B1 (Official Form 1) (04/13) 

UNITED STATES BANKRUPTCY COURT

__________ District of __________ VOLUNTARY PETITION 

Name of Debtor (if individual, enter Last, First, Middle): 

 

Name of Joint Debtor (Spouse) (Last, First, Middle): 

 

All Other Names used by the Debtor in the last 8 years 

(include married, maiden, and trade names): 

 

All Other Names used by the Joint Debtor in the last 8 years 

(include married, maiden, and trade names): 

 

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN)/Complete EIN 

(if more than one, state all): 

 

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN)/Complete EIN 

(if more than one, state all): 

 

Street Address of Debtor (No. and Street, City, and State): 

 

 

 

 ZIP CODE 

Street Address of Joint Debtor (No. and Street, City, and State): 

 

 

 

 ZIP CODE 

County of Residence or of the Principal Place of Business: 

 

County of Residence or of the Principal Place of Business: 

 

Mailing Address of Debtor (if different from street address): 

 

 

 

 ZIP CODE 

Mailing Address of Joint Debtor (if different from street address): 

 

 

 

 ZIP CODE 

Location of Principal Assets of Business Debtor (if different from street address above): 

 ZIP CODE 

Type of Debtor 

(Form of Organization) 

(Check one box.) 

 Individual (includes Joint Debtors) 

 See Exhibit D on page 2 of this form. 

 Corporation (includes LLC and LLP) 

 Partnership 

 Other (If debtor is not one of the above entities, check 

this box and state type of entity below.) 

Nature of Business 

(Check one box.) 

 Health Care Business 

 Single Asset Real Estate as defined in 

11 U.S.C. § 101(51B) 

 Railroad 

 Stockbroker 

 Commodity Broker 

 Clearing Bank 

 Other 

Chapter of Bankruptcy Code Under Which 

the Petition is Filed (Check one box.) 

Chapter 7 Chapter 15 Petition for 

 Chapter 9 Recognition of a Foreign 

 Chapter 11 Main Proceeding 

 Chapter 12 Chapter 15 Petition for 

 Chapter 13 Recognition of a Foreign 

 Nonmain Proceeding 

Chapter 15 Debtors 

Country of debtor’s center of main interests: 

Each country in which a foreign proceeding by, regarding, or 

against debtor is pending: 

Tax-Exempt Entity

(Check box, if applicable.) 

 Debtor is a tax-exempt organization 

 under title 26 of the United States 

 Code (the Internal Revenue Code). 

Nature of Debts 

(Check one box.) 

 Debts are primarily consumer Debts are 

 debts, defined in 11 U.S.C. primarily 

 § 101(8) as “incurred by an business debts. 

 individual primarily for a 

 personal, family, or 

 household purpose.” 

Filing Fee (Check one box.) 

 Full Filing Fee attached. 

 Filing Fee to be paid in installments (applicable to individuals only). Must attach 

signed application for the court’s consideration certifying that the debtor is 

unable to pay fee except in installments. Rule 1006(b). See Official Form 3A. 

 Filing Fee waiver requested (applicable to chapter 7 individuals only). Must 

attach signed application for the court’s consideration. See Official Form 3B. 

Chapter 11 Debtors 

Check one box: 

 Debtor is a small business debtor as defined in 11 U.S.C. § 101(51D). 

 Debtor is not a small business debtor as defined in 11 U.S.C. § 101(51D). 

Check if: 

 Debtor’s aggregate noncontingent liquidated debts (excluding debts owed to 

insiders or affiliates) are less than $2,490,925 (amount subject to adjustment 

on 4/01/16 and every three years thereafter).

 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 

Check all applicable boxes: 

 A plan is being filed with this petition. 

 Acceptances of the plan were solicited prepetition from one or more classes 

of creditors, in accordance with 11 U.S.C. § 1126(b).

Statistical/Administrative Information 

 Debtor estimates that funds will be available for distribution to unsecured creditors. 

 Debtor estimates that, after any exempt property is excluded and administrative expenses paid, there will be no funds available for 

distribution to unsecured creditors. 

