Property

SCHEDULE B - PERSONAL PROPERTY

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2

1. Cash on hand Cash - 50.00

2. Checking, savings or other financial

accounts, certificates of deposit, or

shares in banks, savings and loan,

thrift, building and loan, and

homestead associations, or credit

unions, brokerage houses, or

cooperatives.

Checking acct at BB&T J 150.00

3. Security deposits with public

utilities, telephone companies,

landlords, and others.

X

4. Household goods and furnishings,

including audio, video, and

computer equipment.

Household furnishings J 5,000.00

5. Books, pictures and other art

objects, antiques, stamp, coin,

record, tape, compact disc, and

other collections or collectibles.

X

6. Wearing apparel. Woman's apparel - 1,000.00

7. Furs and jewelry. Jewelry - 3,000.00

8. Firearms and sports, photographic,

and other hobby equipment.

X

9. Interests in insurance policies.

Name insurance company of each

policy and itemize surrender or

refund value of each.

X

10. Annuities. Itemize and name each

issuer.

X

Sub-Total >

(Total of this page)

9,200.00

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 4 of 33
B6B (Official Form 6B) (12/07) - Cont.

Type of Property

N

O

N

E

Description and Location of Property

Husband,

Wife,

Joint, or

Community

Current Value of

Debtor's Interest in Property,

without Deducting any

Secured Claim or Exemption

Sheet of continuation sheets attached

to the Schedule of Personal Property

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

Software Copyright (c) 1996-2014 - Best Case, LLC - www.bestcase.com Best Case Bankruptcy

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

11. Interests in an education IRA as

defined in 26 U.S.C. § 530(b)(1) or

under a qualified State tuition plan

as defined in 26 U.S.C. § 529(b)(1).

Give particulars. (File separately the

record(s) of any such interest(s).

11 U.S.C. § 521(c).)

X

12. Interests in IRA, ERISA, Keogh, or

other pension or profit sharing

plans. Give particulars.

X

13. Stock and interests in incorporated

and unincorporated businesses.

Itemize.

X

14. Interests in partnerships or joint

ventures. Itemize.

X

15. Government and corporate bonds

and other negotiable and

nonnegotiable instruments.

X

16. Accounts receivable. X

17. Alimony, maintenance, support, and

property settlements to which the

debtor is or may be entitled. Give

particulars.

X

18. Other liquidated debts owed to debtor

including tax refunds. Give particulars.

X

19. Equitable or future interests, life

estates, and rights or powers

exercisable for the benefit of the

debtor other than those listed in

Schedule A - Real Property.

X

20. Contingent and noncontingent

interests in estate of a decedent,

death benefit plan, life insurance

policy, or trust.

X

21. Other contingent and unliquidated

claims of every nature, including

tax refunds, counterclaims of the

debtor, and rights to setoff claims.

Give estimated value of each.

X

Sub-Total >

(Total of this page)

0.00

1 2

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 5 of 33
B6B (Official Form 6B) (12/07) - Cont.

Type of Property

N

O

N

E

Description and Location of Property

Husband,

Wife,

Joint, or

Community

Current Value of

Debtor's Interest in Property,

without Deducting any

Secured Claim or Exemption

Sheet of continuation sheets attached

to the Schedule of Personal Property

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

Software Copyright (c) 1996-2014 - Best Case, LLC - www.bestcase.com Best Case Bankruptcy

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

22. Patents, copyrights, and other

intellectual property. Give

particulars.

X

23. Licenses, franchises, and other

general intangibles. Give

particulars.

X

24. Customer lists or other compilations

containing personally identifiable

information (as defined in 11 U.S.C.

§ 101(41A)) provided to the debtor

by individuals in connection with

obtaining a product or service from

the debtor primarily for personal,

family, or household purposes.

X

25. Automobiles, trucks, trailers, and

other vehicles and accessories.

X

26. Boats, motors, and accessories. X

27. Aircraft and accessories. X

28. Office equipment, furnishings, and

supplies.

X

29. Machinery, fixtures, equipment, and

supplies used in business.

X

30. Inventory. X

31. Animals. X

32. Crops - growing or harvested. Give

particulars.

X

33. Farming equipment and

implements.

X

34. Farm supplies, chemicals, and feed. X

35. Other personal property of any kind

not already listed. Itemize.

X

Sub-Total >

(Total of this page)

0.00

2 2 Total >

(Report also on Summary of Schedules)

9,200.00

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 6 of 33
}bk1{Schedul C-Propety Claimed sExpt}bk{

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

B6C (Official Form 6C) (4/13)

Debtor claims the exemptions to which debtor is entitled under: Check if debtor claims a homestead exemption that exceeds

(Check one box) $155,675. (Amount subject to adjustment on 4/1/16, and every three years thereafter

with respect to cases commenced on or after the date of adjustment.) 11 U.S.C. §522(b)(2)

11 U.S.C. §522(b)(3)

Description of Property Specify Law Providing

Each Exemption

Value of

Claimed

Exemption

Current Value of

Property Without

Deducting Exemption

continuation sheets attached to Schedule of Property Claimed as Exempt

SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

Software Copyright (c) 1996-2014 - Best Case, LLC - www.bestcase.com Best Case Bankruptcy

0

Cash on Hand

Cash Va. Code Ann. § 34-4 50.00 50.00

Checking, Savings, or Other Financial Accounts, Certificates of Deposit

Checking acct at BB&T Va. Code Ann. § 34-4 150.00 300.00

Household Goods and Furnishings

Household furnishings Va. Code Ann. § 34-26(4a) 5,000.00 10,000.00

Wearing Apparel

Woman's apparel Va. Code Ann. § 34-26(4) 1,000.00 1,000.00

Furs and Jewelry

Jewelry Va. Code Ann. § 34-4 3,000.00 3,000.00

Total: 9,200.00 14,350.00

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 7 of 33
}bk1{Schedul D-Creditos HldingSecurd Claims}bk{

AMOUNT OF

CLAIM

WITHOUT

DEDUCTING

VALUE OF

COLLATERAL

DATE CLAIM WAS INCURRED,

NATURE OF LIEN, AND

DESCRIPTION AND VALUE

OF PROPERTY

SUBJECT TO LIEN

C

O

D

E

B

T

O

R

C

O

N

T

I

N

G

E

N

T

U

N

L

I

Q

U

I

D

A

T

E

D

D

I

S

P

U

T

E

D

Husband, Wife, Joint, or Community

H

W

J

C

CREDITOR'S NAME 

AND MAILING ADDRESS

INCLUDING ZIP CODE,

AND ACCOUNT NUMBER

(See instructions above.)

Account No.

Value $

Account No.

Value $

Account No.

Value $

Account No.

Value $

Subtotal

_____ continuation sheets attached (Total of this page)

UNSECURED

PORTION, IF

ANY

B6D (Official Form 6D) (12/07)

State the name, mailing address, including zip code, and last four digits of any account number of all entities holding claims secured by property of the debtor as of

the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided

if the debtor chooses to do so. List creditors holding all types of secured interests such as judgment liens, garnishments, statutory liens, mortgages, deeds of trust, and

other security interests.

