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

John

Carla

17-33374-KRH

Taylor Jordan

Yvonne Jordan

X

Eastern District of Virginia

8400 S. Carolina Court

Parcel ID: 10-A-59-

Spotsylvania VA 22553

SPOTSYLVANIA

X

X

358,100.00 358,100.00

Fee Simple Ownership

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 1 of 54
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?

$________________

John Taylor Jordan 17-33374-KRH

358,100.00

X

Ram Truck

1500

2015

X

20,850.00 20,850.00

Subaru

Forester

2011 X

8,050.00 8,050.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 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 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 ............................................................................................................................

$_________________

John Taylor Jordan 17-33374-KRH

32,250.00

X

Toyota

Prius

2007

3,350.00 3,350.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 3 of 54
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 ........................................................................................................................................................

$______________________

1,255.00

John Taylor Jordan 17-33374-KRH

530.00

Drum set - 200; 2 guitars - 180; Kayak - 260; Hand tools - 45; Power tools - 75;

Garden tools - 40 800.00

2 guns 550.00

Personal clothing 480.00

3 rings - 230; 2 necklaces - 100; Costume jewelry - 50 380.00

Generator - 300; Compressor - 125 425.00

4,420.00

X

X

X

X

X

X

X

X

X

Kitchen table - 80; 6 chairs - 60; China cabinet - 30; Desk - 25; Desk chair - 15; Bookcase - 5; Sofa -

See Attachment 1

2 TVs - 150; 2 computers - 50; Speakers - 250; Video game system - 80

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 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 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:

_____________________________________________________________________ ___________%

_____________________________________________________________________ ___________%

_____________________________________________________________________ ___________%

$__________________

$__________________

$__________________

John Taylor Jordan 17-33374-KRH

X

X

X

X

Capital One Stock (8 shares) 668.48

Jordan's Carpentry, Inc. 100 1.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 5 of 54
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:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

$__________________

$__________________

$__________________

John Taylor Jordan 17-33374-KRH

X

X

X

X

VRS Hybrid 401(a) (W) 1,385.78

VRS Hybrid 457 (H) 200.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 6 of 54
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. ...............

$______________________

John Taylor Jordan 17-33374-KRH

X

X

X

X

X

X

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 7 of 54
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........ $_____________________

John Taylor Jordan 17-33374-KRH

2,255.26

X

X

X

X

X

X

X

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 8 of 54
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...........................

$___________________

John Taylor Jordan 17-33374-KRH

0.00

X

X

X

X

X

X

X

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 9 of 54
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........................................................................................ $_________________

John Taylor Jordan 17-33374-KRH

0.00

358,100.00

32,250.00

4,420.00

2,255.26

0.00

0.00

0.00

38,925.26 38,925.26

397,025.26

X

X

X

X

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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Attachment

Debtor: John Taylor Jordan Case No: 17-33374-KRH

Attachment 1

75; Loveseat - 50; Coffee table - 30; End tables - 30; Rocking chairs - 75; Side table - 15; 3

beds - 250; 3 dressers - 170; 2 chests of drawers - 120; Patio table - 100; 4 chairs - 50;

Chest - 75

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 11 of 54
Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __ 

Official Form 106C 

Schedule C: The Property You Claim as Exempt 04/16

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 $160,375?

(Subject to adjustment on 4/01/19 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

_____________________________________________

Carla

Eastern District of Virginia

17-33374-KRH

Yvonne Jordan

X

John Taylor Jordan

2011 Subaru Forester

3.1

8,050.00 X 50.00 CV § 34-26(8)

2007 Toyota Prius

3.2

3,350.00 X 3,350.00 CV § 34-26(8)

Jordan's Carpentry, Inc.