THIS SPACE IS FOR 

COURT USE ONLY

Estimated Number of Creditors 

1-49 50-99 100-199 200-999 1,000-

5,000 

5,001-

10,000 

10,001-

25,000 

25,001-

50,000 

50,001-

100,000 

Over 

100,000 

Estimated Assets 

$0 to 

$50,000 

$50,001 to 

$100,000 

$100,001 to 

$500,000 

$500,001 

to $1 

million 

$1,000,001 

to $10 

million 

$10,000,001 

to $50 

million 

$50,000,001 

to $100 

million 

$100,000,001 

to $500 

million 

$500,000,001 

to $1 billion 

More than 

$1 billion 

Estimated Liabilities 

$0 to 

$50,000 

$50,001 to 

$100,000 

$100,001 to 

$500,000 

$500,001 

to $1 

million 

$1,000,001 

to $10 

million 

$10,000,001 

to $50 

million 

$50,000,001 

to $100 

million 

$100,000,001 

to $500 

million 

$500,000,001 

to $1 billion 

More than 

$1 billion 

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B1 (Official Form 1) (04/13) Page 2 

Voluntary Petition 

(This page must be completed and filed in every case.) 

Name of Debtor(s): 

 

 All Prior Bankruptcy Cases Filed Within Last 8 Years (If more than two, attach additional sheet.) 

Location 

Where Filed: 

Case Number: 

 

Date Filed: 

 

Location 

Where Filed: 

Case Number: 

 

Date Filed: 

 

Pending Bankruptcy Case Filed by any Spouse, Partner, or Affiliate of this Debtor (If more than one, attach additional sheet.) 

Name of Debtor: 

 

Case Number: 

 

Date Filed: 

 

District: 

 

Relationship: 

 

Judge: 

 

Exhibit A 

(To be completed if debtor is required to file periodic reports (e.g., forms 10K and 

10Q) with the Securities and Exchange Commission pursuant to Section 13 or 15(d) 

of the Securities Exchange Act of 1934 and is requesting relief under chapter 11.) 

 Exhibit A is attached and made a part of this petition. 

Exhibit B 

(To be completed if debtor is an individual 

whose debts are primarily consumer debts.) 

I, the attorney for the petitioner named in the foregoing petition, declare that I have 

informed the petitioner that [he or she] may proceed under chapter 7, 11, 12, or 13 

of title 11, United States Code, and have explained the relief available under each 

such chapter. I further certify that I have delivered to the debtor the notice required 

by 11 U.S.C. § 342(b). 

X 

Signature of Attorney for Debtor(s) (Date) 

Exhibit C

Does the debtor own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety? 

 Yes, and Exhibit C is attached and made a part of this petition. 

 No. 

Exhibit D

(To be completed by every individual debtor. If a joint petition is filed, each spouse must complete and attach a separate Exhibit D.) 

 Exhibit D, completed and signed by the debtor, is attached and made a part of this petition. 

If this is a joint petition: 

 Exhibit D, also completed and signed by the joint debtor, is attached and made a part of this petition.

Information Regarding the Debtor - Venue 

(Check any applicable box.) 

 Debtor has been domiciled or has had a residence, principal place of business, or principal assets in this District for 180 days immediately 

preceding the date of this petition or for a longer part of such 180 days than in any other District. 

 There is a bankruptcy case concerning debtor’s affiliate, general partner, or partnership pending in this District. 

 Debtor is a debtor in a foreign proceeding and has its principal place of business or principal assets in the United States in this District, or has 

no principal place of business or assets in the United States but is a defendant in an action or proceeding [in a federal or state court] in this 

District, or the interests of the parties will be served in regard to the relief sought in this District. 

Certification by a Debtor Who Resides as a Tenant of Residential Property 

(Check all applicable boxes.) 

 Landlord has a judgment against the debtor for possession of debtor’s residence. (If box checked, complete the following.) 

 

 (Name of landlord that obtained judgment) 

 

 (Address of landlord) 

 Debtor claims that under applicable nonbankruptcy law, there are circumstances under which the debtor would be permitted to cure the 

entire monetary default that gave rise to the judgment for possession, after the judgment for possession was entered, and 

 Debtor has included with this petition the deposit with the court of any rent that would become due during the 30-day period after the filing 

of the petition. 

