Official Form 106A/B Schedule A/B: Property page 1

Official Form 106A/B

Schedule A/B: Property 12/15

In each category, separately list and describe items. List an asset only once. If an asset fits in more than one category, list the asset in the 

category where you think it fits best. 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 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 Each Residence, Building, Land, or Other Real Estate You Own or Have an Interest In

1. Do you own or have any legal or equitable interest in any residence, building, land, or similar property?

No. Go to Part 2.

Yes. Where is the property?



1.1. _________________________________________

Street address, if available, or other description

_________________________________________

_________________________________________

City State ZIP Code 

_________________________________________

County

What is the property? Check all that apply.

Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$_______________

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

the entireties, or a life estate), if known. 

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

__________________________________________

Check if this is community property 

(see instructions)

Other information you wish to add about this item, such as local 

property identification number: _______________________________

If you own or have more than one, list here:

1.2. ________________________________________

Street address, if available, or other description

________________________________________

________________________________________

City State ZIP Code 

________________________________________

County

What is the property? Check all that apply.

Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$_________________

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

the entireties, or a life estate), if known. 

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

__________________________________________

Check if this is community property 

(see instructions)

Other information you wish to add about this item, such as local 

property identification number: _______________________________

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

Fill in this information to identify your case and this filing:

Check if this is an 

amended filing

Roland

16-32141

Edward Fairchild

X

Eastern District of Virginia

8616 Courthouse Road

aka 8606 Courthouse Road

Spotsylvania VA 22551

SPOTSYLVANIA

X

X

340,900.00 340,900.00

Fee Simple Ownership

8614 Courthouse Road

Spotsylvania VA 22551

SPOTSYLVANIA

X

X

122,200.00 122,200.00

Fee Simple Ownership

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 1 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 2

1.3. ________________________________________

Street address, if available, or other description

________________________________________

________________________________________

City State ZIP Code 

________________________________________

County

What is the property? Check all that apply.

Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$_________________

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

the entireties, or a life estate), if known. 

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

__________________________________________

Check if this is community property 

(see instructions)

Other information you wish to add about this item, such as local 

property identification number: _______________________________

2. Add the dollar value of the portion you own for all of your entries from Part 1, including any entries for pages 

you have attached for Part 1. Write that number here. ...................................................................................... $_________________

Part 2: Describe Your Vehicles 

Do you own, lease, or have legal or equitable interest in any vehicles, whether they are registered or not? Include any vehicles 

you own that someone else drives. If you lease a vehicle, also report it on Schedule G: Executory Contracts and Unexpired Leases.

3. Cars, vans, trucks, tractors, sport utility vehicles, motorcycles

No

Yes

3.1. Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

If you own or have more than one, describe here:

3.2. Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

Roland Edward Fairchild 16-32141

471,675.00

X

GMC

Pickup

2000

120000

2,825.00 2,825.00

X

Harley-D

Triglide

2013

25,465.00 25,465.00

X

8604 Courthouse Road

Spotsylvania VA 22551

SPOTSYLVANIA

X

X

34,300.00 8,575.00

Fee Simple Ownership

1/4 interest in inherited land

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 3

3.3. Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

3.4. Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

$________________

Current value of the 

portion you own?

$________________

4. Watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories 

Examples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle accessories

No

Yes

4.1. Make: ____________________

Model: ____________________

Year: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

If you own or have more than one, list here:

4.2. Make: ____________________

Model: ____________________

Year: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

5. Add the dollar value of the portion you own for all of your entries from Part 2, including any entries for pages 

you have attached for Part 2. Write that number here ............................................................................................................................ $_________________

Roland Edward Fairchild 16-32141

62,890.00

X

Chevrolet

Corvette

2009

70000

28,500.00 28,500.00

X

GMC

Yukon

2005

6,100.00 6,100.00

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 4

Part 3: Describe Your Personal and Household Items 

Do you own or have any legal or equitable interest in any of the following items? Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

6. Household goods and furnishings

Examples: Major appliances, furniture, linens, china, kitchenware

No

Yes. Describe......... $___________________

7. Electronics

Examples: Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music 

collections; electronic devices including cell phones, cameras, media players, games

No

Yes. Describe.......... $___________________

8. Collectibles of value

Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects; 

stamp, coin, or baseball card collections; other collections, memorabilia, collectibles

No

Yes. Describe.......... $___________________

9. Equipment for sports and hobbies

Examples: Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes

and kayaks; carpentry tools; musical instruments

No

Yes. Describe.......... $___________________

10.Firearms 

Examples: Pistols, rifles, shotguns, ammunition, and related equipment

No

Yes. Describe.......... $___________________

11. Clothes

Examples: Everyday clothes, furs, leather coats, designer wear, shoes, accessories

No

Yes. Describe.......... $___________________

12. Jewelry

Examples: Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems, 

gold, silver

No

Yes. Describe.......... $___________________

13. Non-farm animals

Examples: Dogs, cats, birds, horses

No

Yes. Describe.......... $___________________

14. Any other personal and household items you did not already list, including any health aids you did not list

No 

Yes. Give specific 

information............... $___________________

15. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached 

for Part 3. Write that number here ........................................................................................................................................................ $______________________

985.00

Roland Edward Fairchild 16-32141

Personal clothing 400.00

1,385.00

X

X

X

X

X

X

X

X

X

TV - 25; Sofa - 150; Kitchen table w/ 2 chairs - 60; Refrigerator - 150; Stove -

100; Chair - 150; 2 bedrooms - 350

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 4 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 5

Part 4: Describe Your Financial Assets

Do you own or have any legal or equitable interest in any of the following? Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

16. Cash

Examples: Money you have in your wallet, in your home, in a safe deposit box, and on hand when you file your petition

No

Yes..................................................................................................................................................................... Cash: ....................... $__________________

17. Deposits of money

Examples: Checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerage houses, 

and other similar institutions. If you have multiple accounts with the same institution, list each.

No

Yes..................... Institution name:

17.1. Checking account: _________________________________________________________

17.2. Checking account: _________________________________________________________

17.3. Savings account: _________________________________________________________

17.4. Savings account: _________________________________________________________

17.5. Certificates of deposit: _________________________________________________________

17.6. Other financial account: _________________________________________________________

17.7. Other financial account: _________________________________________________________

17.8. Other financial account: _________________________________________________________

17.9. Other financial account: _________________________________________________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

18. Bonds, mutual funds, or publicly traded stocks

Examples: Bond funds, investment accounts with brokerage firms, money market accounts

No

Yes.................. Institution or issuer name:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

$__________________

$__________________

$__________________

19. Non-publicly traded stock and interests in incorporated and unincorporated businesses, including an interest in 

an LLC, partnership, and joint venture

No 

Yes. Give specific 

information about

them. ........................

Name of entity: % of ownership:

_____________________________________________________________________ ___________%

_____________________________________________________________________ ___________%

_____________________________________________________________________ ___________%

$__________________

$__________________

$__________________

Roland Edward Fairchild 16-32141

X

X

X

X

SunTrust Ckg #3646 4.00

Carter Bank Ckg #0706 1,500.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 6

20. Government and corporate bonds and other negotiable and non-negotiable instruments

Negotiable instruments include personal checks, cashiers’ checks, promissory notes, and money orders. 

Non-negotiable instruments are those you cannot transfer to someone by signing or delivering them.

No 

Yes. Give specific 

information about

them. ......................

Issuer name: 

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

$__________________

$__________________

$__________________

21. Retirement or pension accounts

Examples: Interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sharing plans

No

Yes. List each 

account separately.. Type of account: Institution name:

401(k) or similar plan: ___________________________________________________________________

Pension plan: ___________________________________________________________________

IRA: ___________________________________________________________________

Retirement account: ___________________________________________________________________

Keogh: ___________________________________________________________________

Additional account: ___________________________________________________________________

Additional account: ___________________________________________________________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

22.Security deposits and prepayments

Your share of all unused deposits you have made so that you may continue service or use from a company

Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications 

companies, or others

No

Yes........................... Institution name or individual:

Electric: ______________________________________________________________________

Gas: ______________________________________________________________________

Heating oil: ______________________________________________________________________

Security deposit on rental unit: _____________________________________________________________

Prepaid rent: ______________________________________________________________________

Telephone: ______________________________________________________________________

Water: ______________________________________________________________________

Rented furniture: ______________________________________________________________________

Other: ______________________________________________________________________

$___________________

$___________________

$___________________

$___________________

$___________________

$___________________

$___________________

$___________________

$___________________

23. Annuities (A contract for a periodic payment of money to you, either for life or for a number of years)

No

Yes........................... Issuer name and description:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

$__________________

$__________________

$__________________

Roland Edward Fairchild 16-32141

X

X

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 6 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 7

24. Interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program.

26 U.S.C. §§ 530(b)(1), 529A(b), and 529(b)(1).

No

Yes ..................................... Institution name and description. Separately file the records of any interests.11 U.S.C. § 521(c):

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

$_________________

$_________________

$_________________

25.Trusts, equitable or future interests in property (other than anything listed in line 1), and rights or powers 

exercisable for your benefit

No

Yes. Give specific 

information about them. .. $__________________

26. Patents, copyrights, trademarks, trade secrets, and other intellectual property

Examples: Internet domain names, websites, proceeds from royalties and licensing agreements

No

Yes. Give specific 

information about them. .. $__________________

27. Licenses, franchises, and other general intangibles

Examples: Building permits, exclusive licenses, cooperative association holdings, liquor licenses, professional licenses

No

Yes. Give specific 

information about them. .. $__________________

Money or property owed to you? Current value of the 

portion you own?

Do not deduct secured 

claims or exemptions.

28.Tax refunds owed to you

No

Yes. Give specific information 

about them, including whether 

you already filed the returns 

and the tax years. ......................

Federal: $_________________

State: $_________________

Local: $_________________

29. Family support

Examples: Past due or lump sum alimony, spousal support, child support, maintenance, divorce settlement, property settlement

No

Yes. Give specific information. .............

Alimony:

Maintenance:

Support:

Divorce settlement:

Property settlement: 

$________________

$________________

$________________

$________________

$________________

30. Other amounts someone owes you

Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compensation, 

Social Security benefits; unpaid loans you made to someone else

No

Yes. Give specific information. ...............

