Fill in this information to identify your case:

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801

(if known)  Check if this is an

amended filing

Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy 4/16

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 Prior Address: Dates Debtor 1

lived there

Debtor 2 Prior Address: Dates Debtor 2

lived there

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).

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

$48,278.56  Wages, commissions,

bonuses, tips

 Operating a business

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

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 Document Page 1 of 37
Debtor 1 Teresa S Rose Case number (if known) 16-13801

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)

For last calendar year:

(January 1 to December 31, 2015 )

 Wages, commissions,

bonuses, tips

 Operating a business

$51,324.00  Wages, commissions,

bonuses, tips

 Operating a business

For the calendar year before that:

(January 1 to December 31, 2014 )

 Wages, commissions,

bonuses, tips

 Operating a business

$52,499.00  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

(before deductions

and exclusions)

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 and Address Dates of payment Total amount

paid

Amount you

still owe

Was this payment for ...

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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 and Address Dates of payment Total amount

paid

Amount you

still owe

Reason for this payment

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 to an insider

Insider's Name and Address Dates of payment Total amount

paid

Amount you

still owe

Reason for this payment

Include creditor's name

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

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 Name and Address Describe the Property

Explain what happened

Date Value of the

property

Ocwen Loan Servicing Llc

Attn: Research Dept

1661 Worthintong Rd Ste 100

West Palm Beach, FL 33409

2409 Youngs Dr. Haymarket, VA 20169

Prince William County

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized or levied.

November 9,

2016 - stayed

$362,000.00

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 Name and Address Describe the action the creditor took Date action was

taken

Amount

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

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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

Person to Whom You Gave the Gift and

Address:

Describe the gifts Dates you gave

the gifts

Value

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

Charity's Name

Address (Number, Street, City, State and ZIP Code)

Describe what you contributed Dates you

contributed

Value

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

Address

Email or website address

Person Who Made the Payment, if Not You

Description and value of any property

transferred

Date payment

or transfer was

made

Amount of

payment

Tommy Andrews, Jr., P.C.

122 North Alfred Street

Alexandria, VA 22314

11/16 $1,200.00

Debt Education and Certification 11/19 $40.00

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

Address

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

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

include gifts and transfers that you have already listed on this statement.

 No

 Yes. Fill in the details.

Person Who Received Transfer

Address

Person's relationship to you

Description and value of

property transferred

Describe any property or

payments received or debts

paid in exchange

Date transfer was

made

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 of 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 and

Address (Number, Street, City, State and 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

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

Address (Number, Street, City, State and ZIP Code)

Who else had access to it?

Address (Number, Street, City,

State and ZIP Code)

Describe the contents Do you still

have it?

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

Address (Number, Street, City, State and ZIP Code)

Who else has or had access

to it?

Address (Number, Street, City,

State and ZIP Code)

Describe the contents Do you still

have it?

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

Address (Number, Street, City, State and ZIP Code)

Where is the property?

(Number, Street, City, State and ZIP

Code)

Describe the property Value

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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

Address (Number, Street, City, State and ZIP Code)

Governmental unit

Address (Number, Street, City, State and

ZIP Code)

Environmental law, if you

know it

Date of notice

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

 No

 Yes. Fill in the details.

Name of site

Address (Number, Street, City, State and ZIP Code)

Governmental unit

Address (Number, Street, City, State and

ZIP Code)

Environmental law, if you

know it

Date of notice

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

Name

Address (Number, Street, City,

State and ZIP Code)

Nature of the case Status of the

case

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

Address

(Number, Street, City, State and ZIP Code)

Describe the nature of the business

Name of accountant or bookkeeper

Employer Identification number

Do not include Social Security number or ITIN.

Dates business existed

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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

Address

(Number, Street, City, State and ZIP Code)

Date Issued

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.

/s/ Teresa S Rose

Teresa S Rose Signature of Debtor 2

Signature of Debtor 1

Date December 13, 2016 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).

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

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Case 16-13801-RGM Doc 14 Filed 12/13/16 Entered 12/13/16 15:58:17 Desc Main

 Document Page 7 of 37
Fill in this information to identify your case:

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801

(if known)  Check if this is an

amended filing

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................................................................................................ $ 362,000.00

1b. Copy line 62, Total personal property, from Schedule A/B..................................................................................... $ 9,419.00

1c. Copy line 63, Total of all property on Schedule A/B............................................................................................... $ 371,419.00

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... $ 234,182.81

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................................. $ 0.00

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F............................ $ 3,307.00

Your total liabilities $ 237,489.81

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................................................................................ $ 4,445.94

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

Copy your monthly expenses from line 22c of Schedule J.......................................................................... $ 4,145.00

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 8-9g 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.