List creditors in alphabetical order to the extent practicable. If a minor child is a creditor, the child's initials and the name and address of the child's parent or 

guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). If all secured 

creditors will not fit on this page, use the continuation sheet provided. 

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor" ,include the entity on the appropriate

schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be

liable on each claim by placing an "H", "W", "J", or "C" in the column labeled "Husband, Wife, Joint, or Community".

If the claim is contingent, place an "X" in the column labeled "Contingent". If the claim is unliquidated, place an "X" in the column labeled "Unliquidated". If the

claim is disputed, place an "X" in the column labeled "Disputed". (You may need to place an "X" in more than one of these three columns.)

Total the columns labeled "Amount of Claim Without Deducting Value of Collateral" and "Unsecured Portion, if Any" in the boxes labeled "Total(s)" on the last

sheet of the completed schedule. Report the total from the column labeled "Amount of Claim" also on the Summary of Schedules and, if the debtor is an individual with

primarily consumer debts, report the total from the column labeled "Unsecured Portion" on the Statistical Summary of Certain Liabilities and Related Data.

Check this box if debtor has no creditors holding secured claims to report on this Schedule D.

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

Software Copyright (c) 1996-2014 - Best Case, LLC - www.bestcase.com Best Case Bankruptcy

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

0

xxxxxxxxx1983 Opened 11/01/07 Last Active 3/01/11

First Mortgage

SFH at

5226 Fillmore Ave

Alexandria, VA 22311

Seterus Inc

14523 Sw Millikan Way St

Beaverton, OR 97005

-

305,000.00 397,000.00 92,000.00

397,000.00 92,000.00

Total 397,000.00 92,000.00

(Report on Summary of Schedules)

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 8 of 33
}bk1{Schedul E-Creditos HldingUsecurd PiotyClams}bk{

B6E (Official Form 6E) (4/13)

A complete list of claims entitled to priority, listed separately by type of priority, is to be set forth on the sheets provided. Only holders of unsecured claims entitled

to priority should be listed in this schedule. In the boxes provided on the attached sheets, state the name, mailing address, including zip code, and last four digits of the

account number, if any, of all entities holding priority claims against the debtor or the property of the debtor, as of the date of the filing of the petition. Use a separate

continuation sheet for each type of priority and label each with the type of priority.

The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do

so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." 

Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). 

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the appropriate

schedule of creditors, and complete Schedule H-Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be

liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the claim is contingent, place an "X" in the

column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled

"Disputed." (You may need to place an "X" in more than one of these three columns.)

Report the total of claims listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all claims listed on this Schedule E in the box labeled

"Total" on the last sheet of the completed schedule. Report this total also on the Summary of Schedules.

Report the total of amounts entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all amounts entitled to priority

listed on this Schedule E in the box labeled "Totals" on the last sheet of the completed schedule. Individual debtors with primarily consumer debts report this total 

also on the Statistical Summary of Certain Liabilities and Related Data.

Report the total of amounts not entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all amounts not entitled to

priority listed on this Schedule E in the box labeled "Totals" on the last sheet of the completed schedule. Individual debtors with primarily consumer debts report this 

total also on the Statistical Summary of Certain Liabilities and Related Data.

Check this box if debtor has no creditors holding unsecured priority claims to report on this Schedule E.

TYPES OF PRIORITY CLAIMS (Check the appropriate box(es) below if claims in that category are listed on the attached sheets)

Domestic support obligations

Claims for domestic support that are owed to or recoverable by a spouse, former spouse, or child of the debtor, or the parent, legal guardian, or responsible relative 

of such a child, or a governmental unit to whom such a domestic support claim has been assigned to the extent provided in 11 U.S.C. § 507(a)(1).

Extensions of credit in an involuntary case

Claims arising in the ordinary course of the debtor's business or financial affairs after the commencement of the case but before the earlier of the appointment of a 

trustee or the order for relief. 11 U.S.C. § 507(a)(3).

Wages, salaries, and commissions

Wages, salaries, and commissions, including vacation, severance, and sick leave pay owing to employees and commissions owing to qualifying independent sales

representatives up to $12,475* per person earned within 180 days immediately preceding the filing of the original petition, or the cessation of business, whichever

occurred first, to the extent provided in 11 U.S.C. § 507(a)(4).

Contributions to employee benefit plans

Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or the cessation of business,

whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(5).

Certain farmers and fishermen

Claims of certain farmers and fishermen, up to $6,150* per farmer or fisherman, against the debtor, as provided in 11 U.S.C. § 507(a)(6).

Deposits by individuals

Claims of individuals up to $2,775* for deposits for the purchase, lease, or rental of property or services for personal, family, or household use, that were not 

delivered or provided. 11 U.S.C. § 507(a)(7).

Taxes and certain other debts owed to governmental units

Taxes, customs duties, and penalties owing to federal, state, and local governmental units as set forth in 11 U.S.C. § 507(a)(8).

Commitments to maintain the capital of an insured depository institution

Claims based on commitments to the FDIC, RTC, Director of the Office of Thrift Supervision, Comptroller of the Currency, or Board of Governors of the Federal

Reserve System, or their predecessors or successors, to maintain the capital of an insured depository institution. 11 U.S.C. § 507 (a)(9).

Claims for death or personal injury while debtor was intoxicated

Claims for death or personal injury resulting from the operation of a motor vehicle or vessel while the debtor was intoxicated from using alcohol, a drug, or 

another substance. 11 U.S.C. § 507(a)(10).

* Amount subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

 continuation sheets attached

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS

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In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

0

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 9 of 33
}bk1{Schedul F-Creditos HldingUsecurd Nonpirty Claims}bk{

C

O

D

E

B

T

O

R

C

O

N

T

I

N

G

E

N

T

U

N

L

I

Q

U

I

D

A

T

E

D

D

I

S

P

U

T

E

D

Husband, Wife, Joint, or Community

H

W

J

C

CREDITOR'S NAME,

MAILING ADDRESS

INCLUDING ZIP CODE,

AND ACCOUNT NUMBER

(See instructions above.)

Account No.

Account No.

Account No.

Account No.

Subtotal

_____ continuation sheets attached (Total of this page)

DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM. IF CLAIM

IS SUBJECT TO SETOFF, SO STATE. AMOUNT OF CLAIM

B6F (Official Form 6F) (12/07)

State the name, mailing address, including zip code, and last four digits of any account number, of all entities holding unsecured claims without priority against the

debtor or the property of the debtor, as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful to the

trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's 

parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). Do not

include claims listed in Schedules D and E. If all creditors will not fit on this page, use the continuation sheet provided. 

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the appropriate

schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be

liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community."

If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled "Unliquidated." If the

claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than one of these three columns.)

Report the total of all claims listed on this schedule in the box labeled "Total" on the last sheet of the completed schedule. Report this total also on the Summary of

Schedules and, if the debtor is an individual with primarily consumer debts, report this total also on the Statistical Summary of Certain Liabilities and Related Data.

Check this box if debtor has no creditors holding unsecured claims to report on this Schedule F.