$______________________

Roland Edward Fairchild 16-32141

X

X

X

X

X

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 7 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 8

31. Interests in insurance policies 

Examples: Health, disability, or life insurance; health savings account (HSA); credit, homeowner’s, or renter’s insurance

No

Yes. Name the insurance company 

of each policy and list its value. ... Company name: Beneficiary:

___________________________________________ ____________________________

___________________________________________ ____________________________

___________________________________________ ____________________________

Surrender or refund value:

$__________________

$__________________

$__________________

32. Any interest in property that is due you from someone who has died

If you are the beneficiary of a living trust, expect proceeds from a life insurance policy, or are currently entitled to receive 

property because someone has died.

No

Yes. Give specific information. .............

$_____________________

33. Claims against third parties, whether or not you have filed a lawsuit or made a demand for payment 

Examples: Accidents, employment disputes, insurance claims, or rights to sue

No

Yes. Describe each claim......................

$______________________

34.Other contingent and unliquidated claims of every nature, including counterclaims of the debtor and rights 

to set off claims

No

Yes. Describe each claim......................

$_____________________

35. Any financial assets you did not already list

No 

Yes. Give specific information............ $_____________________

36. Add the dollar value of all of your entries from Part 4, including any entries for pages you have attached 

for Part 4. Write that number here ........................................................................................................................................................ $_____________________

Part 5: Describe Any Business-Related Property You Own or Have an Interest In. List any real estate in Part 1. 

37. Do you own or have any legal or equitable interest in any business-related property? 

No. Go to Part 6.

Yes. Go to line 38.

Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

38. Accounts receivable or commissions you already earned

No

Yes. Describe.......

$_____________________

39. Office equipment, furnishings, and supplies

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, electronic devices

No

Yes. Describe....... $_____________________

Roland Edward Fairchild 16-32141

1,504.00

X

X

X

X

X

X

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 8 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 9

40. Machinery, fixtures, equipment, supplies you use in business, and tools of your trade

No

Yes. Describe....... $_____________________

41. Inventory

No

Yes. Describe....... $_____________________

42. Interests in partnerships or joint ventures 

No

Yes. Describe....... Name of entity: % of ownership:

______________________________________________________________________ ________%

______________________________________________________________________ ________%

______________________________________________________________________ ________%

$_____________________

$_____________________

$_____________________

43. Customer lists, mailing lists, or other compilations 

No

Yes. Do your lists include personally identifiable information (as defined in 11 U.S.C. § 101(41A))?

No

Yes. Describe.........

$____________________

44. Any business-related property you did not already list

No

Yes. Give specific 

information ......... ______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

45. Add the dollar value of all of your entries from Part 5, including any entries for pages you have attached 

for Part 5. Write that number here ........................................................................................................................................................ $____________________

Part 6: Describe Any Farm- and Commercial Fishing-Related Property You Own or Have an Interest In.

If you own or have an interest in farmland, list it in Part 1.

46. Do you own or have any legal or equitable interest in any farm- or commercial fishing-related property?

No. Go to Part 7.

Yes. Go to line 47.

Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

47. Farm animals

Examples: Livestock, poultry, farm-raised fish

No

Yes...........................

$___________________

Roland Edward Fairchild 16-32141

2002 Ford Dump Truck (19,000); 2004 Chevrolet Dump Truck (15,000); 1963 Ford

Tractor with backhoe and front-end bucket (1000) 35,000.00

35,000.00

X

X

X

X

X

X

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 9 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106A/B Schedule A/B: Property page 10

48. Crops—either growing or harvested

No 

Yes. Give specific 

information. ............ $___________________

49.Farm and fishing equipment, implements, machinery, fixtures, and tools of trade

No

Yes...........................

$___________________

50.Farm and fishing supplies, chemicals, and feed

No

Yes...........................

$___________________

51. Any farm- and commercial fishing-related property you did not already list

No 

Yes. Give specific 

information. ............ $___________________

52. Add the dollar value of all of your entries from Part 6, including any entries for pages you have attached 

for Part 6. Write that number here ........................................................................................................................................................ $___________________

Part 7: Describe All Property You Own or Have an Interest in That You Did Not List Above 

53. Do you have other property of any kind you did not already list?

Examples: Season tickets, country club membership

No 

Yes. Give specific 

information. ............

$________________

$________________

$________________

54. Add the dollar value of all of your entries from Part 7. Write that number here ................................................................... $________________

Part 8: List the Totals of Each Part of this Form 

55.Part 1: Total real estate, line 2.................................................................................................................................................................... $________________

56.Part 2: Total vehicles, line 5 $________________

57.Part 3: Total personal and household items, line 15 $________________

58.Part 4: Total financial assets, line 36 $________________

59.Part 5: Total business-related property, line 45 $________________

60.Part 6: Total farm- and fishing-related property, line 52 $________________

61.Part 7: Total other property not listed, line 54 + $________________

62.Total personal property. Add lines 56 through 61. ................... $________________ Copy personal property total  + $_________________

63.Total of all property on Schedule A/B. Add line 55 + line 62........................................................................................ $_________________

Roland Edward Fairchild 16-32141

0.00

471,675.00

62,890.00

1,385.00

1,504.00

35,000.00

0.00

0.00

100,779.00 100,779.00

572,454.00

X

X

X

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 10 of 60
Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __ 

	
 106C 

Schedule C: The Property You Claim as Exempt 

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

Using the property you listed on Schedule A/B: Property (Official Form 106A/B) as your source, list the property that you claim as exempt. If more 

space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On the top of any additional pages, write 

your name and case number (if known). 

For each item of property you claim as exempt, you must specify the amount of the exemption you claim. One way of doing so is to state a 

specific dollar amount as exempt. Alternatively, you may claim the full fair market value of the property being exempted up to the amount 

of any applicable statutory limit. Some exemptions—such as those for health aids, rights to receive certain benefits, and tax-exempt 

retirement funds—may be unlimited in dollar amount. However, if you claim an exemption of 100% of fair market value under a law that 

limits the exemption to a particular dollar amount and the value of the property is determined to exceed that amount, your exemption 

would be limited to the applicable statutory amount. 

Part 1: Identify the Property You Claim as Exempt

1. Which set of exemptions are you claiming? Check one only, even if your spouse is filing with you.

You are claiming state and federal nonbankruptcy exemptions. 11 U.S.C. § 522(b)(3)

You are claiming federal exemptions. 11 U.S.C. § 522(b)(2)

2. For any property you list on Schedule A/B that you claim as exempt, fill in the information below.

Brief description of the property and line on 

Schedule A/B that lists this property 

Current value of the 

portion you own 

Copy the value from 

Schedule A/B

Amount of the exemption you claim 

Check only one box for each exemption. 

Specific laws that allow exemption

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description: _________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ Line from 

Schedule A/B: ______ 

3. Are you claiming a homestead exemption of more than $175?

(Subject to adjustment on 4/01/1
 and every 3 years after that for cases filed on or after the date of adjustment.)

No

Yes. Did you acquire the property covered by the exemption within 1,215 days before you filed this case?

No

Yes

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of __________

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

Check if this is an

amended filing

_

Eastern District of Virginia ___________________________________

16-32141

X

Roland Edward Fairchild

2000 GMC Pickup

3.2

2,825.00 X 2,825.00 CV § 34-26(8)

Carter Bank Ckg #0706

17.1

1,500.00 X 1.00 CV § 34-4, 34-13

Household goods

6

985.00 X 985.00 CV § 34-26(4a)

2

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 11 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	
 Schedule C: The Property You Claim as Exempt page ___ of __

Part 2: Additional Page

Brief description of the property and line 

on Schedule A/B that lists this property 

Current value of the 

portion you own 

Copy the value from 

Schedule A/B

Amount of the exemption you claim 

Check only one box for each exemption

Specific laws that allow exemption

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Personal clothing

11

400.00 X 400.00

CV § 34-26(4)

2002 Ford Dump Truck

40

19,000.00 X 1.00 CV §§ 34-4, 34-13

2004 Chevy Dump Truck

40

15,000.00 X 9,001.00 CV § 34-26(7)

CV § 34-4, 34-13

1963 Ford Tractor

40

1,000.00 X 1,000.00 CV § 34-26(7)

2005 GMC Yukon

3.3

6,100.00 X 2,374.13 CV § 34-26(8)

Roland Edward Fairchild 16-32141

2 2

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 12 of 60
Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___

Official Form 106D

Schedule D: Creditors Who Have Claims Secured by Property 12/15

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, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any 

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

1. Do any creditors have claims secured by your property?

No. Check this box and submit this form to the court with your other schedules. You have nothing else to report on this form.

Yes. Fill in all of the information below.

Part 1: List All Secured Claims 

2. List all secured claims. If a creditor has more than one secured claim, list the creditor separately 

for each claim. If more than one creditor has a particular claim, list the other creditors in Part 2.

As much as possible, list the claims in alphabetical order according to the creditor’s name.

Column A

Amount of claim

Do not deduct the 

value of collateral.

Column B

Value of collateral

that supports this 

claim

Column C

Unsecured 

portion

If any

2.1

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

Statutory lien (such as tax lien, mechanic’s lien)

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim relates to a 

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

2.2

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

Statutory lien (such as tax lien, mechanic’s lien)

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim relates to a 

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here: $_________________

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is an 

amended filing

Roland Edward Fairchild

Eastern District of Virginia

16-32141

X

70,185.68

4

BB&T Mortgage

P.O. Box 2027

Greenville SC 29602

X

08/08/2006

8616 Courthouse Road

X

7434

50,960.85 340,900.00 50,960.85

FIA Card Services

P.O. Box 982235

El Paso TX 79998

X

06/11/2014

8614 Courthouse Road

X

1610

19,224.83 122,200.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 13 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___

Part 1: 

Additional Page 

After listing any entries on this page, number them beginning with 2.3, followed 

by 2.4, and so forth.

Column A

Amount of claim

Do not deduct the 

value of collateral.

Column B

Value of collateral 

that supports this 

claim

Column C

Unsecured 

portion

If any

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

Statutory lien (such as tax lien, mechanic’s lien)

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim relates to a 

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

Statutory lien (such as tax lien, mechanic’s lien)

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim relates to a 

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

Statutory lien (such as tax lien, mechanic’s lien)

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim relates to a 

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here: $_________________

If this is the last page of your form, add the dollar value totals from all pages. 

Write that number here: $_________________

Roland Edward Fairchild 16-32141

2 4

464,292.64

2.3

2.4

2.5

Harley Davidson Credit

PO Box 21850

Carson City NV 89721

X

05/31/2013

2013 H-D Triglide

X

4915

29,928.04 25,465.00 4,463.04

Santander Consumer USA

Attn: Bankruptcy Dept.