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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. $ 5,189.53

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.) $ 0.00

9b. Taxes and certain other debts you owe the government. (Copy line 6b.) $ 0.00

9c. Claims for death or personal injury while you were intoxicated. (Copy line 6c.) $ 0.00

9d. Student loans. (Copy line 6f.) $ 0.00

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

priority claims. (Copy line 6g.) $ 0.00

9f. Debts to pension or profit-sharing plans, and other similar debts. (Copy line 6h.) +$ 0.00

9g. Total. Add lines 9a through 9f. $ 0.00

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

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

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801  Check if this is an

amended filing

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 What is the property? Check all that apply

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

2409 Youngs Dr. 





Single-family home

Duplex or multi-unit building

Condominium or cooperative

Street address, if available, or other description

Haymarket VA 20169-0000





Manufactured or mobile home

Land

Current value of the

entire property?

Current value of the

portion you own?

City State ZIP Code  Investment property $362,000.00 $362,000.00

 Timeshare

Describe the nature of your ownership interest

(such as fee simple, tenancy by the entireties, or

a life estate), if known.

 Other

Who has an interest in the property? Check one

 Debtor 1 only

Prince William  Debtor 2 only

County  Debtor 1 and Debtor 2 only

 Check if this is community property  At least one of the debtors and another (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...........................................................................=> $362,000.00

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.

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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

 No

 Yes

3.1 Make: VW Who has an interest in the property? Check one Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Model: Jetta  Creditors Who Have Claims Secured by Property.

 Debtor 1 only

Year: 2008  Debtor 2 only Current value of the

entire property?

Current value of the

Approximate mileage: 170,000  Debtor 1 and Debtor 2 only portion you own?

Other information:  At least one of the debtors and another

 Check if this is community property $3,500.00 $3,500.00

 (see instructions)

3.2 Make: Mazda Who has an interest in the property? Check one Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Model: Tribute  Creditors Who Have Claims Secured by Property.

 Debtor 1 only

Year: 2002  Debtor 2 only Current value of the

entire property?

Current value of the

Approximate mileage: 190,000  Debtor 1 and Debtor 2 only portion you own?

Other information:  At least one of the debtors and another

 Check if this is community property $2,000.00 $2,000.00

 (see instructions)

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

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.............................................................................=> $5,500.00

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.....

Table, chairs, kitchen items, kitchen set, sofa, coffee table, TV,

DVD player, lamps, dressesrs, beds, mattresses, bedding, pillows $1,500.00

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.....

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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.....

Pants, dresses, sweaters, jackets, overcoat, skirts, shirts, shoes,

socks, blouses, scarfs, gloves, jeans, t-shirts $300.00

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.....

Dog, 3 cats $0.00

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 .............................................................................. $1,800.00

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................................................................................................................

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 BB&T checking - joint account with daughter $2,100.00

17.2. Navy FCU savings $19.00

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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:

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:

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:

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.

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.......

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

29. Family support

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

 No

 Yes. Give specific information......

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..

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..................................................................................................................... $2,119.00

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.

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.

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.........

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

54. Add the dollar value of all of your entries from Part 7. Write that number here .................................... $0.00

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

55. Part 1: Total real estate, line 2 ...................................................................................................................... $362,000.00

56. Part 2: Total vehicles, line 5 $5,500.00

57. Part 3: Total personal and household items, line 15 $1,800.00

58. Part 4: Total financial assets, line 36 $2,119.00

59. Part 5: Total business-related property, line 45 $0.00

60. Part 6: Total farm- and fishing-related property, line 52 $0.00

61. Part 7: Total other property not listed, line 54 + $0.00

62. Total personal property. Add lines 56 through 61... $9,419.00 Copy personal property total $9,419.00

63. Total of all property on Schedule A/B. Add line 55 + line 62 $371,419.00

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

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Fill in this information to identify your case:

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801

(if known)  Check if this is an

amended filing

Official Form 106C

Schedule C: The Property You Claim as Exempt 4/16

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

2409 Youngs Dr. Haymarket, VA

20169 Prince William County

Line from Schedule A/B: 1.1

$362,000.00  $5,000.00 Va. Code Ann. § 34-4

 100% of fair market value, up to

any applicable statutory limit

2008 VW Jetta 170,000 miles

Line from Schedule A/B: 3.1

$3,500.00  $0.00 Va. Code Ann. § 34-4

 100% of fair market value, up to

any applicable statutory limit

2002 Mazda Tribute 190,000 miles

Line from Schedule A/B: 3.2

$2,000.00  $2,000.00 Va. Code Ann. § 34-26(8)

 100% of fair market value, up to

any applicable statutory limit

Table, chairs, kitchen items, kitchen

set, sofa, coffee table, TV, DVD

player, lamps, dressesrs, beds,

mattresses, bedding, pillows

Line from Schedule A/B: 6.1

$1,500.00  $1,500.00 Va. Code Ann. § 34-26(4a)

 100% of fair market value, up to

any applicable statutory limit

Pants, dresses, sweaters, jackets,

overcoat, skirts, shirts, shoes, socks,

blouses, scarfs, gloves, jeans,

t-shirts

Line from Schedule A/B: 11.1

$300.00  $300.00 Va. Code Ann. § 34-26(4)

 100% of fair market value, up to

any applicable statutory limit

Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of 2

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

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

Dog, 3 cats

Line from Schedule A/B: 13.1

$0.00  $0.00 Va. Code Ann. § 34-26(5)

 100% of fair market value, up to

any applicable statutory limit

Checking: BB&T checking - joint

account with daughter

Line from Schedule A/B: 17.1

$2,100.00  $0.00 Va. Code Ann. § 34-4

 100% of fair market value, up to

any applicable statutory limit

Navy FCU savings

Line from Schedule A/B: 17.2

$19.00  $0.00 Va. Code Ann. § 34-4

 100% of fair market value, up to

any applicable statutory limit

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

Official Form 106C Schedule C: The Property You Claim as Exempt page 2 of 2

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Fill in this information to identify your case:

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801

(if known)  Check if this is an

amended filing

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

Ocwen Loan Servicing

Llc Describe the property that secures the claim: $193,582.00 $362,000.00 $0.00

Creditor's Name 2409 Youngs Dr. Haymarket, VA

Attn: Research Dept 20169 Prince William County

1661 Worthintong Rd Ste

100

West Palm Beach, FL

33409

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

apply.

 Contingent

Number, Street, City, State & Zip Code  Unliquidated

 Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply.

 Debtor 1 only

 Debtor 2 only

 An agreement you made (such as mortgage or secured

car loan)

 Debtor 1 and Debtor 2 only  Statutory lien (such as tax lien, mechanic's lien)

 At least one of the debtors and another  Judgment lien from a lawsuit

 Check if this claim relates to a

community debt

 Other (including a right to offset)

Date debt was incurred

Opened

06/09 Last

Active

6/27/16 Last 4 digits of account number 4130

2.2 US Department of HUD Describe the property that secures the claim: $36,423.81 $362,000.00 $0.00

Creditor's Name 2409 Youngs Dr. Haymarket, VA

Housing Finance and 20169 Prince William County

Operations

451 7th Street, S.W.

Room 1012

Washington, DC 20410

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

apply.

 Contingent

Number, Street, City, State & Zip Code  Unliquidated

 Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply.

 Debtor 1 only

 Debtor 2 only

 An agreement you made (such as mortgage or secured

car loan)

 Debtor 1 and Debtor 2 only  Statutory lien (such as tax lien, mechanic's lien)

 At least one of the debtors and another  Judgment lien from a lawsuit

Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of 2

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Debtor 1 Teresa S Rose Case number (if know) 16-13801

First Name Middle Name Last Name

 Check if this claim relates to a

community debt

 Other (including a right to offset)

Date debt was incurred Last 4 digits of account number

2.3

Wells Fargo Dealer

Services Describe the property that secures the claim: $4,177.00 $3,500.00 $0.00

Creditor's Name 2008 VW Jetta 170,000 miles

Po Box 3569

Rancho Cucamonga, CA

91729

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

apply.

 Contingent

Number, Street, City, State & Zip Code  Unliquidated

 Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply.