S/N:27480-150901

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

Software Copyright (c) 1996-2014 - Best Case, LLC - www.bestcase.com Best Case Bankruptcy

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

1

xxxxxxx1974 Opened 8/01/12

Collection Attorney Association Of Alexandria

Radi

American Collections E

205 S Whiting St Ste 500

Alexandria, VA 22304

-

1,306.00

xxxxxxx2322 Opened 3/01/11

Collection Attorney Association Of Alexandria

Radi

American Collections E

205 S Whiting St Ste 500

Alexandria, VA 22304

-

256.00

xxxxxxx2278 Opened 4/01/13

Collection Attorney Association Of Alexandria

Radi

American Collections E

205 S Whiting St Ste 500

Alexandria, VA 22304

-

110.00

xxx8827 Medical

Oac

Po Box 500

Baraboo, WI 53913

-

512.00

2,184.00

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 10 of 33
B6F (Official Form 6F) (12/07) - Cont.

C

O

D

E

B

T

O

R

C

O

N

T

I

N

G

E

N

T

U

N

L

I

Q

U

I

D

A

T

E

D

D

I

S

P

U

T

E

D

Husband, Wife, Joint, or Community

H

W

J

C

CREDITOR'S NAME,

MAILING ADDRESS

INCLUDING ZIP CODE,

AND ACCOUNT NUMBER

(See instructions above.)

Account No.

Account No.

Account No.

Account No.

Account No.

Sheet no. _____ of _____ sheets attached to Schedule of Subtotal

Creditors Holding Unsecured Nonpriority Claims (Total of this page)

DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM. IF CLAIM

IS SUBJECT TO SETOFF, SO STATE. AMOUNT OF CLAIM

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

(Continuation Sheet)

Software Copyright (c) 1996-2014 - Best Case, LLC - www.bestcase.com Best Case Bankruptcy

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

xxx9034 Medical

Oac

Po Box 500

Baraboo, WI 53913

-

192.00

xxx1804 Medical

Oac

Po Box 500

Baraboo, WI 53913

-

71.00

263.00

1 1

2,447.00

Total

(Report on Summary of Schedules)

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 11 of 33
}bk1{Schedul G-Executory Cnactsd Unexpird Leas}bk{

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

B6G (Official Form 6G) (12/07)

Describe all executory contracts of any nature and all unexpired leases of real or personal property. Include any timeshare interests. State nature

of debtor's interest in contract, i.e., "Purchaser", "Agent", etc. State whether debtor is the lessor or lessee of a lease. Provide the names and

complete mailing addresses of all other parties to each lease or contract described. If a minor child is a party to one of the leases or contracts, 

state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not 

disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). 

Check this box if debtor has no executory contracts or unexpired leases.

Name and Mailing Address, Including Zip Code,

of Other Parties to Lease or Contract

Description of Contract or Lease and Nature of Debtor's Interest.

State whether lease is for nonresidential real property.

State contract number of any government contract.

continuation sheets attached to Schedule of Executory Contracts and Unexpired Leases

SCHEDULE G - EXECUTORY CONTRACTS AND UNEXPIRED LEASES

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0

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 12 of 33
}bk1{Schedul H-Codebtrs}k{

In re

,

Debtor

Mossammat R. Khatun Case No. 15-13148

B6H (Official Form 6H) (12/07)

Provide the information requested concerning any person or entity, other than a spouse in a joint case, that is also liable on any debts listed

by debtor in the schedules of creditors. Include all guarantors and co-signers. If the debtor resides or resided in a community property state,

commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or

Wisconsin) within the eight year period immediately preceding the commencement of the case, identify the name of the debtor's spouse and of

any former spouse who resides or resided with the debtor in the community property state, commonwealth, or territory. Include all names used

by the nondebtor spouse during the eight years immediately preceding the commencement of this case. If a minor child is a codebtor or a creditor, 

state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not 

disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). 

Check this box if debtor has no codebtors.

NAME AND ADDRESS OF CODEBTOR NAME AND ADDRESS OF CREDITOR

continuation sheets attached to Schedule of Codebtors

SCHEDULE H - CODEBTORS

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0

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 13 of 33
Fill in this information to identify your case:

Debtor 1 Mossammat R. Khatun

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number 15-13148 Check if this is:

(If known)  An amended filing

 A supplement showing post-petition chapter

13 income as of the following date:

 Official Form B 6I MM / DD/ YYYY

Schedule I: Your Income 12/13

Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for

supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your

spouse. If you are separated and your spouse is not filing with you, do not include information about your spouse. If more space is needed,

attach a separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Describe Employment

1. Fill in your employment

information. Debtor 1 Debtor 2 or non-filing spouse

If you have more than one job,

attach a separate page with

information about additional

employers.

Include part-time, seasonal, or

self-employed work.

Occupation may include student

or homemaker, if it applies.

Employment status

 Employed

 Not employed

 Employed

 Not employed

Occupation Baby sitter

Employer's name Self

Employer's address

How long employed there? 19 yrs

Part 2: Give Details About Monthly Income

Estimate monthly income as of the date you file this form. If you have nothing to report for any line, write $0 in the space. Include your non-filing

spouse unless you are separated.

If you or your non-filing spouse have more than one employer, combine the information for all employers for that person on the lines below. If you need

more space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or

non-filing spouse

2.

List monthly gross wages, salary, and commissions (before all payroll

deductions). If not paid monthly, calculate what the monthly wage would be. 2. $ 0.00 $ 0.00

3. Estimate and list monthly overtime pay. 3. +$ 0.00 +$ 0.00

4. Calculate gross Income. Add line 2 + line 3. 4. $ 0.00 $ 0.00

Official Form B 6I Schedule I: Your Income page 1

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 14 of 33
Debtor 1 Mossammat R. Khatun Case number (if known) 15-13148

For Debtor 1 For Debtor 2 or

non-filing spouse

Copy line 4 here 4. $ 0.00 $ 0.00

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a. $ 0.00 $ 0.00

5b. Mandatory contributions for retirement plans 5b. $ 0.00 $ 0.00

5c. Voluntary contributions for retirement plans 5c. $ 0.00 $ 0.00

5d. Required repayments of retirement fund loans 5d. $ 0.00 $ 0.00

5e. Insurance 5e. $ 0.00 $ 0.00

5f. Domestic support obligations 5f. $ 0.00 $ 0.00

5g. Union dues 5g. $ 0.00 $ 0.00

5h. Other deductions. Specify: 5h.+ $ 0.00 + $ 0.00

6. Add the payroll deductions. Add lines 5a+5b+5c+5d+5e+5f+5g+5h. 6. $ 0.00 $ 0.00

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $ 0.00 $ 0.00

8. List all other income regularly received:

8a. Net income from rental property and from operating a business,

profession, or farm

Attach a statement for each property and business showing gross

receipts, ordinary and necessary business expenses, and the total

monthly net income. 8a. $ 3,000.00 $ 0.00

8b. Interest and dividends 8b. $ 0.00 $ 0.00

8c. Family support payments that you, a non-filing spouse, or a dependent

regularly receive

Include alimony, spousal support, child support, maintenance, divorce

settlement, and property settlement. 8c. $ 0.00 $ 0.00

8d. Unemployment compensation 8d. $ 0.00 $ 0.00

8e. Social Security 8e. $ 0.00 $ 496.00

8f. Other government assistance that you regularly receive

Include cash assistance and the value (if known) of any non-cash assistance

that you receive, such as food stamps (benefits under the Supplemental

Nutrition Assistance Program) or housing subsidies.