P.O Box 560284

Dallas TX 75356

X

07/2014

2009 Chevrolet Corvette

X

4495

35,907.80 28,500.00 7,407.80

Seterus

P.O. Box 1077

Hartford CT 06143

X

03/30/2006

8616 Courthouse Road

X

4213

398,456.80 340,900.00 57,556.80

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 14 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___

Part 1: 

Additional Page 

After listing any entries on this page, number them beginning with 2.3, followed 

by 2.4, and so forth.

Column A

Amount of claim

Do not deduct the 

value of collateral.

Column B

Value of collateral 

that supports this 

claim

Column C

Unsecured 

portion

If any

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

Statutory lien (such as tax lien, mechanic’s lien)

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim relates to a 

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

Statutory lien (such as tax lien, mechanic’s lien)

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim relates to a 

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

Statutory lien (such as tax lien, mechanic’s lien)

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim relates to a 

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here: $_________________

If this is the last page of your form, add the dollar value totals from all pages. 

Write that number here: $_________________

Roland Edward Fairchild 16-32141

3 4

8,535.61

543,013.93

2.6

2.7

2.8

Titlemax

5203 Jefferson Davis Highway

Fredericksburg VA 22408

X

10/02/2014

2005 GMC Yukon

X

2192

3,725.87 6,100.00

Union Bank & Trust

successor to StellarOne

P.O. Box 940

Ruther Glen VA 22546

X

02/25/2009

8614 Courthouse Road

X

3346

4,809.74 122,200.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 15 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106D Part 2 of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___

Part 2: List Others to Be Notified for a Debt That You Already Listed 

Use this page only if you have others to be notified about your bankruptcy for a debt that you already listed in Part 1. For example, if a collection 

agency is trying to collect from you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection agency here. Similarly, if 

you have more than one creditor for any of the debts that you listed in Part 1, list the additional creditors here. If you do not have additional persons to 

be notified for any debts in Part 1, do not fill out or submit this page. 

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

Roland Edward Fairchild 16-32141

4 4

Midland Funding

c/o Michael Chabrow

12 S. Summit Avenue, #250

Gaithersburg MD 20877

7434

2.2

Midland Funding, successor in interest to FIA Card Services

8875 Aero Dr, Ste 200

San Diego CA 92123

7434

2.2

Eaglemark Savings Bank

P.O. Box 277940

Sacramento CA 95827

3346

2.3

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 16 of 60
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___

Official Form 106E/F

Schedule E/F: Creditors Who Have Unsecured Claims 12/15

Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY claims and Part 2 for creditors with NONPRIORITY claims.

List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule 

A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any 

creditors with partially secured claims that are listed in Schedule D: Creditors Who Hold Claims Secured by Property. If more space is 

needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of 

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

Part 1: List All of Your PRIORITY Unsecured Claims 

1. Do any creditors have priority unsecured claims against you?

No. Go to Part 2.

Yes.

2.List all of your priority unsecured claims. If a creditor has more than one priority unsecured claim, list the creditor separately for each claim. For 

each claim listed, identify what type of claim it is. If a claim has both priority and nonpriority amounts, list that claim here and show both priority and 

nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor’s name. If you have more than two priority 

unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.

(For an explanation of each type of claim, see the instructions for this form in the instruction booklet.) 

Total claim Priority 

amount

Nonpriority 

amount

2.1 ____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___ $_____________ $___________ $____________

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Type of PRIORITY unsecured claim:

Domestic support obligations

Taxes and certain other debts you owe the government

Claims for death or personal injury while you were 

intoxicated

Other. Specify _________________________________

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

2.2 ____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Type of PRIORITY unsecured claim:

Domestic support obligations

Taxes and certain other debts you owe the government

Claims for death or personal injury while you were 

intoxicated

Other. Specify _________________________________

$_____________ $___________ $____________

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is an 

amended filing

Roland Edward Fairchild

Eastern District of Virginia

16-32141

5

X

Internal Revenue Service

P.O. Box 7346

Philadelphia PA 19101

X

X

X

2262

2013

1,505.00 1,505.00 0.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 17 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: List All of Your NONPRIORITY Unsecured Claims 

3. Do any creditors have nonpriority unsecured claims against you?

No. You have nothing to report in this part. Submit this form to the court with your other schedules.

Yes

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one 

priority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already 

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than four priority unsecured claims 

fill out the Continuation Page of Part 2. 

Total claim

4.1

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___ $__________________

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans 

Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

Debts to pension or profit-sharing plans, and other similar debts

Other. Specify ______________________________________

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

4.2 _____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___ $__________________

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans 

Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

Debts to pension or profit-sharing plans, and other similar debts

Other. Specify ______________________________________

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

4.3

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___ $_________________

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans 

Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

Debts to pension or profit-sharing plans, and other similar debts

Other. Specify ______________________________________

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

2 5

Roland Edward Fairchild 16-32141

X

Chase Bank N/A

P.O. Box 901098

Fort Worth TX 76101

X X

8681

01/2012

Credit Card Charges

1,407.00

Citi

Bankruptcy Department P.O. Box 6042

Sioux Falls SD 57117

X X

0255

03/2014

Credit Card Charges

695.00

OneMain Financial

Bankruptcy Dept. P.O. Box 6042

Sioux Falls SD 57117

X

X

3917

09/2009

Personal Loan

6,625.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 18 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

After listing any entries on this page, number them beginning with 4.5, followed by 4.6, and so forth. Total claim

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans 

Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims

Debts to pension or profit-sharing plans, and other similar debts

Other. Specify________________________________

$____________

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans 

Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims

Debts to pension or profit-sharing plans, and other similar debts

Other. Specify________________________________

$____________

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another 

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans 

Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims

Debts to pension or profit-sharing plans, and other similar debts

Other. Specify________________________________

$____________

3 5

Roland Edward Fairchild 16-32141

4.4

4.5

4.6

Sheffield Financial Co.

2554 Lewisville Clemmons

Clemmons NC 27012

X

X

7404

06/2009

Credit Card Charges

461.00

SYNCB

Attn: Bankruptcy Dept P.O. Box 965015

Orlando FL 32896

X

X

2695

11/2012

Credit Card Charges

527.00

SYNCB

Attn: Bankruptcy Dept P.O. Box 965015

Orlando FL 32896

X

X

4560

12/2012

Credit Card Charges

866.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 19 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 3: List Others to Be Notified About a Debt That You Already Listed 

5. Use this page only if you have others to be notified about your bankruptcy, for a debt that you already listed in Parts 1 or 2. For 

example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or 

2, then list the collection agency here. Similarly, if you have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the 

additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill out or submit this page. 

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims

Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims

Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims

Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims

Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims

Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims

Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims

Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

4 5

Roland Edward Fairchild 16-32141

Chase Bank N/A

c/o Midland Credit Management

8875 Aero Drive, #200

San Diego, CA 92123

4.1

X

8681

Citi

c/o Midland Credit Management

8875 Aero Drive, #200

San Diego, CA 92123

4.2

X

0255

SYNCB

c/o Allgate Financial LLC

160 N. Franklin Street, #30

Chicago, IL 60606

4.5

X

2695

SYNCB

c/o Portfolio Recovery Assoc

120 Corporate Boulevard, #1

Norfolk, VA 23502

4.6

X

4560

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 20 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 4: Add the Amounts for Each Type of Unsecured Claim

6. Total the amounts of certain types of unsecured claims. This information is for statistical reporting purposes only. 28 U.S.C. §159.

Add the amounts for each type of unsecured claim. 

Total claim

Total claims 

from Part 1

6a. Domestic support obligations 6a. $_________________________

6b. Taxes and certain other debts you owe the 

government 6b. $_________________________

6c. Claims for death or personal injury while you were 

intoxicated 6c. $_________________________

6d. Other. Add all other priority unsecured claims. 

Write that amount here. 6d. +$_________________________

6e. Total. Add lines 6a through 6d. 6e.

$_________________________

Total claim

Total claims 

from Part 2

6f. Student loans 6f.

$_________________________

6g. Obligations arising out of a separation agreement 

or divorce that you did not report as priority 

claims 6g. $_________________________

6h. Debts to pension or profit-sharing plans, and other 

similar debts 6h. $_________________________

6i. Other. Add all other nonpriority unsecured claims. 

Write that amount here. 6i. + $_________________________

6j. Total. Add lines 6f through 6i. 6j.

$_________________________

Roland Edward Fairchild 16-32141

0.00

1,505.00

0.00

0.00

1,505.00

0.00

0.00

0.00

10,581.00

10,581.00

5 5

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 21 of 60
Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15

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, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any 

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

1. Do you have any executory contracts or unexpired leases?

No. Check this box and file this form with the court with your other schedules. You have nothing else to report on this form.

Yes. Fill in all of the information below even if the contracts or leases are listed on Schedule A/B: Property (Official Form 106A/B).

2. List separately each person or company with whom you have the contract or lease. Then state what each contract or lease is for (for 

example, rent, vehicle lease, cell phone). See the instructions for this form in the instruction booklet for more examples of executory contracts and 

unexpired leases.

Person or company with whom you have the contract or lease State what the contract or lease is for

2.1 _____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.2 _____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.3 _____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.4 _____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.5 _____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

Debtor __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse If filing) First Name Middle Name Last Name

United States Bankruptcy Court for the:______________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is an 

amended filing

Roland Edward Fairchild

Eastern District of Virginia

16-32141

X

1

x

8614 Courthouse Road

Spotsylvania, VA 22551

Residential Lease of 8614 Courthouse Road

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 22 of 60
Official Form 106H Schedule H: Your Codebtors page 1 of ___

Official Form 106H

Schedule H: Your Codebtors 12/15

Codebtors are people or entities who are also liable for any debts you may have. 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, copy the Additional Page, fill it out, 

and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and 

case number (if known). Answer every question.

1. Do you have any codebtors? (If you are filing a joint case, do not list either spouse as a codebtor.)

No

Yes

2. Within the last 8 years, have you lived in a community property state or territory? (Community property states and territories include

Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)

No. Go to line 3.

Yes. Did your spouse, former spouse, or legal equivalent live with you at the time? 

No

Yes. In which community state or territory did you live? __________________. Fill in the name and current address of that person.

______________________________________________________________________

Name of your spouse, former spouse, or legal equivalent

______________________________________________________________________

Number Street

______________________________________________________________________

City State ZIP Code

3. In Column 1, list all of your codebtors. Do not include your spouse as a codebtor if your spouse is filing with you. List the person 

shown in line 2 again as a codebtor only if that person is a guarantor or cosigner. Make sure you have listed the creditor on 

Schedule D (Official Form 106D), Schedule E/F (Official Form 106E/F), or Schedule G (Official Form 106G). Use Schedule D,

Schedule E/F, or Schedule G to fill out Column 2.