19

1.00 X 1.00 CV § 34-4

2

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 12 of 54
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

 Official Form 106C 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

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Capital One Stock

18

668.48 X 668.48

CV § 34-4

VRS Hybrid 401(a) (W)

21

1,385.78 X 1,385.78 U.S.C. 11 § 522(b)(3)(C)

VRS Hybrid 457 (H)

21

200.00 X 200.00

CV § 34-34

Household goods

6

1,255.00 X 1,255.00 CV § 34-26(4a)

Electronics

7

530.00 X 530.00 CV § 34-26(4a)

Hobby

9

800.00 X 800.00 CV § 34-4

2 guns

10

550.00 X 550.00 CV § 34-26(4b)

Jewelry

12

380.00 X 380.00 CV § 34-4

Personal clothing

11

480.00 X 480.00 CV § 34-26(4)

Generator/compressor

14

425.00 X 425.00 CV § 34-4

John Taylor Jordan 17-33374-KRH

2 2

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 13 of 54
 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

John Taylor Jordan

Carla Yvonne Jordan

Eastern District of Virginia

17-33374-KRH

X

40,315.00

2

Chrysler Capital

Attn: Bankruptcy Dept.

P.O. Box 961278

Fort Worth TX 76161

X

3/4/2015

2015 Ram Truck 1500

X

0 8 6 7

32,315.00 20,850.00 11,465.00

Frye, Mike and Carolyn

3901 Mine Road

Fredericksburg VA 22407

2011 Subaru Forester

X

8,000.00 8,050.00 8,000.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 14 of 54
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: $_________________

John Taylor Jordan 17-33374-KRH

2 2

367,000.00

407,315.00

2.3

2.4

2.5

U.S. Bank Home Mortgage

P.O. Box 20005

Owensboro KY 42304

X

8400 S. Carolina Court

X

8 0 1 7

367,000.00 358,100.00 8,900.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 15 of 54
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

John Taylor Jordan

Carla Yvonne Jordan

Eastern District of Virginia

17-33374-KRH

12

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 16 of 54
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 12

John Taylor Jordan 17-33374-KRH

X

American Anesthesiology of Virginia

P.O. Box 535386

Atlanta GA 30353

X

X X

6 2 7 8

Medical Services

154.00

Cash-2-U Loans

5151 Plank Road

Fredericksburg VA 22407

X

X X

4 6 0 5

Personal Loan

803.29

Central VA OB/GYN Group PC

1011 Care Way Suite 200

Fredericksburg VA 22401

X

X

X

9 8 0 8

Medical Services

44.91

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 17 of 54
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 12

John Taylor Jordan 17-33374-KRH

4.4

4.5

4.6

ClearCare Dental

10 Chatham Heights Road

Fredericksburg VA 22407

X

X Dental Services

3,148.70

X

Efficient Roll-off & Recycling, Inc.

P.O. Box 250

Culpeper VA 22701

X

X

2017

Business Loan

1,219.15

X

Fredbg Ambulatory Surgery Ctr

1201 Sam Perry Blvd. Suite 101

Fredericksburg VA 22401

X

X

X

1 3 2 2

Medical Services

1,099.60

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 18 of 54
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________________________________

$____________

4 12

John Taylor Jordan 17-33374-KRH

4.7

4.8

4.9

Labcorp

c/o LCA Collections P.O. Box 2240

Burlington NC 27216

X

X

X

8 0 9 1

11/8/2016

Medical Services

39.19

LoanMe, Inc.

1900 S. State College Blvd., #300

Anaheim CA 92806

X

X

1 0 7 0

1/28/2017

Personal Guaranty on Business Loan

11,999.00

X

Mary Washington Hospital

2300 Fall Hill Avenue, #313

Fredericksburg VA 22401

X

X

X

7 1 8 3

2017

Medical Services

368.79

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 19 of 54
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________________________________

$____________

5 12

John Taylor Jordan 17-33374-KRH

4.10

4.11

4.12

Mary Washington Hospital

2300 Fall Hill Avenue, #313

Fredericksburg VA 22401

X

X

X

0 9 2 7

Medical Services

222.48

Mary Washington Hospital

2300 Fall Hill Avenue, #313

Fredericksburg VA 22401

X

X

X

6 7 1 0

12/22/2016

Medical Services

42.60

Mary Washington Rheumatology

1101 Sam Perry Boulevard, #413

Fredericksburg VA 22401

X

X

X

7 2 4 0

2017

Medical Services

172.20

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 20 of 54
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________________________________