Specify: 8f. $ 0.00 $ 0.00

8g. Pension or retirement income 8g. $ 0.00 $ 0.00

8h. Other monthly income. Specify: Help from son 8h.+ $ 1,100.00 + $ 0.00

9. Add all other income. Add lines 8a+8b+8c+8d+8e+8f+8g+8h. 9. $ 4,100.00 $ 496.00

10. Calculate monthly income. Add line 7 + line 9. 10. $ 4,100.00 + $ 496.00 = $ 4,596.00

Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse.

11. State all other regular contributions to the expenses that you list in Schedule J.

Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and

other friends or relatives.

Do not include any amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J.

Specify: 11. +$ 0.00

12. Add the amount in the last column of line 10 to the amount in line 11. The result is the combined monthly income.

12. $ 4,596.00

Write that amount on the Summary of Schedules and Statistical Summary of Certain Liabilities and Related Data, if it

applies

Combined

monthly income

13. Do you expect an increase or decrease within the year after you file this form?

 No.

 Yes. Explain:

Official Form B 6I Schedule I: Your Income page 2

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 15 of 33
Fill in this information to identify your case:

Debtor 1 Mossammat R. Khatun Check if this is:

 An amended filing

Debtor 2  A supplement showing post-petition chapter

(Spouse, if filing) 13 expenses as of the following date:

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA MM / DD / YYYY

Case number 15-13148  A separate filing for Debtor 2 because Debtor

(If known) 2 maintains a separate household

Official Form B 6J

Schedule J: Your Expenses 12/13

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct

information. If more space is needed, attach another sheet to this form. On the top of any additional pages, write your name and case

number (if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

 Yes. Does Debtor 2 live in a separate household?

 No

 Yes. Debtor 2 must file a separate Schedule J.

2. Do you have dependents?  No

Do not list Debtor 1

and Debtor 2.

 Yes. Fill out this information for

each dependent..............

Dependent’s relationship to

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent

live with you?

Do not state the

dependents' names. Spouse 72

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

3. Do your expenses include

expenses of people other than

yourself and your dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

Estimate your expenses as of your bankruptcy filing date unless you are using this form as a supplement in a Chapter 13 case to report

expenses as of a date after the bankruptcy is filed. If this is a supplemental Schedule J, check the box at the top of the form and fill in the

applicable date.

Include expenses paid for with non-cash government assistance if you know

the value of such assistance and have included it on Schedule I: Your Income

(Official Form 6I.) Your expenses

4. The rental or home ownership expenses for your residence. Include first mortgage

payments and any rent for the ground or lot. 4. $ 2,549.00

If not included in line 4:

4a. Real estate taxes 4a. $ 0.00

4b. Property, homeowner’s, or renter’s insurance 4b. $ 0.00

4c. Home maintenance, repair, and upkeep expenses 4c. $ 50.00

4d. Homeowner’s association or condominium dues 4d. $ 0.00

5. Additional mortgage payments for your residence, such as home equity loans 5. $ 0.00

Official Form B 6J Schedule J: Your Expenses page 1

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 16 of 33
Debtor 1 Mossammat R. Khatun Case number (if known) 15-13148

6. Utilities:

6a. Electricity, heat, natural gas 6a. $ 0.00

6b. Water, sewer, garbage collection 6b. $ 0.00

6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $ 0.00

6d. Other. Specify: 6d. $ 0.00

7. Food and housekeeping supplies 7. $ 250.00

8. Childcare and children’s education costs 8. $ 0.00

9. Clothing, laundry, and dry cleaning 9. $ 50.00

10. Personal care products and services 10. $ 50.00

11. Medical and dental expenses 11. $ 100.00

12. Transportation. Include gas, maintenance, bus or train fare.

Do not include car payments. 12. $ 50.00

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $ 0.00

14. Charitable contributions and religious donations 14. $ 0.00

15. Insurance.

Do not include insurance deducted from your pay or included in lines 4 or 20.

15a. Life insurance 15a. $ 0.00

15b. Health insurance 15b. $ 0.00

15c. Vehicle insurance 15c. $ 0.00

15d. Other insurance. Specify: 15d. $ 0.00

16. Taxes. Do not include taxes deducted from your pay or included in lines 4 or 20.

Specify: 16. $ 0.00

17. Installment or lease payments:

17a. Car payments for Vehicle 1 17a. $ 0.00

17b. Car payments for Vehicle 2 17b. $ 0.00

17c. Other. Specify: 17c. $ 0.00

17d. Other. Specify: 17d. $ 0.00

18. Your payments of alimony, maintenance, and support that you did not report as

deducted from your pay on line 5, Schedule I, Your Income (Official Form 6I). 18. $ 0.00

19. Other payments you make to support others who do not live with you. $ 0.00

Specify: 19.

20. Other real property expenses not included in lines 4 or 5 of this form or on Schedule I: Your Income.

20a. Mortgages on other property 20a. $ 0.00

20b. Real estate taxes 20b. $ 0.00

20c. Property, homeowner’s, or renter’s insurance 20c. $ 0.00

20d. Maintenance, repair, and upkeep expenses 20d. $ 0.00

20e. Homeowner’s association or condominium dues 20e. $ 0.00

21. Other: Specify: 21. +$ 0.00

22. Your monthly expenses. Add lines 4 through 21.

The result is your monthly expenses.

22. $ 3,099.00

23. Calculate your monthly net income.

23a. Copy line 12 (your combined monthly income) from Schedule I. 23a. $ 4,596.00

23b. Copy your monthly expenses from line 22 above. 23b. -$ 3,099.00

23c. Subtract your monthly expenses from your monthly income.

The result is your monthly net income. 23c. $ 1,497.00

24. Do you expect an increase or decrease in your expenses within the year after you file this form?

For example, do you expect to finish paying for your car loan within the year or do you expect your mortgage payment to increase or decrease because of a

modification to the terms of your mortgage?

 No.

 Yes.

Explain:

Official Form B 6J Schedule J: Your Expenses page 2

Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 17 of 33
B6 Declaration (Official Form 6 - Declaration). (12/07)

United States Bankruptcy Court

Eastern District of Virginia

In re Mossammat R. Khatun Case No. 15-13148

Debtor(s) Chapter 13

DECLARATION CONCERNING DEBTOR'S SCHEDULES

DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR

I declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of 17 

sheets, and that they are true and correct to the best of my knowledge, information, and belief.

Date September 24, 2015 Signature /s/ Mossammat R. Khatun

Mossammat R. Khatun

Debtor

Penalty for making a false statement or concealing property: Fine of up to $500,000 or imprisonment for up to 5 years or both.

18 U.S.C. §§ 152 and 3571.

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Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 18 of 33
B7 (Official Form 7) (04/13)

United States Bankruptcy Court

Eastern District of Virginia

In re Mossammat R. Khatun Case No. 15-13148

Debtor(s) Chapter 13

STATEMENT OF FINANCIAL AFFAIRS

This statement is to be completed by every debtor. Spouses filing a joint petition may file a single statement on which the information for

both spouses is combined. If the case is filed under chapter 12 or chapter 13, a married debtor must furnish information for both spouses whether or

not a joint petition is filed, unless the spouses are separated and a joint petition is not filed. An individual debtor engaged in business as a sole

proprietor, partner, family farmer, or self-employed professional, should provide the information requested on this statement concerning all such

activities as well as the individual's personal affairs. To indicate payments, transfers and the like to minor children, state the child's initials and the

name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11

U.S.C. § 112; Fed. R. Bankr. P. 1007(m).