Column 1: Your codebtor Column 2: The creditor to whom you owe the debt

Check all schedules that apply:

3.1 ________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

Schedule D, line ______

Schedule E/F, line ______

Schedule G, line ______

3.2 ________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

Schedule D, line ______

Schedule E/F, line ______

Schedule G, line ______

3.3 ________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

Schedule D, line ______

Schedule E/F, line ______

Schedule G, line ______

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the:_______________________________________

Case number ____________________________________________

(If known)

Fill in this information to identify your case:

Check if this is an 

amended filing

1

Roland Edward Fairchild

Eastern District of Virginia

16-32141

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 23 of 60
Official Form 106I Schedule I: Your Income page 1

Official Form 106I

Schedule I: Your Income 12/15

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.

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.

Debtor 1 Debtor 2 or non-filing spouse

Employment status Employed

Not employed

Employed

Not employed 

Occupation __________________________________ __________________________________

Employer’s name __________________________________ __________________________________

Employer’s address _______________________________________

Number Street

_______________________________________

_______________________________________

_______________________________________

City State ZIP Code

________________________________________

Number Street

________________________________________

________________________________________

________________________________________

City State ZIP Code

How long employed there? _______ _______

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. $___________ $____________

3. Estimate and list monthly overtime pay. 3. +$___________ + $____________

4. Calculate gross income. Add line 2 + line 3. 4. $__________ $____________

Debtor 1 ____________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ____________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ___________________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is:

An amended filing

A supplement showing post-petition 

chapter 13 income as of the following date: 

________________

MM / DD / YYYY

Roland Edward Fairchild

Eastern District of Virginia

16-32141

1,275.52

0.00

1,275.52 0.00

0.00

0.00

Custodian

County of Spotsylvania

Spotsylvania, VA 22553

6 yrs

P.O. Box 215

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 24 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106I Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or 

non-filing spouse

Copy line 4 here ............................................................................................ 4. $___________ $_____________

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a. $____________ $_____________

5b. Mandatory contributions for retirement plans 5b. $____________ $_____________

5c. Voluntary contributions for retirement plans 5c. $____________ $_____________

5d. Required repayments of retirement fund loans 5d. $____________ $_____________

5e. Insurance 5e. $____________ $_____________

5f. Domestic support obligations 5f. $____________ $_____________

5g. Union dues 5g. $____________ $_____________

5h. Other deductions. Specify: __________________________________ 5h. +$____________ + $_____________

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

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

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. $____________ $_____________

8b. Interest and dividends 8b. $____________ $_____________

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. $____________ $_____________

8d. Unemployment compensation 8d. $____________ $_____________

8e. Social Security 8e. $____________ $_____________

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.

$____________ $_____________

8g. Pension or retirement income 8g. $____________ $_____________

8h. Other monthly income. Specify: _______________________________ 8h. +$____________ +$_____________

9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h. 9. $____________ $_____________

10. Calculate monthly income. Add line 7 + line 9.

Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse. 10. $___________ + $_____________ = $_____________

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. + $_____________

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

Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies 12. $_____________

Combined 

monthly income

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

No.

Yes. Explain:

1,275.52 0.00

Roland Edward Fairchild 16-32141

209.21

0.00

0.00

0.00

0.00

0.00

209.21 0.00

1,066.31 0.00

8,095.53 0.00

0.00 0.00

0.00 0.00

0.00 0.00

9,295.53 0.00

10,361.84 0.00 10,361.84

0.00

0.00

0.00

0.00

0.00

0.00

0.00 0.00

0.00 0.00

0.00 0.00

0.00 0.00

0.00

Rent of 8614 Courthouse Road 1,200.00 0.00

10,361.84

0.00

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 25 of 60
UNITED STATES BANKRUPTCY COURT

In re: Case No.

Chapter

BUSINESS INCOME AND EXPENSES

operation.)

PART A - GROSS BUSINESS INCOME FOR PREVIOUS 12 MONTHS:

 1. Gross Income For 12 Months Prior to Filing:

PART B - ESTIMATED AVERAGE FUTURE GROSS MONTHLY INCOME: 

 2. Gross Monthly Income:

$

$

PART C - ESTIMATED FUTURE MONTHLY EXPENSES:

 3. Net Employee Payroll (Other Than Debtor) $

 4. Payroll Taxes

 5. Unemployment Taxes

 6. Worker's Compensation

 7. Other Taxes

 8. Inventory Purchases (Including raw materials)

 9. Purchase of Feed/Fertilizer/Seed/Spray

 10. Rent (Other than debtor's principal residence)

 11. Utilities

 12. Office Expenses and Supplies

 13. Repairs and Maintenance

 14. Vehicle Expenses 

 15. Travel and Entertainment

 16. Equipment Rental and Leases

 17. Legal/Accounting/Other Professional Fees

 18. Insurance

 19. Employee Benefits (e.g., pension, medical, etc.)

FINANCIAL REVIEW OF THE DEBTOR'S BUSINESS (NOTE: ONLY INCLUDE information directly related to the business

 20. Payments to Be Made Directly By Debtor to Secured Creditors For

Pre-Petition Business Debts (Specify):

 21. Other (Specify):

 22. Total Monthly Expenses (Add items 3 - 21) $

PART D - ESTIMATED AVERAGE NET MONTHLY INCOME:

 23. AVERAGE NET MONTHLY INCOME (Subtract Item 22 from Item 2) $

Roland Edward Fairchild 16-32141

Eastern District of Virginia

137,110.00

11,425.83

N/A

200.00

178.38

94.42

2,780.00

3,330.30

8,095.53

13

Storage 77.50

Eastern District of Virginia

Richmond Division

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 26 of 60
Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J

Schedule J: Your Expenses 12/15

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 Official Forms 106J-2, Expenses for Separate Household of Debtor 2.

2. Do you have dependents?

Do not list Debtor 1 and

Debtor 2. 

Do not state the dependents’ 

names.

No

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?

_________________________ ________ No

Yes

_________________________ ________ 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 B 106I.) 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. $_____________________

If not included in line 4:

4a. Real estate taxes 4a. $_____________________

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

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

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

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is:

An amended filing

A supplement showing post-petition chapter 13 

expenses as of the following date: 

________________

MM / DD / YYYY

Roland Edward Fairchild

Eastern District of Virginia

16-32141

X

X

X

X

2,295.50

40.00

100.00

0.00

0.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 27 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106J Schedule J: Your Expenses page 2

Your expenses

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

6. Utilities: 

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

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

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

6d. Other. Specify: _______________________________________________ 6d. $_____________________

7. Food and housekeeping supplies 7. $_____________________

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

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

10. Personal care products and services 10. $_____________________

11. Medical and dental expenses 11. $_____________________

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

Do not include car payments. 12. $_____________________

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

14. Charitable contributions and religious donations 14. $_____________________

15. Insurance.

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

1

15a. Life insurance 15a. $_____________________

15b. Health insurance 15b. $_____________________

15c. Vehicle insurance 15c. $_____________________

15d. Other insurance. Specify:_______________________________________ 15d. $_____________________

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

Specify: ________________________________________________________ 16.

$_____________________

17. Installment or lease payments:

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

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

17c. Other. Specify:_______________________________________________ 17c. $_____________________

17d. Other. Specify:_______________________________________________ 17d. $_____________________

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 106I). 18. $_____________________

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

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. $_____________________

20b. Real estate taxes 20b. $_____________________

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

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

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

Roland Edward Fairchild 16-32141

250.00

0.00

80.00

300.00

260.00

0.00

250.00

100.00

0.00

0.00

0.00

114.00

739.70

0.00

0.00

586.99

2,757.93

0.00

0.00

25.00

0.00

See Attachment 1

0.00

149.00

80.00

0.00

0.00

0.00

Motorcycle 728.12

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 28 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 106J Schedule J: Your Expenses page 3

21. Other. Specify: _________________________________________________ 21. +$_____________________

22. Calculate your monthly expenses. 

22a. Add lines 4 through 21.

22b. Copy line 22 (monthly expenses for Debtor 2), if any, from Official Form 106J-2

22c. Add line 22a and 22b. The result is your monthly expenses. 22.

$_____________________

$_____________________

$_____________________

23. Calculate your monthly net income. 

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

23b. Copy your monthly expenses from line 22 above. 23b. – $_____________________

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

The result is your monthly net income. 23c. $_____________________

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 here:

Roland Edward Fairchild 16-32141

10,361.84

1,505.60

0.00

X

8,856.24

8,856.24

8,856.24

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 29 of 60
Attachment

Debtor: Roland Edward Fairchild Case No: 16-32141

Attachment 1

Description: Personal property taxes

Amount: 75.00

Description: Income tax

Amount: 2,682.93

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 30 of 60
Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2

Official Form 106Sum

Summary of Your Assets and Liabilities and Certain Statistical Information 12/15

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

information. Fill out all of your schedules first; then complete the information on this form. If you are filing amended schedules after you file 

your original forms, you must fill out a new Summary and check the box at the top of this page.

Part 1: Summarize Your Assets 

Your assets

Value of what you own

1. Schedule A/B: Property (Official Form 106A/B)

1a. Copy line 55, Total real estate, from Schedule A/B........................................................................................................ $ ________________

1b. Copy line 62, Total personal property, from Schedule A/B............................................................................................. $ ________________

1c. Copy line 63, Total of all property on Schedule A/B ....................................................................................................... $ ________________

Part 2: Summarize Your Liabilities 

Your liabilities

Amount you owe

2. Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D)

2a. Copy the total you listed in Column A, Amount of claim, at the bottom of the last page of Part 1 of Schedule D ............ $ ________________

3. Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F)

3a. Copy the total claims from Part 1 (priority unsecured claims) from line 6e of Schedule E/F .......................................... $ ________________

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F...................................... + $ ________________

Your total liabilities $ ________________

Part 3: Summarize Your Income and Expenses 

4. Schedule I: Your Income (Official Form 106I)

Copy your combined monthly income from line 12 of Schedule I ........................................................................................ $ ________________

5. Schedule J: Your Expenses (Official Form 106J)

Copy your monthly expenses from line 22, Column A, of Schedule J.................................................................................. $ ________________

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is an 

amended filing

Roland Edward Fairchild

Eastern District of Virginia

16-32141

471,675.00

100,779.00

572,454.00

543,013.93

1,505.00

10,581.00

555,099.93

10,361.84

8,856.24

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 31 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

 Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 2 of 2

Part 4: Answer These Questions for Administrative and Statistical Records

6. Are you filing for bankruptcy under Chapters 7, 11, or 13?

No. You have nothing to report on this part of the form. Check this box and submit this form to the court with your other schedules.