$____________

6 12

John Taylor Jordan 17-33374-KRH

4.13

4.14

4.15

Neurology Associates of Fredbg

220 Executive Center Pkwy

Fredericksburg VA 22401

X

X

X

8 0 1 3

2017

Medical Services

396.81

NextCare Urgent Care VA

2550 N. Thunderbird Circle, #123

Mesa AZ 85215

X

X

X

8 7 1 5

1/9/2017

Medical Services

22.86

Quest Diagnostics

1901 Sulphur Spring Road

Baltimore MD 21227

X

X

X

8 7 6 1

2017

Medical Services

37.01

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 21 of 54
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________________________________

$____________

7 12

John Taylor Jordan 17-33374-KRH

4.16

4.17

4.18

Quest Diagnostics

1901 Sulphur Spring Road

Baltimore MD 21227

X

X

X

6 7 4 1

2017

Medical Services

25.83

Spotsylvania Regional Medical Ctr

P.O. Box 13620

Richmond VA 23225

X

X

X

1 0 9 5

8/2/2016

Medical Services

426.20

SYNCB/Lowes

Attn: Bankruptcy Dept P.O. Box 965060

Orlando FL 32896

X

X

X

8 5 6 2

2010

Business Credit Card

2,297.99

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 22 of 54
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________________________________

$____________

8 12

John Taylor Jordan 17-33374-KRH

4.19

4.20

4.21

SYNCB/Regency Furniture

Attn: Bankruptcy Dept P.O. Box 965061

Orlando FL 32896

X

X

1 2 8 7

7/2016

Credit Card Charges

1,099.09

X

U.S. Department of Education

Direct Loan Servicing Center P.O. Box 5609

Greenville TX 75403

X

X

X

69,965.87

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 23 of 54
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 ___ ___ ___ ___

9 12

John Taylor Jordan 17-33374-KRH

American Anesthesiology of Virginia

c/o Frost-Arnett Company

P.O. Box 198988

Nashville, TN 32719

4.1

X

6 2 7 8

Central VA OB/GYN Group PC

c/o American Medical Collection Agency

4 Westchester Plaza, #110

Elmsford, NY 10523

4.3

X

9 8 0 8

Central VA OB/GYN Group PC

c/o Walter J. Sheffield

P.O. Box 7906

Fredericksburg, VA 22404

4.3

X

9 8 0 8

Fredbg Ambulatory Surgery Ctr

c/o ODC Recovery Services

2300 Fall Hill Avenue, #314

Fredericksburg, VA 22401

4.6

X

1 3 2 2

Mary Washington Hospital

c/o ODC Recovery Services

2300 Fall Hill Avenue, #314

Fredericksburg, VA 22401

4.9

X

7 1 8 3

Mary Washington Hospital

c/o United Consumers, Inc.

P.O. Box 4466

Woodbridge, VA 22194

4.10

X

0 9 2 7

Mary Washington Rheumatology

c/o ODC Recovery Services

2300 Fall Hill Avenue, #314

Fredericksburg, VA 22401

4.12

X

7 2 4 0

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 24 of 54
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 ___ ___ ___ ___

10 12

John Taylor Jordan 17-33374-KRH

Neurology Associates of Fredbg

c/o Walter J. Sheffield

P.O. Box 7906

Fredericksburg, VA 22404

4.13

X

8 0 1 3

NextCare Urgent Care VA

c/o Nemo's Investigations & Collections

P.O. Box 30517

Phoenix, AZ 85046

4.14

X

8 7 1 5

Quest Diagnostics

c/o American Medical Collection Agency

4 Westchester Plaza, #110

Elmsford, NY 10523

4.15

X

8 7 6 1

Quest Diagnostics

c/o American Medical Collection Agency

4 Westchester Plaza, #110

Elmsford, NY 10523

4.16

X

6 7 4 1

Spotsylvania Regional Medical Ctr

c/o NPAS, Inc.

P.O. Box 99400

Louisville, KY 40269

4.17

X

1 0 9 5

Spotsylvania Regional Medical Ctr

c/o Focused Recovery Solutions

9701 Metropolitan Ct, Ste B

Richmond, VA 23236

4.17

X

1 0 9 5

SYNCB/Lowe's

c/o Allied Interstate LLC

P.O. Box 361445

Columbus, OH 43236

4.18

X

8 5 6 2

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 25 of 54
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 ___ ___ ___ ___

11 12

John Taylor Jordan 17-33374-KRH

U.S. Department of Education

c/o GC Services Limited Partnership

6330 Gulfton Street

Houston, TX 77081

4.20

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 26 of 54
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.