Questions 1 - 18 are to be completed by all debtors. Debtors that are or have been in business, as defined below, also must complete

Questions 19 - 25. If the answer to an applicable question is "None," mark the box labeled "None." If additional space is needed for the answer

to any question, use and attach a separate sheet properly identified with the case name, case number (if known), and the number of the question.

DEFINITIONS

"In business." A debtor is "in business" for the purpose of this form if the debtor is a corporation or partnership. An individual debtor is "in

business" for the purpose of this form if the debtor is or has been, within six years immediately preceding the filing of this bankruptcy case, any of

the following: an officer, director, managing executive, or owner of 5 percent or more of the voting or equity securities of a corporation; a partner,

other than a limited partner, of a partnership; a sole proprietor or self-employed full-time or part-time. An individual debtor also may be "in business"

for the purpose of this form if the debtor engages in a trade, business, or other activity, other than as an employee, to supplement income from the

debtor's primary employment.

"Insider." The term "insider" includes but is not limited to: relatives of the debtor; general partners of the debtor and their relatives;

corporations of which the debtor is an officer, director, or person in control; officers, directors, and any persons in control of a corporate debtor and

their relatives; affiliates of the debtor and insiders of such affiliates; and any managing agent of the debtor. 11 U.S.C. § 101(2), (31).

None



1. Income from employment or operation of business

State the gross amount of income the debtor has received from employment, trade, or profession, or from operation of the debtor's

business, including part-time activities either as an employee or in independent trade or business, from the beginning of this calendar

year to the date this case was commenced. State also the gross amounts received during the two years immediately preceding this

calendar year. (A debtor that maintains, or has maintained, financial records on the basis of a fiscal rather than a calendar year may

report fiscal year income. Identify the beginning and ending dates of the debtor's fiscal year.) If a joint petition is filed, state income for

each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income of both spouses whether or not a joint

petition is filed, unless the spouses are separated and a joint petition is not filed.)

AMOUNT SOURCE

$9,000.00 2015 YTD: Wife Babysitting

$15,000.00 2014: Wife Babysitting

$14,000.00 2013: Wife Babysitting

None



2. Income other than from employment or operation of business

State the amount of income received by the debtor other than from employment, trade, profession, or operation of the debtor's business

during the two years immediately preceding the commencement of this case. Give particulars. If a joint petition is filed, state income for

each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income for each spouse whether or not a joint

petition is filed, unless the spouses are separated and a joint petition is not filed.)

AMOUNT SOURCE

$4,250.00 2015 YTD: Husband SSI Benefits

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Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 19 of 33
B7 (Official Form 7) (04/13)

2

AMOUNT SOURCE

$5,500.00 2014: Husband SSI Benefits

$5,250.00 2013: Husband SSI Benefits

None



3. Payments to creditors

Complete a. or b., as appropriate, and c.

a. Individual or joint debtor(s) with primarily consumer debts: List all payments on loans, installment purchases of goods or

services, and other debts to any creditor made within 90 days immediately preceding the commencement of this case unless the

aggregate value of all property that constitutes or is affected by such transfer is less than $600. Indicate with an asterisk (*) any

payments that were made to a creditor on account of a domestic support obligation or as part of an alternative repayment schedule under

a plan by an approved nonprofit budgeting and credit counseling agency. (Married debtors filing under chapter 12 or chapter 13 must

include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is

not filed.)

NAME AND ADDRESS

OF CREDITOR

DATES OF

PAYMENTS AMOUNT PAID

AMOUNT STILL

OWING

None



b. Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor made within 90 days

immediately preceding the commencement of the case unless the aggregate value of all property that constitutes or is affected by such

transfer is less than $6,225*. If the debtor is an individual, indicate with an asterisk (*) any payments that were made to a creditor on

account of a domestic support obligation or as part of an alternative repayment schedule under a plan by an approved nonprofit

budgeting and credit counseling agency. (Married debtors filing under chapter 12 or chapter 13 must include payments and other

transfers by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not

filed.)

NAME AND ADDRESS OF CREDITOR

DATES OF

PAYMENTS/

TRANSFERS

AMOUNT

PAID OR

VALUE OF

TRANSFERS

AMOUNT STILL

OWING

None



c. All debtors: List all payments made within one year immediately preceding the commencement of this case to or for the benefit of

creditors who are or were insiders. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both

spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR AND

RELATIONSHIP TO DEBTOR DATE OF PAYMENT AMOUNT PAID

AMOUNT STILL

OWING

None



4. Suits and administrative proceedings, executions, garnishments and attachments

a. List all suits and administrative proceedings to which the debtor is or was a party within one year immediately preceding the filing of

this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both spouses

whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

CAPTION OF SUIT

AND CASE NUMBER

NATURE OF

PROCEEDING

COURT OR AGENCY

AND LOCATION

STATUS OR

DISPOSITION

None



b. Describe all property that has been attached, garnished or seized under any legal or equitable process within one year immediately

preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning

property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not

filed.)

NAME AND ADDRESS OF PERSON FOR WHOSE

BENEFIT PROPERTY WAS SEIZED DATE OF SEIZURE

DESCRIPTION AND VALUE OF

PROPERTY

 * Amount subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

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Case 15-13148-BFK Doc 11 Filed 09/24/15 Entered 09/24/15 10:10:01 Desc Main

 Document Page 20 of 33
B7 (Official Form 7) (04/13)

3

None



5. Repossessions, foreclosures and returns

List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure or

returned to the seller, within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12

or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the

spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF

CREDITOR OR SELLER

DATE OF REPOSSESSION,

FORECLOSURE SALE,

TRANSFER OR RETURN

DESCRIPTION AND VALUE OF

PROPERTY

None



6. Assignments and receiverships

a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of

this case. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by either or both spouses whether or not a

joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF ASSIGNEE

DATE OF

ASSIGNMENT TERMS OF ASSIGNMENT OR SETTLEMENT

None



b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately

preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning

property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not

filed.)

NAME AND ADDRESS

OF CUSTODIAN

NAME AND LOCATION

OF COURT

CASE TITLE & NUMBER

DATE OF

ORDER

DESCRIPTION AND VALUE OF

PROPERTY

None



7. Gifts

List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary

and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions

aggregating less than $100 per recipient. (Married debtors filing under chapter 12 or chapter 13 must include gifts or contributions by

either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF

PERSON OR ORGANIZATION

RELATIONSHIP TO

DEBTOR, IF ANY DATE OF GIFT

DESCRIPTION AND

VALUE OF GIFT

None



8. Losses

List all losses from fire, theft, other casualty or gambling within one year immediately preceding the commencement of this case or

since the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include losses by either or both

spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

DESCRIPTION AND VALUE

OF PROPERTY

DESCRIPTION OF CIRCUMSTANCES AND, IF

LOSS WAS COVERED IN WHOLE OR IN PART

BY INSURANCE, GIVE PARTICULARS DATE OF LOSS

None



9. Payments related to debt counseling or bankruptcy

List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation

concerning debt consolidation, relief under the bankruptcy law or preparation of the petition in bankruptcy within one year immediately

preceding the commencement of this case.