Yes

7. What kind of debt do you have?

Your debts are primarily consumer debts. Consumer debts are those “incurred by an individual primarily for a personal, 

family, or household purpose.” 11 U.S.C. § 101(8). Fill out lines 8-10 for statistical purposes. 28 U.S.C. § 159.

Your debts are not primarily consumer debts. You have nothing to report on this part of the form. Check this box and submit 

this form to the court with your other schedules.

8. From the Statement of Your Current Monthly Income: Copy your total current monthly income from Official 

Form 122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14. $ _________________

9. Copy the following special categories of claims from Part 4, line 6 of Schedule E/F:

Total claim

From Part 4 on Schedule E/F, copy the following:

9a. Domestic support obligations (Copy line 6a.)

$_____________________

9b. Taxes and certain other debts you owe the government. (Copy line 6b.) $_____________________

9c. Claims for death or personal injury while you were intoxicated. (Copy line 6c.) $_____________________

9d. Student loans. (Copy line 6f.)

$_____________________

9e. Obligations arising out of a separation agreement or divorce that you did not report as 

priority claims. (Copy line 6g.) $_____________________

9f. Debts to pension or profit-sharing plans, and other similar debts. (Copy line 6h.) + $_____________________

9g. Total. Add lines 9a through 9f. $_____________________

10,422.06

0.00

1,505.00

0.00

0.00

0.00

0.00

Roland Edward Fairchild 16-32141

1,505.00

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 32 of 60
Official Form 106Dec Declaration About an Individual Debtor’s Schedules page 1 

Official Form 106Dec

Declaration About an Individual Debtor’s Schedules 12/15

If two married people are filing together, both are equally responsible for supplying correct information. 

You must file this form whenever you file bankruptcy schedules or amended schedules. Making a false statement, concealing property, or 

obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 

years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

Sign Below

Did you pay or agree to pay someone who is NOT an attorney to help you fill out bankruptcy forms?

No

Yes. Name of person__________________________________________________. Attach Bankruptcy Petition Preparer’s Notice, Declaration, and 

Signature (Official Form 119).

Under penalty of perjury, I declare that I have read the summary and schedules filed with this declaration and 

that they are true and correct.

______________________________________________ _____________________________ Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: _______________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is an 

amended filing

16-32141

/s/ Roland Edward Fairchild

04/26/2016

X

Eastern District Of Virginia

Roland Edward Fairchild

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 33 of 60
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy 04/16

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 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: Give Details About Your Marital Status and Where You Lived Before

1. What is your current marital status?

Married 

Not married 

2. During the last 3 years, have you lived anywhere other than where you live now? 

No

Yes. List all of the places you lived in the last 3 years. Do not include where you live now.

Debtor 1: Dates Debtor 1 

lived there 

Debtor 2: Dates Debtor 2 

lived there 

__________________________________________

Number Street

__________________________________________

__________________________________________

City State ZIP Code

From ________

To ________

Same as Debtor 1

___________________________________________

Number Street

___________________________________________

___________________________________________

City State ZIP Code

Same as Debtor 1

From ________

To ________

__________________________________________

Number Street

__________________________________________

__________________________________________

City State ZIP Code

From ________

To ________

Same as Debtor 1

___________________________________________

Number Street

___________________________________________

___________________________________________

City State ZIP Code

Same as Debtor 1

From ________

To ________

3. Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory? (Community property states 

and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.) 

No

Yes. Make sure you fill out Schedule H: Your Codebtors (Official Form 106H).

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ____________________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is an 

amended filing

Roland

16-32141

Edward Fairchild

X

X

Eastern District of Virginia

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 34 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 2

Part 2: Explain the Sources of Your Income 

4. Did you have any income from employment or from operating a business during this year or the two previous calendar years?

Fill in the total amount of income you received from all jobs and all businesses, including part-time activities. 

If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.

No

Yes. Fill in the details.

Debtor 1 Debtor 2 

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy:

Wages, commissions, 

bonuses, tips

Operating a business

$________________

Wages, commissions, 

bonuses, tips

Operating a business

$________________

For last calendar year:

(January 1 to December 31, _________) YYYY

Wages, commissions, 

bonuses, tips

Operating a business

$________________

Wages, commissions, 

bonuses, tips

Operating a business

$________________

For the calendar year before that: 

(January 1 to December 31, _________) YYYY

Wages, commissions, 

bonuses, tips

Operating a business $________________

Wages, commissions, 

bonuses, tips

Operating a business $________________

5. Did you receive any other income during this year or the two previous calendar years?

Include income regardless of whether that income is taxable. Examples of other income are alimony; child support; Social Security, unemployment, 

and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and gambling and lottery 

winnings. If you are filing a joint case and you have income that you received together, list it only once under Debtor 1.

List each source and the gross income from each source separately. Do not include income that you listed in line 4.

No

Yes. Fill in the details.

Debtor 1 Debtor 2 

Sources of income

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

Sources of income 

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy:

__________________

__________________

__________________

$_________________

$_________________

$_________________

_____________________

_____________________

_____________________

$_________________

$_________________

$_________________

For last calendar year:

(January 1 to December 31, ______) YYYY

__________________

__________________

__________________

$_________________

$_________________

$_________________

_____________________

_____________________

_____________________

$_________________

$_________________

$_________________

For the calendar year before that: 

(January 1 to December 31, ______) YYYY

__________________

__________________

__________________

$_________________

$_________________

$_________________

_____________________

_____________________

_____________________

$_________________

$_________________

$_________________

16-32141

X

X

2015

2014

Roland Edward Fairchild

2015

2014

3,532.20

15,373.00

14,998.00

X

X

X

Fairchild Vault Svc 25,978.83

Fairchild Vault Svc 76,666.50

Fairchild Vault Svc 75,000.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 35 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	
 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3

Part 3: List Certain Payments You Made Before You Filed for Bankruptcy 

6. Are either Debtor 1’s or Debtor 2’s debts primarily consumer debts?

No. Neither Debtor 1 nor Debtor 2 has primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8) as

“incurred by an individual primarily for a personal, family, or household purpose.” 

During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,25* or more? 

No. Go to line 7.

Yes. List below each creditor to whom you paid a total of $6,25* or more in one or more payments and the

total amount you paid that creditor. Do not include payments for domestic support obligations, such as 

child support and alimony. Also, do not include payments to an attorney for this bankruptcy case. 

* Subject to adjustment on 4/01/
 and every 3 years after that for cases filed on or after the date of adjustment.

Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts.

During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more? 

No. Go to line 7.

Yes. List below each creditor to whom you paid a total of $600 or more and the total amount you paid that

creditor. Do not include payments for domestic support obligations, such as child support and 

alimony. Also, do not include payments to an attorney for this bankruptcy case. 

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Dates of 

payment

Total amount paid Amount you still owe Was this payment for...

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

16-32141

X

X

See Attachment 1

Roland Edward Fairchild

Titlemax

5203 Jefferson Davis Highway

Fredericksburg VA 22408

04/04/16

03/05/16

02/05/16

2,008.00 3,725.87

X

Harley Davidson Credit

PO Box 21850

Carson City NV 89721

03/22/16

02/23/16

1,460.00 29,928.04

X

Santander Consumer USA

Attn: Bankruptcy Dept.

P.O Box 560284

Dallas TX 75356

03/01/16 740.00 35,907.80

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 36 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 4

7. Within 1 year before you filed for bankruptcy, did you make a payment on a debt you owed anyone who was an insider?

Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner; 

corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing 

agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations, 

such as child support and alimony. 

No

Yes. List all payments to an insider. 

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

8. Within 1 year before you filed for bankruptcy, did you make any payments or transfer any property on account of a debt that benefited 

an insider? 

Include payments on debts guaranteed or cosigned by an insider.

No

Yes. List all payments that benefited an insider. 

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

Include creditor’s name

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

X

X

Roland Edward Fairchild 16-32141

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 37 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 5

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

9. Within 1 year before you filed for bankruptcy, were you a party in any lawsuit, court action, or administrative proceeding? 

List all such matters, including personal injury cases, small claims actions, divorces, collection suits, paternity actions, support or custody modifications, 

and contract disputes. 

No

Yes. Fill in the details.

Case title_____________________________

____________________________________

Case number ________________________

Nature of the case Court or agency Status of the case

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

Pending 

On appeal 

Concluded

Case title_____________________________

____________________________________

Case number ________________________

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

Pending 

On appeal 

Concluded

10. Within 1 year before you filed for bankruptcy, was any of your property repossessed, foreclosed, garnished, attached, seized, or levied? 

Check all that apply and fill in the details below.

No. Go to line 11.

Yes. Fill in the information below.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

Property was repossessed. 

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

Property was repossessed. 

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

Roland Edward Fairchild 16-32141

X

X

Midland Funding LLC v.

Roland Fairchild

GV14001610-02

Garnishment

General District Court

Spotsylvania VA

X

Portfolio Recovery Associates

LLC v. Roland Fairchild

GV14004712-00

Warrant in Debt

General District Court

Spotsylvania VA

X

Internal Revenue Service

2015 Tax Refund

X

04/25/2016 917.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 38 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 6

11. Within 90 days before you filed for bankruptcy, did any creditor, including a bank or financial institution, set off any amounts from your 

accounts or refuse to make a payment because you owed a debt? 

No

Yes. Fill in the details.

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the action the creditor took Date action 

was taken

Amount

____________ $________________

Last 4 digits of account number: XXXX–___ ___ ___ ___

12. Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of 

creditors, a court-appointed receiver, a custodian, or another official? 

No

Yes

Part 5: List Certain Gifts and Contributions 

13.Within 2 years before you filed for bankruptcy, did you give any gifts with a total value of more than $600 per person? 

No

Yes. Fill in the details for each gift. 

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

X

Roland Edward Fairchild 16-32141

X

X

Number Street

Number Street

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 39 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 7

14.Within 2 years before you filed for bankruptcy, did you give any gifts or contributions with a total value of more than $600 to any charity? 

No

Yes. Fill in the details for each gift or contribution.

Gifts or contributions to charities 

that total more than $600

Describe what you contributed Date you 

contributed

Value 

_____________________________________

Charity’s Name

_____________________________________

_____________________________________

_____________________________________

City State ZIP Code

_________

_________

$_____________

$_____________

Part 6: List Certain Losses 

15. Within 1 year before you filed for bankruptcy or since you filed for bankruptcy, did you lose anything because of theft, fire, other disaster, 

or gambling? 

