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B 1 (Adapted from Official Form 1) (04/13)

United States Bankruptcy Court

Eastern District of Virginia Voluntary Petition

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

Cliggott, Timothy E.

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

N/A

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

(include married, maiden, and trade names):

N/A

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

(include married, maiden, and trade names):

N/A

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

more than one state all):

-7433

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN) (if more than one

state all):

NA

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

12849 LeMaster Drive

Nokesville, VA Zip Code 20181

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

N/A

County of Residence or of the Principal Place of Business:

Prince William

County of Residence or of the Principal Place of Business:

N/A

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

N/A Zip Code 

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

N/A Zip Code 

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

N/A

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 04/01/2016 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.

Estimated Number of Creditors

1-49 50-99 100-199 200-299 1,000- 5,001 10,001- 25,001 50,001- Over

5,000 510,000 25,000 50,000 100,000 100,000

Estimated Assets

$0 to $50,001 to $100,001 to $500,001 $1,000,001 $10,000,001 $50,000,001 $100,000,001 $500,000,001 More than

$50,000 $100,000 $500,000 to $1 to $10 to $50 to $100 to $500 to $1 billion $1 billion

million million million million million

Estimated Liabilities

$0 to $50,001 to $100,001 to $500,001 $1,000,001 $10,000,001 $50,000,001 $100,000,001 $500,000,001 More than

$50,000 $100,000 $500,000 to $1 to $10 to $50 to $100 to $500 to $1 billion $1 billion

million million million million million

THIS SPACE

FOR COURT

USE ONLY

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B 1 (After Official Form 1) Page 2

Voluntary Petition

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

Name of Debtor(s):

Cliggott, Timothy

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

Location Where Filed:

N/A

Case Number: Date Filed:

Location Where Filed: Case Number: Date Filed:

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

Name of Debtor:

N/A

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).

/s/ Daniel Press 08/24/2015

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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B 1 (After Official Form 1) Page 3

Voluntary Petition

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

Name of Debtor(s):

Cliggott, Timothy

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.

/s/ Timothy E. Cliggott

Signature of Debtor

/s/

Signature of Joint Debtor

Telephone Number (if not represented by attorney)

08/24/2015

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.

/s/ 

Signature of Foreign Representative

Printed Name of Foreign Representative

Date

Signature of Attorney*

/s/ Daniel Press

Signature of Attorney for Debtor(s)

Daniel Press

Printed Name of Attorney for Debtor(s)

08/24/2015

Date

Firm Name: Chung & Press, PC

Address: 6718 Whittier Avenue, Suite 200

Mc Lean, VA 22101

Telephone: 7037343800

E-mail: dpress@chung-press.com

*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 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.

/s/ 

Signature of Authorized Individual

Printed Name of Authorized Individual

Title of Authorized Individual

Date

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

by that section.

This section of the signature page is not relevant to this Petition

because the BkAssist® software used to produce this petition is not

licensed for use by paid bankruptcy petition preparers.

If the bankruptcy petition preparer is not an individual, state the name,

title (if any), address, and social-security number of the officer,

principal, responsible person, or partner who signs this document.

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

signed 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. 18 U.S.C. § 156.

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B 1D (Adapted from Official Form 1, Exhibit D) (12/09)

United States Bankruptcy Court

Eastern District of Virginia

In re: Cliggott, Timothy Case No. 

EXHIBIT D - INDIVIDUAL DEBTOR’S STATEMENT OF

COMPLIANCE WITH CREDIT COUNSELING REQUIREMENT

Warning: You must be able to truthfully check one of the five statements regarding credit counseling. If you

cannot do so, you are not eligible to file a bankruptcy case, and the court can dismiss any case you do file. If

that happens, you will lose whatever filing fee you paid, and your creditors will be able to resume collection

activities against you. If your case is dismissed and you file another bankruptcy case later, you may be

required to pay a second filing fee and you may have to take extra steps to stop creditors’ collection activities.

Every individual debtor must file this Exhibit D. If a joint petition is filed, each spouse must complete and file a

separate Exhibit D. Attach any documents as directed.

1. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a credit

counseling agency approved by the United States trustee or bankruptcy administrator that outlined the

opportunities for available credit counseling and assisted me in performing a related budget analysis, and I

have a certificate from the agency describing the services provided to me. Attach a copy of the

certificate and a copy of any debt repayment plan developed through the agency.

2. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a credit

counseling agency approved by the United States trustee or bankruptcy administrator that outlined the

opportunities for available credit counseling and assisted me in performing a related budget analysis, but I

do not have a certificate from the agency describing the services provided to me. You must file a copy of

a certificate from the agency describing the services provided to you and a copy of any debt repayment

plan developed through the agency no later than 15 days after your bankruptcy case is filed.