 Debtor certifies that he/she has served the Landlord with this certification. (11 U.S.C. § 362(l)). 

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B1 (Official Form 1) (04/13) Page 3 

Voluntary Petition 

(This page must be completed and filed in every case.) 

Name of Debtor(s): 

Signatures 

Signature(s) of Debtor(s) (Individual/Joint) 

I declare under penalty of perjury that the information provided in this petition is true 

and correct. 

[If petitioner is an individual whose debts are primarily consumer debts and has 

chosen to file under chapter 7] I am aware that I may proceed under chapter 7, 11, 12 

or 13 of title 11, United States Code, understand the relief available under each such 

chapter, and choose to proceed under chapter 7. 

[If no attorney represents me and no bankruptcy petition preparer signs the petition] I 

have obtained and read the notice required by 11 U.S.C. § 342(b). 

I request relief in accordance with the chapter of title 11, United States Code, 

specified in this petition. 

X 

 Signature of Debtor 

X 

 Signature of Joint Debtor 

 

 Telephone Number (if not represented by attorney) 

 Date 

Signature of a Foreign Representative 

I declare under penalty of perjury that the information provided in this petition is true 

and correct, that I am the foreign representative of a debtor in a foreign proceeding, 

and that I am authorized to file this petition. 

(Check only one box.) 

 I request relief in accordance with chapter 15 of title 11, United States Code. 

 Certified copies of the documents required by 11 U.S.C. § 1515 are attached. 

 Pursuant to 11 U.S.C. § 1511, I request relief in accordance with the 

 chapter of title 11 specified in this petition. A certified copy of the 

 order granting recognition of the foreign main proceeding is attached. 

X 

 (Signature of Foreign Representative) 

 

 (Printed Name of Foreign Representative) 

 

 Date 

Signature of Attorney* 

X 

 Signature of Attorney for Debtor(s) 

 

 Printed Name of Attorney for Debtor(s) 

 Firm Name 

 

 

 Address 

 

 Telephone Number 

 

 Date 

*In a case in which § 707(b)(4)(D) applies, this signature also constitutes a 

certification that the attorney has no knowledge after an inquiry that the information 

in the schedules is incorrect. 

Signature of Non-Attorney Bankruptcy Petition Preparer 

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as 

defined in 11 U.S.C. § 110; (2) I prepared this document for compensation and have 

provided the debtor with a copy of this document and the notices and information 

required under 11 U.S.C. §§ 110(b), 110(h), and 342(b); and, (3) if rules or 

guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum 

fee for services chargeable by bankruptcy petition preparers, I have given the debtor 

notice of the maximum amount before preparing any document for filing for a debtor 

or accepting any fee from the debtor, as required in that section. Official Form 19 is 

attached. 

 

 Printed Name and title, if any, of Bankruptcy Petition Preparer 

 

 Social-Security number (If the bankruptcy petition preparer is not an individual, 

state the Social-Security number of the officer, principal, responsible person or 

partner of the bankruptcy petition preparer.) (Required by 11 U.S.C. § 110.) 

 

 Address 

 

X 

 Signature 

 

 Date 

Signature of bankruptcy petition preparer or officer, principal, responsible person, or 

partner whose Social-Security number is provided above. 

Names and Social-Security numbers of all other individuals who prepared or assisted 

in preparing this document unless the bankruptcy petition preparer is not an 

individual. 

If more than one person prepared this document, attach additional sheets conforming 

to the appropriate official form for each person. 

A bankruptcy petition preparer’s failure to comply with the provisions of title 11 and 

the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or 

both. 11 U.S.C. § 110; 18 U.S.C. § 156.

Signature of Debtor (Corporation/Partnership) 

I declare under penalty of perjury that the information provided in this petition is true 

and correct, and that I have been authorized to file this petition on behalf of the 

debtor. 

The debtor requests the relief in accordance with the chapter of title 11, United States 

Code, specified in this petition. 

X 

 Signature of Authorized Individual 

 

 Printed Name of Authorized Individual 

 Title of Authorized Individual 

 Date 

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