No

Yes. Fill in the details.

Describe the property you lost and how 

the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending insurance 

claims on line 33 of Schedule A/B: Property.

Date of your loss Value of property 

lost

_________ $_____________

Part 7: List Certain Payments or Transfers 

16. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone you 

consulted about seeking bankruptcy or preparing a bankruptcy petition?

Include any attorneys, bankruptcy petition preparers, or credit counseling agencies for services required in your bankruptcy.

No

Yes. Fill in the details.

___________________________________

Person Who Was Paid 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

____________________________________________

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

Roland Edward Fairchild 16-32141

X

X

X

Number Street

001 Debtorcc, Inc.

378 Summit Avenue

Jersey City NJ 07306

www.debtorcc.org

04/08/16 25.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 40 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 8

____________________________________

Person Who Was Paid 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

________________________________________________

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of 

payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

17. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone who 

promised to help you deal with your creditors or to make payments to your creditors? 

Do not include any payment or transfer that you listed on line 16.

No

Yes. Fill in the details.

____________________________________

Person Who Was Paid 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code 

Description and value of any property transferred Date payment or 

transfer was made

Amount of payment

_________

_________

$____________

$____________

18. Within 2 years before you filed for bankruptcy, did you sell, trade, or otherwise transfer any property to anyone, other than property 

transferred in the ordinary course of your business or financial affairs? 

Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property).

Do not include gifts and transfers that you have already listed on this statement.

No

Yes. Fill in the details.

___________________________________

Person Who Received Transfer 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Description and value of property 

transferred

Describe any property or payments received 

or debts paid in exchange

Date transfer 

was made

_________

Person’s relationship to you _____________

___________________________________

Person Who Received Transfer 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

_________

Person’s relationship to you _____________

Roland Edward Fairchild 16-32141

X

X

Robert B. Easterling

2217 Princess Anne Street, #100-2

Fredericksburg VA 22401

eastlaw@easterlinglaw.com

04/19/16 1,843.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 41 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 9

19.Within 10 years before you filed for bankruptcy, did you transfer any property to a self-settled trust or similar device of which you 

are a beneficiary? (These are often called asset-protection devices.)

No

Yes. Fill in the details.

Name of trust __________________________

______________________________________

Description and value of the property transferred Date transfer 

was made

_________

Part 8: List Certain Financial Accounts, Instruments, Safe Deposit Boxes, and Storage Units 

20. Within 1 year before you filed for bankruptcy, were any financial accounts or instruments held in your name, or for your benefit, 

closed, sold, moved, or transferred? 

Include checking, savings, money market, or other financial accounts; certificates of deposit; shares in banks, credit unions, 

brokerage houses, pension funds, cooperatives, associations, and other financial institutions.

No 

Yes. Fill in the details.

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code 

Last 4 digits of account number Type of account or 

instrument

Date account was 

closed, sold, moved, 

or transferred

Last balance before 

closing or transfer

XXXX–___ ___ ___ ___ Checking

Savings

Money market

Brokerage 

Other__________

_________ $___________

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

XXXX–___ ___ ___ ___ Checking

Savings

Money market

Brokerage 

Other__________

_________ $___________

21. Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for 

securities, cash, or other valuables?

No 

Yes. Fill in the details.

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Who else had access to it? Describe the contents Do you still 

have it?

_______________________________________

Name 

_______________________________________

Number Street

_______________________________________

City State ZIP Code

No 

Yes



Roland Edward Fairchild 16-32141

X

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 42 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 10

22. Have you stored property in a storage unit or place other than your home within 1 year before you filed for bankruptcy? 

No 

Yes. Fill in the details.

___________________________________

Name of Storage Facility

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Who else has or had access to it? Describe the contents Do you still 

have it?

_______________________________________

Name 

_______________________________________

Number Street

_______________________________________

CityState ZIP Code

No 

Yes



Part 9: Identify Property You Hold or Control for Someone Else 

23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for, 

or hold in trust for someone.

No 

Yes. Fill in the details.

___________________________________

Owner’s Name

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Where is the property? Describe the property Value

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

$__________

Part 10: Give Details About Environmental Information 

For the purpose of Part 10, the following definitions apply:

 Environmental law means any federal, state, or local statute or regulation concerning pollution, contamination, releases of 

hazardous or toxic substances, wastes, or material into the air, land, soil, surface water, groundwater, or other medium, 

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

 Site means any location, facility, or property as defined under any environmental law, whether you now own, operate, or utilize 

it or used to own, operate, or utilize it, including disposal sites. 

 Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance, toxic 

substance, hazardous material, pollutant, contaminant, or similar term.

Report all notices, releases, and proceedings that you know about, regardless of when they occurred.

24. Has any governmental unit notified you that you may be liable or potentially liable under or in violation of an environmental law? 

No 

Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

Roland Edward Fairchild 16-32141

X

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 43 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 11

25. Have you notified any governmental unit of any release of hazardous material? 

No 

Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

26. Have you been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders.

No 

Yes. Fill in the details.

Case title______________________________

______________________________________

______________________________________

Case number

Court or agency Nature of the case Status of the 

case

________________________________

Court Name

________________________________

Number Street

________________________________

City State ZIP Code

Pending 

On appeal 

Concluded



Part 11: Give Details About Your Business or Connections to Any Business 

27. Within 4 years before you filed for bankruptcy, did you own a business or have any of the following connections to any business? 

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

A member of a limited liability company (LLC) or limited liability partnership (LLP)

A partner in a partnership 

An officer, director, or managing executive of a corporation

An owner of at least 5% of the voting or equity securities of a corporation

No. None of the above applies. Go to Part 12.

Yes. Check all that apply above and fill in the details below for each business.

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

Roland Edward Fairchild 16-32141

X

X

X

X

Fairchild Vault Service

8616 Courthouse Road

Spotsylvania VA 22551

Gravedigging

2006 n/a

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 44 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 12

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

28. Within 2 years before you filed for bankruptcy, did you give a financial statement to anyone about your business? Include all financial 

institutions, creditors, or other parties. 

No 

Yes. Fill in the details below.

____________________________________

Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Date issued

____________

MM / DD / YYYY

Part 12: Sign Below 

I have read the answers on this Statement of Financial Affairs and any attachments, and I declare under penalty of perjury that the 

answers are true and correct. I understand that making a false statement, concealing property, or obtaining money or property by fraud 

in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both. 

18 U.S.C. §§ 152, 1341, 1519, and 3571.

______________________________________________ _____________________________ Signature of Debtor 1 Signature of Debtor 2

Date ________________ Date _________________

Did you attach additional pages to Your Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107)?

No

Yes

Did you pay or agree to pay someone who is not an attorney to help you fill out bankruptcy forms?

No

Yes. Name of person_____________________________________________________________. Attach the Bankruptcy Petition Preparer’s Notice, 

Declaration, and Signature (Official Form 119).

Roland Edward Fairchild 16-32141

X

/s/ Roland Edward Fairchild

26 April 2016

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 45 of 60
Attachment

Debtor: Roland Edward Fairchild Case No: 16-32141

Attachment 1 Additional Payments or Transfers to Creditors:

Creditor’s Name: Seterus

Creditor’s Address: P.O. Box 1077, Hartford, CT 06143

Date of Payments or Transfers: March 23, 2016; February 23, 2016; January 20, 2016

Total Amount or Value: $6,900.00

Amount Still Owing: $398,456.80

Reasons for Payment or Transfer: Mortgage

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 46 of 60
Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 1

Official Form 122C–1

Chapter 13 Statement of Your Current Monthly Income 

and Calculation of Commitment Period 12/15

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). $__________ $__________

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

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. Do not include payments from a spouse. Do not include payments you 

listed on line 3. $_________ $__________

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

farm Debtor 1 Debtor 2

Gross receipts (before all deductions) $______ $______

Ordinary and necessary operating expenses – $______ – $______

Net monthly income from a business, profession, or farm $______ $______

Copy 

here $_________ $__________

6. Net income from rental and other real property Debtor 1 Debtor 2

Gross receipts (before all deductions) $______ $______

Ordinary and necessary operating expenses – $______ – $______

Net monthly income from rental or other real property $______ $______ Copy 

here $_________ $__________

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 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ______________________________________ 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is an amended filing

X

X

16-32141

Roland Edward Fairchild

1,275.52

0.00

0.00

X

EASTERN DISTRICT OF VIRGINIA

1,051.00

1,200.00

149.00

1,051.00

See

3,330.29

8,095.54 8,095.54

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 47 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 2

Column A

Debtor 1

Column B

Debtor 2 or 

non-filing spouse

7. Interest, dividends, and royalties $____________ $__________

8. Unemployment compensation $____________ $__________

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..................................................................................... $_____________

For your spouse..................................................................... $_____________

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

benefit under the Social Security Act. $____________ $__________

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 below.

__________________________________________________________________ $____________ $___________

__________________________________________________________________ $____________ $___________

Total amounts from separate pages, if any. + $____________ + $__________

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. $____________ + $___________ = $________

Total average

monthly income

Part 2: Determine How to Measure Your Deductions from Income

12. Copy your total average monthly income from line 11. .......................................................................................................................... $_____________

13. Calculate the marital adjustment. Check one:

You are not married. Fill in 0 below.

You are married and your spouse is filing with you. Fill in 0 below.

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.

Below, 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 below.

__________________________________________________________________________ $___________

__________________________________________________________________________ $___________

__________________________________________________________________________ +$___________

Total................................................................................................................................................ $___________ Copy here ─____________

14. Your current monthly income. Subtract the total in line 13 from line 12. $ __________

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

15a. Copy line 14 here ........................................................................................................................................................................................... $ ____________

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. ................................................................................... $___________

Roland Edward Fairchild 16-32141

0.00

0.00

0.00

0.00

10,422.06 10,422.06

10,422.06

X

0.00 0.00

10,422.06

125,064.72

10,422.06

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 48 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 3

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

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

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

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

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 122C–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 122C–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. ............................................................................................................................. $__________

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 13.

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

19b. Subtract line 19a from line 18. $__________

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

20a. Copy line 19b.. .............................................................................................................................................................................................. $___________

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. $___________

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

$___________

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.

___________________________________________________ ____________________________________ Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

If you checked 17a, do NOT fill out or file Form 122C–2.

If you checked 17b, fill out Form 122C–2 and file it with this form. On line 39 of that form, copy your current monthly income from line 14 above.