3. I certify that I requested credit counseling services from an approved agency but was unable to obtain the

services during the five days from the time I made my request, and the following exigent circumstances

merit a temporary waiver of the credit counseling requirement so I can file my bankruptcy case now. 

[Summarize exigent circumstances here.]

If your certification is satisfactory to the court, you must still obtain the credit counseling

briefing within the first 30 days after you file your bankruptcy petition and promptly file a

certificate from the agency that provided the counseling, together with a copy of any debt

management plan developed through the agency. Failure to fulfill these requirements may result in

dismissal of your case. Any extension of the 30-day deadline can be granted only for cause and is

limited to a maximum of 15 days. Your case may also be dismissed if the court is not satisfied with

your reasons for filing your bankruptcy case without first receiving a credit counseling briefing.

4. I am not required to receive a credit counseling briefing because of: [Must be accompanied by a motion

for determination by the court.]

Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental illness or mental

deficiency so as to be incapable of realizing and making rational decisions with respect to financial

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responsibilities.)

Disability. (Defined in 11 U.S.C. § 109(h)(4) as physically impaired to the extent of being unable,

after reasonable effort, to participate in a credit counseling briefing in person, by telephone, or through

the Internet.)

Active military duty in a military combat zone.

5. The United States trustee or bankruptcy administrator has determined that the credit counseling

requirement of 11 U.S.C. § 109(h) does not apply in this district.

I certify under penalty of perjury that the information provided above is true and correct.

/s/ Timothy E. Cliggott 08/24/2015

Debtor Date

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United States Bankruptcy Court

Eastern District of Virginia

Alexandria Division

In re: Cliggott, Timothy Case No. 

COVER SHEET FOR LIST OF CREDITORS

I hereby certify under penalty of perjury that the master mailing list of creditors submitted

either on computer diskette or by a typed hard copy in scannable format, with Request for

Waiver attached, is a true, correct and complete listing to the best of my knowledge.

I further acknowledge that (1) the accuracy and completeness in preparing the creditor listing

are the shared responsibility of the debtor and the debtor's attorney, (2) the court will rely on

the creditor listing for all mailings, and (3) that the various schedules and statements required

by the Bankruptcy Rules are not used for mailing purposes.

Master mailing list of creditors submitted via:

(a) computer diskette listing a total of N/A creditors;

(b) scannable hard copy, with Request for Waiver attached, consisting of N/A

pages, listing a total of N/A creditors; or

(c) ASCII text file uploaded via CM/ECF, listing a total of 30 creditors

[Check if applicable] Creditor(s) with foreign addresses included on disk/hard copy.

/s/ Timothy E. Cliggott 08/24/2015

Debtor Date

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American Medical Collection Agency

4 Westchester Plz Ste 110

Elmsford, NY 10523-1615

Best Buy

PO Box 1802

Dayton, OH 45401-1802

Bill LeMaster & Diane L. LeMaster

12950 LeMaster Drive

Nokesville, VA 20181

Capital One Bank

PO Box 85015

Richmond, VA 23285-5015

Carrington Mortgage Services, LLC

599 W. Putnam Avenue

Greenwich, CT 06830

Chase Bankcard Svcs Inc

PO Box 30755

Tampa, FL 33630-3755

Chex System, Inc.

Attn: Consumer Relations

7805 Hudson Road, Suite 100

Saint Paul, MN 55125

ECMC

1 Imation Place, Building 2

Saint Paul, MN 55128-3422

Emerald AR Systems

1850 N Central Ave, #1010

Phoenix, AZ 85004

Equifax

P.O. Box 740241

Atlanta, GA 30374

Experian

PO Box 9701

Allen, TX 75013

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Fredericksburg Credit Bureau

10506 Wakeman Dr

Fredericksburg, VA 22407-8040

Georgetown Univ. Hosp.

PO Box 32233

Washington, DC 20007-0533

IC Systems Inc.

PO Box 64886

Saint Paul, MN 55164-0886

Internal Revenue Service

Centralized Insolvency Operation

Philadelphia, PA 19101-7346

JPMorgan Chase Bank

501 Bleeker Street

Utica, NY 13501

Law office of Mitchell Kitroser

631 US Highway 1 Suite 410

North Palm Beach, FL 33408

Mary Washington Hospital

1001 Sam Perry Boulevard

Fredericksburg, VA 22401

Medical Data Systems, Inc.