$_________________________

John Taylor Jordan 17-33374-KRH

69,965.87

0.00

0.00

23,619.70

93,585.57

12 12

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 27 of 54
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

John Taylor Jordan

Carla Yvonne Jordan

Eastern District of Virginia

17-33374-KRH

X

1

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 28 of 54
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

John Taylor Jordan

Carla Yvonne Jordan

Eastern District of Virginia

17-33374-KRH

X

X

Jordan's Carpentry, Inc.

8400 S. Carolina Court

Spotsylvania VA 22553

X 4.5, 4.8, 4.18

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 29 of 54
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 Fill out this information:

 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

John Taylor Jordan

Carla Yvonne Jordan

Eastern District of Virginia

17-33374-KRH

4,124.90

0.00

4,124.90 4,144.42

0.00

4,144.42

Stafford County School Board

Stafford, VA 22554

31 Stafford Avenue

County of Spotsylvania

Spotsylvania, VA 22553

2 mos.

P.O. Box 215

X X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 30 of 54
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:

4,124.90 4,144.42

John Taylor Jordan 17-33374-KRH

745.16

379.17

0.00

831.52

94.41

0.00

1,347.78 1,199.46

2,777.12 2,944.96

0.00 0.00

0.00 4.16

0.00 0.00

0.00 0.00

0.00 4.16

2,777.12 2,949.12 5,726.24

223.45

0.00

0.00

0.00

273.53

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 from Upstairs Tenant (no contract)

6,526.24

800.00

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 31 of 54
 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

John Taylor Jordan

Carla Yvonne Jordan

Eastern District of Virginia

17-33374-KRH

X

X

X

X

2,000.00

0.00

0.00

0.00

0.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 32 of 54
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.

16.

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. $_____________________

John Taylor Jordan 17-33374-KRH

350.00

0.00

660.00

700.00

0.00

52.00

335.00

0.00

0.00

207.20

0.00

170.42

750.72

0.00

0.00

0.00

98.00

0.00

0.00

50.00

0.00

Personal Property Taxes

360.00

0.00

0.00

0.00

0.00

0.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 33 of 54
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:

John Taylor Jordan 17-33374-KRH

6,526.24

792.90

0.00

X

5,733.34

5,733.34

5,733.34

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 34 of 54
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

John Taylor Jordan

Carla Yvonne Jordan

Eastern District of Virginia

17-33374-KRH

358,100.00

38,925.26

396,225.26

407,315.00

0.00

93,585.57

500,900.57

6,526.24

5,733.34

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 35 of 54
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. $_____________________

6,213.62

0.00

0.00

0.00

69,965.87

0.00

0.00

John Taylor Jordan 17-33374-KRH

69,965.87

X

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 36 of 54
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

17-33374-KRH

/s/ John Taylor Jordan /s/ Carla Yvonne Jordan

07/06/2017 07/06/2017

X

Eastern District Of Virginia

John Taylor Jordan

Carla Yvonne Jordan

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 37 of 54
 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

John

Carla

17-33374-KRH

Taylor

Yvonne

Jordan

Jordan

X

Eastern District of Virginia

X

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 38 of 54
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

__________________ 

__________________

__________________

$_________________

$_________________

$_________________

_____________________ 

_____________________

_____________________

$_________________

$_________________

$_________________

17-33374-KRH

X

X

John Taylor Jordan

2016

2015

9,519.00

71,000.00

67,804.00 0.00

0.00

24,866.52

X

X

X

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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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 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 $6,425* or more? 

 No. Go to line 7.

 Yes. List below each creditor to whom you paid a total of $6,425* 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 4/01/19 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 ____________

17-33374-KRH

X

X

John Taylor Jordan

Chrysler Capital

Attn: Bankruptcy Dept.

P.O. Box 961278

Fort Worth TX 76161

06/01/17

05/01/17

04/01/17

2,252.16 32,315.00

X

LoanMe, Inc.

1900 S. State College Blvd., #300

Anaheim CA 92806

05/01/17 1,000.00

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 40 of 54
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

John Taylor Jordan 17-33374-KRH

Frye, Mike and Carolyn

3901 Mine Road

Fredericksburg VA 22407

06/01/17

05/01/17

See Attachment 1

1,080.00 8,000.00

Payment on car

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 41 of 54
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.