Roland Edward Fairchild 16-32141

VA

1

55,055.00

0.00

10,422.06

10,422.06

10,422.06

125,064.72

55,055.00

/s/ Roland Edward Fairchild

04/26/2016

X

X

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 49 of 60
Attachment

Debtor: Roland Edward Fairchild Case No: 16-32141

Attachment Line 5. Gross receipts

11,425.83

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 Document Page 50 of 60
Official Form 122C─2 Chapter 13 Calculation of Your Disposable Income page 1

Official Form 122C–2

Chapter 13 Calculation of Your Disposable Income 04/16

To fill out this form, you will need your completed copy of Chapter 13 Statement of Your Current Monthly Income and Calculation of 

Commitment Period (Official Form 122C–1).

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 Deductions from Your Income

The Internal Revenue Service (IRS) issues National and Local Standards for certain expense amounts. Use these amounts 

to answer the questions in lines 6-15. To find the IRS standards, go online using the link specified in the separate 

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

Deduct the expense amounts set out in lines 6-15 regardless of your actual expense. In later parts of the form, you will use 

some of your actual expenses if they are higher than the standards. Do not include any operating expenses that you 

subtracted from income in lines 5 and 6 of Form 122C–1, and do not deduct any amounts that you subtracted from your 

spouse’s income in line 13 of Form 122C–1. 

If your expenses differ from month to month, enter the average expense.

Note: Line numbers 1-4 are not used in this form. These numbers apply to information required by a similar form used in chapter 7 cases.

5. The number of people used in determining your deductions from income

Fill in the number of people who could be claimed as exemptions on your federal income tax 

return, plus the number of any additional dependents whom you support. This number may 

be different from the number of people in your household.

National 

Standards You must use the IRS National Standards to answer the questions in lines 6-7.

6. Food, clothing, and other items: Using the number of people you entered in line 5 and the IRS National 

Standards, fill in the dollar amount for food, clothing, and other items. $___________

7. Out-of-pocket health care allowance: Using the number of people you entered in line 5 and the IRS National 

Standards, fill in the dollar amount for out-of-pocket health care. The number of people is split into two 

categories─people who are under 65 and people who are 65 or older─because older people have a higher IRS 

allowance for health care costs. If your actual expenses are higher than this IRS amount, you may deduct the 

additional amount on line 22.

 

 

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: _______________________________________ 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is an amended filing

16-32141

EASTERN DISTRICT OF VIRGINIA

Roland Edward Fairchild

1

585.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 51 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122C─2 Chapter 13 Calculation of Your Disposable Income page 2

People who are under 65 years of age

7a. Out-of-pocket health care allowance per person $______________

7b. Number of people who are under 65 X ______

7c. Subtotal. Multiply line 7a by line 7b. $______________ Copy 

here $___________

People who are 65 years of age or older

7d. Out-of-pocket health care allowance per person $______________

7e. Number of people who are 65 or older X ______

7f. Subtotal. Multiply line 7d by line 7e. $______________ Copy 

here + $__________

7g. Total. Add lines 7c and 7f. ......................................................................................................... $___________ Copy here....... $___________

Local 

Standards You must use the IRS Local Standards to answer the questions in lines 8-15.

Based on information from the IRS, the U.S. Trustee Program has divided the IRS Local Standard for housing for 

bankruptcy purposes into two parts: 

 Housing and utilities – Insurance and operating expenses

 Housing and utilities – Mortgage or rent expenses

To answer the questions in lines 8-9, use the U.S. Trustee Program chart. To find the chart, go online using the link 

specified in the separate instructions for this form. This chart may also be available at the bankruptcy clerk’s office.

8. Housing and utilities – Insurance and operating expenses: Using the number of people you entered in line 5, fill 

in the dollar amount listed for your county for insurance and operating expenses. $___________

9. Housing and utilities – Mortgage or rent expenses:

9a. Using the number of people you entered in line 5, fill in the dollar amount 

listed for your county for mortgage or rent expenses. $____________

9b. Total average monthly payment for all mortgages and other debts secured by 

your home.

To calculate the total average monthly payment, add all amounts that are 

contractually due to each secured creditor in the 60 months after you file 

for bankruptcy. Next divide by 60.

Name of the creditor Average monthly 

payment

_________________________________ $__________

_________________________________ $__________

_________________________________ + $__________

9b. Total average monthly payment $__________ Copy 

here ─ $____________Repeat this amount 

on line 33a.

9c. Net mortgage or rent expense.

Subtract line 9b (total average monthly payment) from line 9a (mortgage or 

rent expense). If this number is less than $0, enter $0. $____________ Copy here........ $___________

10. If you claim that the U.S. Trustee Program’s division of the IRS Local Standard for housing is incorrect and affects 

the calculation of your monthly expenses, fill in any additional amount you claim. $___________

Explain 

why: _______________________________________________________________

_______________________________________________________________

Roland Edward Fairchild 16-32141

60.00

0

0.00 0.00

144.00

1

144.00 144.00

144.00 144.00

441.00

1,362.00

0.00 0.00

2,882.49 2,882.49

0.00

Seterus 2,295.50

BB&T Mortgage 586.99

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 52 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122C─2 Chapter 13 Calculation of Your Disposable Income page 3

11. Local transportation expenses: Check the number of vehicles for which you claim an ownership or operating expense. 

0. Go to line 14.

1. Go to line 12.

2 or more. Go to line 12.

12. Vehicle operation expense: Using the IRS Local Standards and the number of vehicles for which you claim the operating 

expenses, fill in the Operating Costs that apply for your Census region or metropolitan statistical area. $___________

13. Vehicle ownership or lease expense: Using the IRS Local Standards, calculate the net ownership or lease expense for 

each vehicle below. You may not claim the expense if you do not make any loan or lease payments on the vehicle. In 

addition, you may not claim the expense for more than two vehicles. 

Vehicle 1 Describe Vehicle 1: _________________________________________________________________

_________________________________________________________________

13a. Ownership or leasing costs using IRS Local Standard ...................................... $____________

13b. Average monthly payment for all debts secured by Vehicle 1.

Do not include costs for leased vehicles.

To calculate the average monthly payment here and on line 13e,

add all amounts that are contractually due to each secured 

creditor in the 60 months after you file for bankruptcy. Then divide 

by 60. 

Name of each creditor for Vehicle 1 Average monthly 

payment

_________________________________ $__________

_________________________________ + $__________

Total average monthly payment $__________

Copy

here ─ $___________ Repeat this amount 

on line 33b.

13c. Net Vehicle 1 ownership or lease expense

Subtract line 13b from line 13a. If this number is less than $0, enter $0. ............. $___________

Copy net Vehicle 

1 expense here$___________

Vehicle 2 Describe Vehicle 2: _________________________________________________________________

_________________________________________________________________

13d. Ownership or leasing costs using IRS Local Standard................................... $___________

13e. Average monthly payment for all debts secured by Vehicle 2.

Do not include costs for leased vehicles.

Name of each creditor for Vehicle 2 Average monthly 

payment

_________________________________ $__________

_________________________________ + $__________

Total average monthly payment $__________

Copy 

here ─ $___________ Repeat this amount 

on line 33c.

13f. Net Vehicle 2 ownership or lease expense

Subtract line 13e from 13d. If this number is less than $0, enter $0. ................. $__________

Copy net Vehicle 

2 expense here

 $___________

14. Public transportation expense: If you claimed 0 vehicles in line 11, using the IRS Local Standards, fill in the Public 

Transportation expense allowance regardless of whether you use public transportation. $___________

15. Additional public transportation expense: If you claimed 1 or more vehicles in line 11 and if you claim that you may also 

deduct a public transportation expense, you may fill in what you believe is the appropriate expense, but you may not claim 

more than the IRS Local Standard for Public Transportation. $___________

554.00

517.00

665.73

665.73

0.00 0.00

Santander

Harley Davidson Credit

517.00

606.77

606.77

0.00 0.00

0.00

Roland Edward Fairchild 16-32141

2009 Chevrolet Corvette

2013 Harley-Davidson Triglide

X

665.73

606.77

0.00

0.00

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

 Document Page 53 of 60
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122C─2 Chapter 13 Calculation of Your Disposable Income page 4

Other Necessary 

Expenses

In addition to the expense deductions listed above, you are allowed your monthly expenses for the 

following IRS categories.

16. Taxes: The total monthly amount that you actually pay for federal, state and local taxes, such as income taxes, 

self-employment taxes, social security taxes, and Medicare taxes. You may include the monthly amount withheld 

from your pay for these taxes. However, if you expect to receive a tax refund, you must divide the expected 

refund by 12 and subtract that number from the total monthly amount that is withheld to pay for taxes.

Do not include real estate, sales, or use taxes.

$___________

17. Involuntary deductions: The total monthly payroll deductions that your job requires, such as retirement contributions, 

union dues, and uniform costs. 

Do not include amounts that are not required by your job, such as voluntary 401(k) contributions or payroll savings. $___________

18. Life insurance: The total monthly premiums that you pay for your own term life insurance. If two married people are filing 

together, include payments that you make for your spouse’s term life insurance. 

Do not include premiums for life insurance on your dependents, for a non-filing spouse’s life insurance, or for any form of 

life insurance other than term. $___________

19. Court-ordered payments: The total monthly amount that you pay as required by the order of a court or administrative 

agency, such as spousal or child support payments.

Do not include payments on past due obligations for spousal or child support. You will list these obligations in line 35.

$___________

20. Education: The total monthly amount that you pay for education that is either required:

 as a condition for your job, or 

 for your physically or mentally challenged dependent child if no public education is available for similar services. 

$___________

21. Childcare: The total monthly amount that you pay for childcare, such as babysitting, daycare, nursery, and preschool.

Do not include payments for any elementary or secondary school education. $___________

22. Additional health care expenses, excluding insurance costs: The monthly amount that you pay for health care that is 

required for the health and welfare of you or your dependents and that is not reimbursed by insurance or paid by a health 

savings account. Include only the amount that is more than the total entered in line 7.

Payments for health insurance or health savings accounts should be listed only in line 25. $___________

23. Optional telephones and telephone services: The total monthly amount that you pay for telecommunication services

for you and your dependents, such as pagers, call waiting, caller identification, special long distance, or business cell 

phone service, to the extent necessary for your health and welfare or that of your dependents or for the production of 

income, if it is not reimbursed by your employer. 

Do not include payments for basic home telephone, internet or cell phone service. Do not include self-employment 

expenses, such as those reported on line 5 of Form 122C-1, or any amount you previously deducted.

+$_________

24. Add all of the expenses allowed under the IRS expense allowances.

Add lines 6 through 23. $___________

Additional Expense 

Deductions 

These are additional deductions allowed by the Means Test. 