NAME AND ADDRESS

OF PAYEE

DATE OF PAYMENT,

NAME OF PAYER IF OTHER

THAN DEBTOR

AMOUNT OF MONEY

OR DESCRIPTION AND VALUE

OF PROPERTY

Sawyer & Azarcon, P.C.

10605 B2 Judicial Drive

Fairfax, VA 22030

9/15 $3,690.00 atty. fees; $310 filing

fees

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None



10. Other transfers

a. List all other property, other than property transferred in the ordinary course of the business or financial affairs of the debtor,

transferred either absolutely or as security within two years immediately preceding the commencement of this case. (Married debtors

filing under chapter 12 or chapter 13 must include transfers by either or both spouses whether or not a joint petition is filed, unless the

spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF TRANSFEREE,

RELATIONSHIP TO DEBTOR DATE

DESCRIBE PROPERTY TRANSFERRED

AND VALUE RECEIVED

None



b. List all property transferred by the debtor within ten years immediately preceding the commencement of this case to a self-settled

trust or similar device of which the debtor is a beneficiary.

NAME OF TRUST OR OTHER

DEVICE DATE(S) OF

TRANSFER(S)

AMOUNT OF MONEY OR DESCRIPTION AND

VALUE OF PROPERTY OR DEBTOR'S INTEREST

IN PROPERTY

None



11. Closed financial accounts

List all financial accounts and instruments held in the name of the debtor or for the benefit of the debtor which were closed, sold, or

otherwise transferred within one year immediately preceding the commencement of this case. Include checking, savings, or other

financial accounts, certificates of deposit, or other instruments; shares and share accounts held in banks, credit unions, pension funds,

cooperatives, associations, brokerage houses and other financial institutions. (Married debtors filing under chapter 12 or chapter 13 must

include information concerning accounts or instruments held by or for either or both spouses whether or not a joint petition is filed,

unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF INSTITUTION

TYPE OF ACCOUNT, LAST FOUR

DIGITS OF ACCOUNT NUMBER,

AND AMOUNT OF FINAL BALANCE

AMOUNT AND DATE OF SALE

OR CLOSING

None



12. Safe deposit boxes

List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables within one year

immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include boxes or

depositories of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not

filed.)

NAME AND ADDRESS OF BANK

OR OTHER DEPOSITORY

NAMES AND ADDRESSES

OF THOSE WITH ACCESS

TO BOX OR DEPOSITORY

DESCRIPTION

OF CONTENTS

DATE OF TRANSFER OR

SURRENDER, IF ANY

None



13. Setoffs

List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days preceding the

commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both

spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR DATE OF SETOFF AMOUNT OF SETOFF

None



14. Property held for another person

List all property owned by another person that the debtor holds or controls.

NAME AND ADDRESS OF OWNER DESCRIPTION AND VALUE OF PROPERTY LOCATION OF PROPERTY

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15. Prior address of debtor

If the debtor has moved within three years immediately preceding the commencement of this case, list all premises which the debtor

occupied during that period and vacated prior to the commencement of this case. If a joint petition is filed, report also any separate

address of either spouse.

ADDRESS NAME USED DATES OF OCCUPANCY

None



16. Spouses and Former Spouses

If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho,

Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within eight years immediately preceding the

commencement of the case, identify the name of the debtor’s spouse and of any former spouse who resides or resided with the debtor in

the community property state.

NAME

17. Environmental Information.

For the purpose of this question, the following definitions apply:

"Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous

or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to,

statutes or regulations regulating the cleanup of these substances, wastes, or material.

"Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or

operated by the debtor, including, but not limited to, disposal sites.

"Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material,

pollutant, or contaminant or similar term under an Environmental Law

None



a. List the name and address of every site for which the debtor has received notice in writing by a governmental unit that it may be liable

or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known,

the Environmental Law:

SITE NAME AND ADDRESS

NAME AND ADDRESS OF

GOVERNMENTAL UNIT

DATE OF

NOTICE

ENVIRONMENTAL

LAW

None



b. List the name and address of every site for which the debtor provided notice to a governmental unit of a release of Hazardous

Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

SITE NAME AND ADDRESS

NAME AND ADDRESS OF

GOVERNMENTAL UNIT

DATE OF

NOTICE

ENVIRONMENTAL

LAW

None



c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which

the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the

docket number.

NAME AND ADDRESS OF

GOVERNMENTAL UNIT DOCKET NUMBER STATUS OR DISPOSITION

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18 . Nature, location and name of business

a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and

ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partner in a

partnership, sole proprietor, or was self-employed in a trade, profession, or other activity either full- or part-time within six years

immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities

within six years immediately preceding the commencement of this case.

If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and

ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within six

years immediately preceding the commencement of this case.

If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and

ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within six

years immediately preceding the commencement of this case.

NAME

LAST FOUR DIGITS OF

SOCIAL-SECURITY OR

OTHER INDIVIDUAL

TAXPAYER-I.D. NO.

(ITIN)/ COMPLETE EIN ADDRESS NATURE OF BUSINESS

BEGINNING AND

ENDING DATES

n/a 5955 Babysitting 1996 - present

None



b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C. § 101.

NAME ADDRESS

The following questions are to be completed by every debtor that is a corporation or partnership and by any individual debtor who is or has

been, within six years immediately preceding the commencement of this case, any of the following: an officer, director, managing executive, or

owner of more than 5 percent of the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership, a sole

proprietor, or self-employed in a trade, profession, or other activity, either full- or part-time.

(An individual or joint debtor should complete this portion of the statement only if the debtor is or has been in business, as defined above,

within six years immediately preceding the commencement of this case. A debtor who has not been in business within those six years should go

directly to the signature page.)

None



19. Books, records and financial statements

a. List all bookkeepers and accountants who within two years immediately preceding the filing of this bankruptcy case kept or

supervised the keeping of books of account and records of the debtor.

NAME AND ADDRESS DATES SERVICES RENDERED

None



b. List all firms or individuals who within the two years immediately preceding the filing of this bankruptcy case have audited the books

of account and records, or prepared a financial statement of the debtor.

NAME ADDRESS DATES SERVICES RENDERED

None



c. List all firms or individuals who at the time of the commencement of this case were in possession of the books of account and records

of the debtor. If any of the books of account and records are not available, explain.

NAME ADDRESS

None



d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was

issued by the debtor within two years immediately preceding the commencement of this case.

NAME AND ADDRESS DATE ISSUED

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20. Inventories

a. List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory,

and the dollar amount and basis of each inventory.

DATE OF INVENTORY INVENTORY SUPERVISOR

DOLLAR AMOUNT OF INVENTORY

(Specify cost, market or other basis)

None



b. List the name and address of the person having possession of the records of each of the inventories reported in a., above.

DATE OF INVENTORY

NAME AND ADDRESSES OF CUSTODIAN OF INVENTORY

RECORDS

None



21 . Current Partners, Officers, Directors and Shareholders

a. If the debtor is a partnership, list the nature and percentage of partnership interest of each member of the partnership.