2001 9th Svenue, #312

Vero Beach, FL 32960

Medical Imaging of Fredericksburg

1300 Hospital Drive, #100

Fredericksburg, VA 22401

Natalie Corneuille

650 Potomac Avenue

Alexandria, VA 22301

Novant Health

8700 Sudley Road

Manassas, VA 20110

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Prince William County, Virginia

1 County Complex Court

Woodbridge, VA 22192

Receivables Management Systems

PO Box 8630

Richmond, VA 23226-0630

Receivables Outsourcing, LLC

1920 Greenspring Drive, #200

Lutherville Timonium, MD 21093

Robert Barlow

3516 Plank Rd Ste 104

Fredericksburg, VA 22407

TransUnion Consumer Solutions

PO Box 2000

Crum Lynne, PA 19022

USAA Savings Bank

PO Box 14050

Las Vegas, NV 89114-4050

Verizon

500 Technology Dr Ste 300

Saint Charles, MO 63304

Vintage Security

8220 Stayton Dr Ste A

Jessup, MD 20794

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FB 201A (Form 201A) (6/14)

UNITED STATES BANKRUPTCY COURT

NOTICE TO CONSUMER DEBTOR(S) UNDER §342(b) 

OF THE BANKRUPTCY CODE

In accordance with § 342(b) of the Bankruptcy Code, this notice to individuals with primarily consumer

debts: (1) Describes briefly the services available from credit counseling services; (2) Describes briefly the

purposes, benefits and costs of the four types of bankruptcy proceedings you may commence; and (3) Informs you

about bankruptcy crimes and notifies you that the Attorney General may examine all information you supply in

connection with a bankruptcy case. 

You are cautioned that bankruptcy law is complicated and not easily described. Thus, you may wish to seek

the advice of an attorney to learn of your rights and responsibilities should you decide to file a petition. Court

employees cannot give you legal advice. 

Notices from the bankruptcy court are sent to the mailing address you list on your bankruptcy petition. In

order to ensure that you receive information about events concerning your case, Bankruptcy Rule 4002 requires that

you notify the court of any changes in your address. If you are filing a joint case (a single bankruptcy case for two

individuals married to each other), and each spouse lists the same mailing address on the bankruptcy petition, you

and your spouse will generally receive a single copy of each notice mailed from the bankruptcy court in a jointlyaddressed envelope, unless you file a statement with the court requesting that each spouse receive a separate copy of

all notices. 

1. Services Available from Credit Counseling Agencies

With limited exceptions, § 109(h) of the Bankruptcy Code requires that all individual debtors who file

for bankruptcy relief on or after October 17, 2005, receive a briefing that outlines the available opportunities

for credit counseling and provides assistance in performing a budget analysis. The briefing must be given

within 180 days before the bankruptcy filing. The briefing may be provided individually or in a group (including

briefings conducted by telephone or on the Internet) and must be provided by a nonprofit budget and credit

counseling agency approved by the United States trustee or bankruptcy administrator. The clerk of the bankruptcy

court has a list that you may consult of the approved budget and credit counseling agencies. Each debtor in a joint

case must complete the briefing.

In addition, after filing a bankruptcy case, an individual debtor generally must complete a financial

management instructional course before he or she can receive a discharge. The clerk also has a list of approved

financial management instructional courses. Each debtor in a joint case must complete the course.

2. The Four Chapters of the Bankruptcy Code Available to Individual Consumer Debtors

Chapter 7: Liquidation ($245 filing fee, $75 administrative fee, $15 trustee surcharge: Total fee $335)

Chapter 7 is designed for debtors in financial difficulty who do not have the ability to pay their existing

debts. Debtors whose debts are primarily consumer debts are subject to a “means test” designed to determine

whether the case should be permitted to proceed under chapter 7. If your income is greater than the median income

for your state of residence and family size, in some cases, the United States trustee (or bankruptcy administrator), the

trustee, or creditors have the right to file a motion requesting that the court dismiss your case under § 707(b) of the

Code. It is up to the court to decide whether the case should be dismissed.

Under chapter 7, you may claim certain of your property as exempt under governing law. A trustee may have

the right to take possession of and sell the remaining property that is not exempt and use the sale proceeds to pay

your creditors.

The purpose of filing a chapter 7 case is to obtain a discharge of your existing debts. If, however, you are

found to have committed certain kinds of improper conduct described in the Bankruptcy Code, the court may deny

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Form B 201A, Notice to Consumer Debtor(s) Page 2

your discharge and, if it does, the purpose for which you filed the bankruptcy petition will be defeated.

Even if you receive a general discharge, some particular debts are not discharged under the law. Therefore,

you may still be responsible for most taxes and student loans; debts incurred to pay nondischargeable taxes; domestic

support and property settlement obligations; most fines, penalties, forfeitures, and criminal restitution obligations;

certain debts which are not properly listed in your bankruptcy papers; and debts for death or personal injury caused

by operating a motor vehicle, vessel, or aircraft while intoxicated from alcohol or drugs. Also, if a creditor can

prove that a debt arose from fraud, breach of fiduciary duty, or theft, or from a willful and malicious injury, the

bankruptcy court may determine that the debt is not discharged. 