John Taylor Jordan 17-33374-KRH

X

X

Surgical Associates (see

"Nature of Case" for full title)

GV17002046-00

Surgical Associates of

Fredericksburg v. Carla Y Jordan

and John Jordan - Warrant in Debt

(Dismissed)

General District Court

Fredericksburg VA

X

Neurology Associates of

Fredericksburg v. John T. Jordan

GV17003216-00

Warrant in Debt (Dismissed)

General District Court

Fredericksburg VA

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 42 of 54
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

John Taylor Jordan 17-33374-KRH

X

X

Number Street

Number Street

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

 Document Page 43 of 54
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

John Taylor Jordan 17-33374-KRH

X

X

X

Number Street

Robert B. Easterling

2217 Princess Anne Street, #100-2

Fredericksburg VA 22401

eastlaw@easterlinglaw.com

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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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 _____________

John Taylor Jordan 17-33374-KRH

X

X

DECAF

114 Goliad Street

Benbrook TX 76126

www.bkcert.com

06/27/17 40.00

John Scheurenbrand

Plumb Inc Properties

AR-15 Gun $800

1/2017

Craig's List Air Compressor $700

4/9/2017

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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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



John Taylor Jordan 17-33374-KRH

X

X

X

Bank of America

X 3/2017 35.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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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

_________

John Taylor Jordan 17-33374-KRH

X

X

X

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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 _______

John Taylor Jordan 17-33374-KRH

X

X

X

X

Jordan's Carpentry, Inc.

8400 S. Carolina Court

Spotsylvania VA 22553

Carpentry

2/7/2003 3/2017

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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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).

John Taylor Jordan 17-33374-KRH

X

/s/ John Taylor Jordan /s/ Carla Yvonne Jordan

6 July 2017 6 July 2017

X

X

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Attachment

Debtor: John Taylor Jordan Case No: 17-33374-KRH

Attachment 1

Additional Payments Benefiting Frye, Mike and Carolyn: April 1, 2017

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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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

17-33374-KRH

John Taylor Jordan

Carla Yvonne Jordan

1,269.20 4,144.42

0.00 0.00

0.00 0.00

X

EASTERN DISTRICT OF VIRGINIA

800.00 0.00

800.00

0.00

800.00

0.00

0.00

0.00

0.00

0.00

0.00 0.00 0.00

0.00

0.00

0.00

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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

John Taylor Jordan 17-33374-KRH

0.00 0.00

0.00 0.00

0.00 0.00

0.00 0.00

2,069.20 4,144.42 6,213.62

6,213.62

X

0.00 0.00

6,213.62

74,563.44

6,213.62

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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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.

John Taylor Jordan 17-33374-KRH

VA

4

97,731.00

0.00

6,213.62

6,213.62

6,213.62

74,563.44

97,731.00

/s/ John Taylor Jordan /s/ Carla Yvonne Jordan

07/06/2017 07/06/2017

X

X

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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UNITED STATES BANKRUPTCY COURT

EASTERN DISTRICT OF VIRGINIA

RICHMOND DIVISION

In re

John Taylor Jordan and Carla Yvonne

Jordan

Debtors.

Chapter 13

Case No. 17-33374-KRH

STATEMENT OF MONTHLY NET INCOME

The undersigned certifies the following is the debtor's monthly income.

Income: Debtor Joint Debtor

Six months ago $ 0.00 $ 2,683.73

Five months ago $ 0.00 $ 2,665.69

Four months ago $ 0.00 $ 2,665.69

Three months ago $ 0.00 $ 2,665.69

Two months ago $ 2,814.10 $ 2,665.69

Last month $ 2,563.50 $ 2,944.96

Total Net income for six

months preceding filing $ 5,377.60 $ 16,291.45

Average Monthly Net Income $ 896.27 $ 2,715.24

 

Dated: July 6, 2017

/s/ John Taylor Jordan

John Taylor Jordan

Debtor

/s/ Carla Yvonne Jordan

Carla Yvonne Jordan

Joint Debtor

Case 17-33374-KRH Doc 13 Filed 07/08/17 Entered 07/08/17 14:36:28 Desc Main

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