NAME AND ADDRESS NATURE OF INTEREST PERCENTAGE OF INTEREST

None



b. If the debtor is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns,

controls, or holds 5 percent or more of the voting or equity securities of the corporation.

NAME AND ADDRESS TITLE

NATURE AND PERCENTAGE

OF STOCK OWNERSHIP

None



22 . Former partners, officers, directors and shareholders

a. If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately preceding the

commencement of this case.

NAME ADDRESS DATE OF WITHDRAWAL

None



b. If the debtor is a corporation, list all officers, or directors whose relationship with the corporation terminated within one year

immediately preceding the commencement of this case.

NAME AND ADDRESS TITLE DATE OF TERMINATION

None



23 . Withdrawals from a partnership or distributions by a corporation

If the debtor is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation

in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the

commencement of this case.

NAME & ADDRESS

OF RECIPIENT,

RELATIONSHIP TO DEBTOR

DATE AND PURPOSE

OF WITHDRAWAL

AMOUNT OF MONEY

OR DESCRIPTION AND

VALUE OF PROPERTY

None



24. Tax Consolidation Group.

If the debtor is a corporation, list the name and federal taxpayer identification number of the parent corporation of any consolidated

group for tax purposes of which the debtor has been a member at any time within six years immediately preceding the commencement

of the case.

NAME OF PARENT CORPORATION TAXPAYER IDENTIFICATION NUMBER (EIN)

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25. Pension Funds.

If the debtor is not an individual, list the name and federal taxpayer-identification number of any pension fund to which the debtor, as an

employer, has been responsible for contributing at any time within six years immediately preceding the commencement of the case.

NAME OF PENSION FUND TAXPAYER IDENTIFICATION NUMBER (EIN)

* * * * * *

DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR

I declare under penalty of perjury that I have read the answers contained in the foregoing statement of financial affairs and any attachments thereto

and that they are true and correct.

Date September 24, 2015 Signature /s/ Mossammat R. Khatun

Mossammat R. Khatun

Debtor

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571

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Form B203 2014 USBC, Eastern District of Virginia

United States Bankruptcy Court

Eastern District of Virginia

In re Mossammat R. Khatun Case No. 15-13148

Debtor(s) Chapter 13

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

1. Pursuant to 11 U.S.C. § 329(a) and Bankruptcy Rule 2016(b), I certify that I am the attorney for the above-named debtor(s) and that

compensation paid to me, for services rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the

bankruptcy case is as follows:

For legal services, I have agreed to accept $ 5,000.00

Prior to the filing of this statement I have received $ 3,690.00

Balance Due $ 1,310.00

2. $ 310.00 of the filing fee has been paid.

3. The source of the compensation paid to me was:

 Debtor  Other (specify)

4. The source of compensation to be paid to me is:

 Debtor  Other (specify)

5.  I have not agreed to share the above-disclosed compensation with any other person unless they are members and associates of my law firm.

 I have agreed to share the above-disclosed compensation with a person or persons who are not members or associates of my law firm. A

copy of the agreement, together with a list of the names of the people sharing in the compensation, is attached.

6. In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy case, including:

a. Analysis of the debtor's financial situation, and rendering advice to the debtor in determining whether to file a petition in bankruptcy;

b. Preparation and filing of any petition, schedules, statement of affairs and plan which may be required;

c. Representation of the debtor at the meeting of creditors and confirmation hearing, and any adjourned hearings thereof;

d. Other provisions as needed:

In Chapter 7 cases, all additional work performed, i.e. amendments, adversary proceedings, and reaffirmation

agreements, will be billed at the hourly rate of $300.00, plus $60/hr for paralegal plus costs & expenses.

In Chapter 11 and 13 cases, attorney fee is not a fixed fee; all work performed will be billed at the hourly rate of

$300.00 plus $60/hr for paralegal plus costs & expenses.

7. By agreement with the debtor(s), the above-disclosed fee does not include the following services:

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Form B203 2014 USBC, Eastern District of Virginia

CERTIFICATION

I certify that the foregoing is a complete statement of any agreement or arrangement for payment to me for representation of the debtor(s) in

this bankruptcy proceeding.

September 24, 2015 /s/ Januario G. Azarcon

Date Januario G. Azarcon 22810

Signature of Attorney

Sawyer & Azarcon, P.C.

Name of Law Firm

10605 B2 Judicial Drive

Fairfax, VA 22030

(703) 893 0760 Fax: (703) 273 9886

For use in Chapter 13 Cases where Fees Requested Not in Excess of $5,000

(For all Cases Filed on or after 8/1/2014)

NOTICE TO DEBTOR(S), STANDING CHAPTER 13 TRUSTEE AND UNITED

STATES TRUSTEE

PURSUANT TO LOCAL BANKRUPTCY RULE 2016-1(C) AND

CLERK’S CM/ECF POLICY 9

Notice is hereby given that pursuant to Local Bankruptcy Rule 2016-1(C), you must file an objection with the court to the fees requested

in this disclosure of compensation opposing said fees in their entirety, or in a specific amount, no later than the last day for filing objections to

confirmation of the chapter 13 plan.

PROOF OF SERVICE

The undersigned hereby certifies that on this date the foregoing Notice was served upon the debtor(s), the standing Chapter 13 trustee,

and U. S. trustee pursuant to Local Bankruptcy Rule 2016-1(C) and the Clerk’s CM/ECF Policy 9, either electronically or in paper form (first class

mail).

September 24, 2015 /s/ Januario G. Azarcon

Date Januario G. Azarcon 22810

Signature of Attorney

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Fill in this information to identify your case: Check as directed in lines 17 and 21:

According to the calculations required by this

Statement:

 1. Disposable income is not determined under

11 U.S.C. § 1325(b)(3).

 2. Disposable income is determined under 11

U.S.C. § 1325(b)(3).

 3. The commitment period is 3 years.

 4. The commitment period is 5 years.

Debtor 1 Mossammat R. Khatun

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: Eastern District of Virginia

Case number 15-13148

(if known)

 Check if this is an amended filing

Official Form 22C-1

Chapter 13 Statement of Your Current Monthly Income

and Calculation of Commitment Period 12/14

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more

space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any

additional pages, write your name and case number (if known).

Part 1: Calculate Your Average Monthly Income

1. What is your marital and filing status? Check one only.

 Not married. Fill out Column A, lines 2-11.

 Married. Fill out both Columns A and B, lines 2-11.

Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this bankruptcy

case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through August 31. If the amount

of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6. Fill in the result. Do not include any

income amount more than once. For example, if both spouses own the same rental property, put the income from that property in one column only.

If you have nothing to report for any line, write $0 in the space.

Column A

Debtor 1

Column B

Debtor 2 or

non-filing spouse

2. Your gross wages, salary, tips, bonuses, overtime, and commissions (before

all payroll deductions). $ 0.00 $ 0.00

3. Alimony and maintenance payments. Do not include payments from a spouse if

Column B is filled in. $ 0.00 $ 0.00

4. All amounts from any source which are regularly paid for household expenses

of you or your dependents, including child support. Include regular contributions

from an unmarried partner, members of your household, your dependents, parents,

and roommates. Include regular contributions from a spouse only if Column B is not

filled in. Do not include payments you listed on line 3.