Chapter 13: Repayment of All or Part of the Debts of an Individual with Regular Income ($235 filing

fee, $75 administrative fee: Total fee $310)

Chapter 13 is designed for individuals with regular income who would like to pay all or part of 

their debts in installments over a period of time. You are only eligible for chapter 13 if your debts do not exceed

certain dollar amounts set forth in the Bankruptcy Code.

Under chapter 13, you must file with the court a plan to repay your creditors all or part of the money that you

owe them, using your future earnings. The period allowed by the court to repay your debts may be three years or

five years, depending upon your income and other factors. The court must approve your plan before it can take

effect.

After completing the payments under your plan, your debts are generally discharged except for domestic

support obligations; most student loans; certain taxes; most criminal fines and restitution obligations; certain debts

which are not properly listed in your bankruptcy papers; certain debts for acts that caused death or personal injury;

and certain long term secured obligations.

Chapter 11: Reorganization ($1,167 filing fee, $550 administrative fee: Total fee $1,717)

Chapter 11 is designed for the reorganization of a business but is also available to consumer debtors. Its

provisions are quite complicated, and any decision by an individual to file a chapter 11 petition should be reviewed

with an attorney.

Chapter 12: Family Farmer or Fisherman ($200 filing fee, $75 administrative fee: Total fee $275)

Chapter 12 is designed to permit family farmers and fishermen to repay their debts over a period of time from

future earnings and is similar to chapter 13. The eligibility requirements are restrictive, limiting its use to those

whose income arises primarily from a family-owned farm or commercial fishing operation.

3. Bankruptcy Crimes and Availability of Bankruptcy Papers to Law Enforcement Officials

A person who knowingly and fraudulently conceals assets or makes a false oath or statement under penalty of

perjury, either orally or in writing, in connection with a bankruptcy case is subject to a fine, imprisonment, or both. 

All information supplied by a debtor in connection with a bankruptcy case is subject to examination by the Attorney

General acting through the Office of the United States Trustee, the Office of the United States Attorney, and other

components and employees of the Department of Justice.

WARNING: Section 521(a)(1) of the Bankruptcy Code requires that you promptly file detailed information regarding your

creditors, assets, liabilities, income, expenses and general financial condition. Your bankruptcy case may be dismissed if

this information is not filed with the court within the time deadlines set by the Bankruptcy Code, the Bankruptcy Rules, and

the local rules of the court. The documents and the deadlines for filing them are listed on Form B200, which is posted at

http://www.uscourts.gov/bkforms/bankruptcy_forms.html#procedure.

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B 201B (Form 201B) (12/09)

UNITED STATES BANKRUPTCY COURT

__________ District Of __________

In re ___________________________________ Case No. _______________

Debtor

Chapter ________________

CERTIFICATION OF NOTICE TO CONSUMER DEBTOR(S)

UNDER § 342(b) OF THE BANKRUPTCY CODE

Certification of [Non-Attorney] Bankruptcy Petition Preparer

I, the [non-attorney] bankruptcy petition preparer signing the debtor’s petition, hereby certify that I delivered to the debtor the

attached notice, as required by § 342(b) of the Bankruptcy Code.

_____________________________________________ _______________________________________

Printed name and title, if any, of Bankruptcy Petition Preparer Social Security number (If the bankruptcy petition

Address: preparer is not an individual, state the Social Security 

 number of the officer, principal, responsible person, or 

partner of the bankruptcy petition preparer.) (Required

X_______________________________________________ by 11 U.S.C. § 110.)

Signature of Bankruptcy Petition Preparer or officer,

principal, responsible person, or partner whose Social

Security number is provided above.

Certification of the Debtor

I (We), the debtor(s), affirm that I (we) have received and read the attached notice, as required by § 342(b) of the Bankruptcy

Code.

_________________________________________ X______________________________________________

Printed Name(s) of Debtor(s) Signature of Debtor Date

Case No. (if known) ________________________ X______________________________________________

Signature of Joint Debtor (if any) Date

___________________________________________________________________________________________________

Instructions: Attach a copy of Form B 201A, Notice to Consumer Debtor(s) Under § 342(b) of the Bankruptcy Code.

Use this form to certify that the debtor has received the notice required by 11 U.S.C. § 342(b) only if the certification has

NOT been made on the Voluntary Petition, Official Form B1. Exhibit B on page 2 of Form B1 contains a certification by the

debtor’s attorney that the attorney has given the notice to the debtor. The Declarations made by debtors and bankruptcy

petition preparers on page 3 of Form B1 also include this certification.

Eastern District of Virginia

Cliggott, Timothy

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N/A

Timothy E. Cliggott /s/ Timothy E. Cliggott 08/24/2015

Case 15-12929-BFK Doc 1 Filed 08/24/15 Entered 08/24/15 11:23:29 Desc Main

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