Note: Do not include any expense allowances listed in lines 6-24.

25. Health insurance, disability insurance, and health savings account expenses. The monthly expenses for health 

insurance, disability insurance, and health savings accounts that are reasonably necessary for yourself, your spouse, or 

your dependents.

Health insurance $__________

Disability insurance $__________

Health savings account + $__________

Total $__________ Copy total here ........................................................................$___________

Do you actually spend this total amount?

No. How much do you actually spend?

Yes $__________

26. Continuing contributions to the care of household or family members. The actual monthly expenses that you will 

continue to pay for the reasonable and necessary care and support of an elderly, chronically ill, or disabled member of 

your household or member of your immediate family who is unable to pay for such expenses. These expenses may 

include contributions to an account of a qualified ABLE program. 26 U.S.C. § 529A(b).

$___________

27. Protection against family violence. The reasonably necessary monthly expenses that you incur to maintain the safety of 

you and your family under the Family Violence Prevention and Services Act or other federal laws that apply. 

By law, the court must keep the nature of these expenses confidential. $___________

2,967.14

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4,691.14

0.00

0.00

0.00

0.00 0.00

X

0.00

0.00

Roland Edward Fairchild 16-32141

Case 16-32141-KRH Doc 11 Filed 05/10/16 Entered 05/10/16 15:58:37 Desc Main

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	
 Chapter 13 Calculation of Your Disposable Income page 5

28. Additional home energy costs. Your home energy costs are included in your insurance and operating expenses on line 8.

If you believe that you have home energy costs that are more than the home energy costs included in expenses on line 8,

then fill in the excess amount of home energy costs.

You must give your case trustee documentation of your actual expenses, and you must show that the additional amount

claimed is reasonable and necessary.

 $_______ 

29. Education expenses for dependent children who are younger than 18. The monthly expenses (not more

than $1* per child) that you pay for your dependent children who are younger than 18 years old to attend a

private or public elementary or secondary school.

You must give your case trustee documentation of your actual expenses, and you must explain why the amount

claimed is reasonable and necessary and not already accounted for in lines 6-23.

* Subject to adjustment on 4/01/1
, and every 3 years after that for cases begun on or after the date of adjustment.

 $_______ 

30. Additional food and clothing expense. The monthly amount by which your actual food and clothing expenses are

higher than the combined food and clothing allowances in the IRS National Standards. That amount cannot be more

than 5% of the food and clothing allowances in the IRS National Standards.

To find a chart showing the maximum additional allowance, go online using the link specified in the separate

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

You must show that the additional amount claimed is reasonable and necessary.

 $_______ 

31. Continuing charitable contributions. The amount that you will continue to contribute in the form of cash or financial

instruments to a religious or charitable organization. 11 U.S.C. § 548(d)(3) and (4).

Do not include any amount more than 15% of your gross monthly income.

+ $________ 

32. Add all of the additional expense deductions.

Add lines 25 through 31.

 $_________ 

Deductions for Debt Payment 

33. For debts that are secured by an interest in property that you own, including home mortgages, vehicle

loans, and other secured debt, fill in lines 33a through 33e.

To calculate the total average monthly payment, add all amounts that are contractually due

to each secured creditor in the 60 months after you file for bankruptcy. Then divide by 60.

Average monthly 

payment 

Mortgages on your home 

33a. Copy line 9b here ...................................................................................................  $___________ 

Loans on your first two vehicles

33b. Copy line 13b here. ...............................................................................................  $___________ 

33c. Copy line 13e here. ...............................................................................................  $___________ 

33d. List other secured debts: 

Name of each creditor for other 

secured debt

Identify property that 

secures the debt 

Does 

payment 

include taxes 

or insurance?

 ___________________________________ ________________________

No

Yes $___________ 

 ___________________________________ ________________________

No

Yes $___________ 

 ___________________________________ ________________________

No 

Yes

+ $___________

33e. Total average monthly payment. Add lines 33a through 33d. .......................................... $___________ Copy total 

here $_______ 

0.00

0.00

0.00

0.00

0.00

Roland Edward Fairchild 16-32141

4,573.78 4,573.78

2,882.49

665.73

606.77

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122C─2 Chapter 13 Calculation of Your Disposable Income page 6

34. Are any debts that you listed in line 33 secured by your primary residence, a vehicle, or other property necessary 

for your support or the support of your dependents?

No. Go to line 35.

Yes. State any amount that you must pay to a creditor, in addition to the payments listed in line 33, to keep 

possession of your property (called the cure amount). Next, divide by 60 and fill in the information below.

Name of the creditor Identify property that 

secures the debt 

Total cure 

amount

Monthly cure amount

_________________________ __________________ $__________ ÷ 60 = $___________

_________________________ __________________ $__________ ÷ 60 = $___________

_________________________ __________________ $__________ ÷ 60 = + $___________

Total $___________

Copy 

total 

here $___________

35. Do you owe any priority claimssuch as a priority tax, child support, or alimonythat are past due as of 

the filing date of your bankruptcy case? 11 U.S.C. § 507.

No. Go to line 36.

Yes. Fill in the total amount of all of these priority claims. Do not include current or 

ongoing priority claims, such as those you listed in line 19. 

Total amount of all past-due priority claims. ...................................................................... $______________ ÷ 60 $___________

36. Projected monthly Chapter 13 plan payment $______________

Current multiplier for your district as stated on the list issued by the Administrative 

Office of the United States Courts (for districts in Alabama and North Carolina) or by 

the Executive Office for United States Trustees (for all other districts).

To find a list of district multipliers that includes your district, 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.

x ______

Average monthly administrative expense $______________

Copy 

total 

here

$___________

37. Add all of the deductions for debt payment. Add lines 33e through 36. $___________

Total Deductions from Income

38. Add all of the allowed deductions.

Copy line 24, All of the expenses allowed under IRS expense allowances .................................... $______________

Copy line 32, All of the additional expense deductions........................................................................ $______________

Copy line 37, All of the deductions for debt payment ...........................................................................+ $______________

Total deductions ............................................................................................................................................ $______________

Copy 

total 

here 

$___________

508.33

See Attachment Line 34: Other Cure Amounts

508.33

1,505.00 25.08

1,326.00

6.7

88.84

5,196.03

88.84

4,691.14

5,196.03

0.00

9,887.17 9,887.17

Roland Edward Fairchild 16-32141

X

X

%

Seterus

8616 Courthouse

Road 14,000.00 233.33

BB&T Mortgage

8616 Courthouse

Road 10,000.00 166.67

Santander Consumer

USA

2009 Chevrolet

Corvette 4,000.00 66.67

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122C─2 Chapter 13 Calculation of Your Disposable Income page 7

 Part 2: Determine Your Disposable Income Under 11 U.S.C. § 1325(b)(2)

39. Copy your total current monthly income from line 14 of Form 122C-1, Chapter 13 

Statement of Your Current Monthly Income and Calculation of Commitment Period....................................................................... $___________

40. Fill in any reasonably necessary income you receive for support for dependent 

children. The monthly average of any child support payments, foster care payments, or 

disability payments for a dependent child, reported in Part I of Form 122C-1, that you 

received in accordance with applicable nonbankruptcy law to the extent reasonably 

necessary to be expended for such child.

$____________

41. Fill in all qualified retirement deductions. The monthly total of all amounts that your 

employer withheld from wages as contributions for qualified retirement plans, as 

specified in 11 U.S.C. § 541(b)(7) plus all required repayments of loans from retirement 

plans, as specified in 11 U.S.C. § 362(b)(19).

$____________

42. Total of all deductions allowed under 11 U.S.C. § 707(b)(2)(A). Copy line 38 here ............ $____________

43. Deduction for special circumstances. If special circumstances justify additional 

expenses and you have no reasonable alternative, describe the special circumstances 

and their expenses. You must give your case trustee a detailed explanation of the 

special circumstances and documentation for the expenses.

Describe the special circumstances Amount of expense

______________________________________________________ $___________

______________________________________________________ $___________

______________________________________________________ + $___________

Total $___________ Copy here

 +$_____________

44. Total adjustments. Add lines 40 through 43........................................................................................$____________ Copy here – $________

45. Calculate your monthly disposable income under § 1325(b)(2). Subtract line 44 from line 39. $___________

Part 3: Change in Income or Expenses 

46. Change in income or expenses. If the income in Form 122C-1 or the expenses you reported in this form have changed 

or are virtually certain to change after the date you filed your bankruptcy petition and during the time your case will be 

open, fill in the information below. For example, if the wages reported increased after you filed your petition, check 

122C-1 in the first column, enter line 2 in the second column, explain why the wages increased, fill in when the increase 

occurred, and fill in the amount of the increase. 

Form Line Reason for change Date of change Increase or 

decrease?

Amount of change

122C─1

122C─2

____ _______________________________ ____________ Increase

Decrease

$____________

122C─1

122C─2

____ _______________________________ ____________ Increase

Decrease

$____________

122C─1

122C─2

____ _______________________________ ____________ Increase

Decrease

$____________

122C─1

122C─2

____ _______________________________ ____________ Increase

Decrease

$____________

10,422.06

9,887.17

0.00 0.00

9,887.17

534.89

9,887.17

Roland Edward Fairchild 16-32141

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122C─2 Chapter 13 Calculation of Your Disposable Income page 8

Part 4: Sign Below

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

___________________________________________________ __________________________________ Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

/s/ Roland Edward Fairchild

04/26/2016

Roland Edward Fairchild 16-32141

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Attachment

Debtor: Roland Edward Fairchild Case No: 16-32141

Attachment Line 34: Other Cure Amounts

Name of Creditor: Harley Davidson Credit

Property Securing the Debt: 2013 H-D Triglide

Total Cure Amount: $2,500.00 ÷ 60 =

Monthly Cure Amount: $41.67

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UNITED STATES BANKRUPTCY COURT

EASTERN DISTRICT OF VIRGINIA

RICHMOND DIVISION

In re 

Roland Edward Fairchild

Debtors.

Chapter 13

Case No. 16-32141

STATEMENT OF MONTHLY NET INCOME

The undersigned certifies the following is the debtor's monthly income.

Income: Debtor

Six months ago $ 1,476.42

Five months ago $ 984.28

Four months ago $ 984.28

Three months ago $ 984.28

Two months ago $ 984.28

Last month $ 984.28

Income from other sources $ 48,573.25

Total Net income for six 

months preceding filing $ 54,971.07

Average Monthly Net Income $ 9,161.85

 

Dated: April 26, 2016 

/s/ Roland Edward Fairchild

Roland Edward Fairchild

Debtor

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