$ 0.00 $ 0.00

5. Net income from operating a business, profession, or farm

Gross receipts (before all deductions) $ 1,250.00

Ordinary and necessary operating expenses -$ 0.00

Net monthly income from a business,

profession, or farm $ 1,250.00

Copy

here -> $ 1,250.00 $ 0.00

6. Net income from rental and other real property

Gross receipts (before all deductions) $ 0.00

Ordinary and necessary operating expenses -$ 0.00

Net monthly income from rental or other real property $ 0.00 Copy here -> $ 0.00 $ 0.00

Official Form 22C-1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 1

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Debtor 1 Mossammat R. Khatun Case number (if known) 15-13148

Column A

Debtor 1

Column B

Debtor 2 or

non-filing spouse

7. Interest, dividends, and royalties $ 0.00 $ 0.00

8. Unemployment compensation $ 0.00 $ 0.00

Do not enter the amount if you contend that the amount received was a benefit

under the Social Security Act. Instead, list it here:

For you $ 0.00

For your spouse $ 0.00

9. Pension or retirement income. Do not include any amount received that was a

benefit under the Social Security Act. $ 0.00 $ 0.00

10. Income from all other sources not listed above. Specify the source and amount.

Do not include any benefits received under the Social Security Act or payments

received as a victim of a war crime, a crime against humanity, or international or

domestic terrorism. If necessary, list other sources on a separate page and put the

total on line 10c.

10a. $ 0.00 $ 0.00

10b. $ 0.00 $ 0.00

10c. Total amounts from separate pages, if any. + $ 0.00 $ 0.00

11. Calculate your total average monthly income. Add lines 2 through 10 for

each column. Then add the total for Column A to the total for Column B. $ 1,250.00 + $ 0.00 = $ 1,250.00

Total average

monthly income

Part 2: Determine How to Measure Your Deductions from Income

12. Copy your total average monthly income from line 11. $ 1,250.00

13. Calculate the marital adjustment. Check one:

 You are not married. Fill in 0 on line 3d.

 You are married and your spouse is filing with you. Fill in 0 in line 13d.

 You are married and your spouse is not filing with you.

Fill in the amount of the income listed in line 11, Column B, that was NOT regularly paid for the household expenses of you or your

dependents, such as payment of the spouse's tax liability or the spouse's support of someone other than you or your dependents.

In lines 13a-c, specify the basis for excluding this income and the amount of income devoted to each purpose. If necessary, list additional

adjustments on a separate page.

If this adjustment does not apply, enter 0 on line 13d.

13a. $

13b. $

13c. +$

13d. Total $ 0.00 Copy here=> 13d. - 0.00

14. Your current monthly income. Subtract line 13d from line 12. 14. $ 1,250.00

15. Calculate your current monthly income for the year. Follow these steps:

15a. Copy line 14 here=> 15a. $

1,250.00

Multiply line 15a by 12 (the number of months in a year). x 12

15b. The result is your current monthly income for the year for this part of the form. 15b. $ 15,000.00

Official Form 22C-1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 2

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Debtor 1 Mossammat R. Khatun Case number (if known) 15-13148

16. Calculate the median family income that applies to you. Follow these steps:

16a. Fill in the state in which you live. VA

16b. Fill in the number of people in your household. 2

16c. Fill in the median family income for your state and size of household. 16c. $ 68,108.00

To find a list of applicable median income amounts, go online using the link specified in the separate

instructions for this form. This list may also be available at the bankruptcy clerk's office.

17. How do the lines compare?

17a.  Line 15b is less than or equal to line 16c. On the top of page 1 of this form, check box 1, Disposable income is not determined under

11 U.S.C. § 1325(b)(3). Go to Part 3. Do NOT fill out Calculation of Disposable Income (Official Form 22C-2).

17b.  Line 15b is more than line 16c. On the top of page 1 of this form, check box 2, Disposable income is determined under 11 U.S.C. §

1325(b)(3). Go to Part 3 and fill out Calculation of Disposable Income (Official Form 22C-2). On line 39 of that form, copy your

current monthly income from line 14 above.

Part 3: Calculate Your Commitment Period Under 11 U.S.C. §1325(b)(4)

18. Copy your total average monthly income from line 11 . 18. $ 1,250.00

19. Deduct the marital adjustment if it applies. If you are married, your spouse is not filing with you, and you

contend that calculating the commitment period under 11 U.S.C. § 1325(b)(4) allows you to deduct part of your

spouse's income, copy the amount from line 13d.

If the marital adjustment does not apply, fill in 0 on line 19a. 19a.-$ 0.00

Subtract line 19a from line 18. 19b. $ 1,250.00

20. Calculate your current monthly income for the year. Follow these steps:

20a. Copy line 19b 20a. $

1,250.00

Multiply by 12 (the number of months in a year). x 12

20b. The result is your current monthly income for the year for this part of the form 20b. $ 15,000.00

20c. Copy the median family income for your state and size of household from line 16c $ 68,108.00

21. How do the lines compare?

 Line 20b is less than line 20c. Unless otherwise ordered by the court, on the top of page 1 of this form, check box 3, The commitment

period is 3 years. Go to Part 4.

 Line 20b is more than or equal to line 20c. Unless otherwise ordered by the court, on the top of page 1 of this form, check box 4, The

commitment period is 5 years. Go to Part 4.

Part 4: Sign Below

By signing here, under penalty of perjury I declare that the information on this statement and in any attachments is true and correct.

X /s/ Mossammat R. Khatun

Mossammat R. Khatun

Signature of Debtor 1

Date September 24, 2015

MM / DD / YYYY

If you checked 17a, do NOT fill out or file Form 22C-2.

If you checked 17b, fill out Form 22C-2 and file it with this form. On line 39 of that form, copy your current monthly income from line 14 above.

Official Form 22C-1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 3

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Debtor 1 Mossammat R. Khatun Case number (if known) 15-13148

Current Monthly Income Details for the Debtor

Debtor Income Details:

Income for the Period 03/01/2015 to 08/31/2015.

Line 5 - Income from operation of a business, profession, or farm

Source of Income: Babysitting

Income/Expense/Net by Month:

Date Income Expense Net

6 Months Ago: 03/2015 $1,250.00 $0.00 $1,250.00

5 Months Ago: 04/2015 $1,250.00 $0.00 $1,250.00

4 Months Ago: 05/2015 $1,250.00 $0.00 $1,250.00

3 Months Ago: 06/2015 $1,250.00 $0.00 $1,250.00

2 Months Ago: 07/2015 $1,250.00 $0.00 $1,250.00

Last Month: 08/2015 $1,250.00 $0.00 $1,250.00

Average per month: $1,250.00 $0.00

Average Monthly NET Income: $1,250.00

Official Form 22C-1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 4

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Debtor 1 Mossammat R. Khatun Case number (if known) 15-13148

Current Monthly Income Details for the Debtor's Spouse

Spouse Income Details:

Income for the Period 03/01/2015 to 08/31/2015.

Non-CMI - Social Security Act Income

Source of Income: Social security

Constant income of $496.00 per month.

Official Form 22C-1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 5

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