 Debtor 1 only

 Debtor 2 only

 An agreement you made (such as mortgage or secured

car loan)

 Debtor 1 and Debtor 2 only  Statutory lien (such as tax lien, mechanic's lien)

 At least one of the debtors and another  Judgment lien from a lawsuit

 Check if this claim relates to a

community debt

 Other (including a right to offset)

Date debt was incurred

Opened

08/12 Last

Active

9/06/16 Last 4 digits of account number 4589

Add the dollar value of your entries in Column A on this page. Write that number here: $234,182.81

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

Write that number here: $234,182.81

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

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

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

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

debts in Part 1, do not fill out or submit this page.

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

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Fill in this information to identify your case:

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801

(if known)  Check if this is an

amended filing

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 Have 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. If you have no information to report in a Part, do not file that Part. 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.

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 nonpriority

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 three nonpriority unsecured claims fill out the Continuation Page of

Part 2.

Total claim

4.1 AMCB Last 4 digits of account number $0.00

Nonpriority Creditor's Name

P.O. Box 37007

Baltimore, MD 21297

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify daughter's med bill

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 1 of 5

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Debtor 1 Teresa S Rose Case number (if know) 16-13801

4.2 Arcadia Recovery Bureau Last 4 digits of account number $0.00

Nonpriority Creditor's Name

PO BOX 70256

Philadelphia, PA 19176

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify med bill for daughter

4.3 Capital One Last 4 digits of account number 5531 $327.00

Nonpriority Creditor's Name

Po Box 30285

Salt Lake City, UT 84130

When was the debt incurred?

Opened 10/15 Last Active

10/14/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify Credit Card

4.4 Client Services, Inc Last 4 digits of account number $0.00

Nonpriority Creditor's Name

3451 Harry Truman Blvd

Saint Charles, MO 63301-4047

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify son's med bill

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 2 of 5

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Debtor 1 Teresa S Rose Case number (if know) 16-13801

4.5 EMA Last 4 digits of account number $0.00

Nonpriority Creditor's Name

20010 Century Blvd

Ste 200

Germantown, MD 20874-1118

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify med bill for daughter

4.6 Franklin Collection Service, Inc Last 4 digits of account number 1076 $33.00

Nonpriority Creditor's Name

Po Box 3910

Tupelo, MS 38801

When was the debt incurred? Opened 08/14

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify

Collection Attorney Solstas Lab Partners

Group Ll

4.7 Inova Last 4 digits of account number $0.00

Nonpriority Creditor's Name

PO Box 37013

Baltimore, MD 21297

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify daughter's med bill

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 3 of 5

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Debtor 1 Teresa S Rose Case number (if know) 16-13801

4.8 INOVA Health Care Services Last 4 digits of account number $0.00

Nonpriority Creditor's Name

c/o Golinowski & Colarusso

4015 Chain Bridge Road

Fairfax, VA 22030

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify daughter's med bill

4.9 Novant Heath Haymarket Med Ctr Last 4 digits of account number $0.00

Nonpriority Creditor's Name

PO Box 7428

Merrifield, VA 22116

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify son's med bill

4.1

0 Stellar Recovery Inc Last 4 digits of account number 2121 $0.00

Nonpriority Creditor's Name

Attn: Bankruptcy

4500 Salisbury Road Ste 105

Jackonville, FL 32216

When was the debt incurred?

Opened 08/16 Last Active

10/18/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify Collection Attorney Comcast

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 4 of 5

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 Document Page 23 of 37
Debtor 1 Teresa S Rose Case number (if know) 16-13801

4.1

1 Wffnb Dual L Last 4 digits of account number 0093 $2,947.00

Nonpriority Creditor's Name

Po Box 94498

Las Vegas, NV 89193

When was the debt incurred?

Opened 02/15 Last Active

8/21/15

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

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

 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

 Yes  Other. Specify Credit Card

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.

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

6a. Domestic support obligations 6a. $ 0.00

Total

claims

from Part 1 6b. Taxes and certain other debts you owe the government 6b. $ 0.00

6c. Claims for death or personal injury while you were intoxicated 6c. $ 0.00

6d. Other. Add all other priority unsecured claims. Write that amount here. 6d. $ 0.00

6e. Total Priority. Add lines 6a through 6d. 6e. $ 0.00

Total Claim

6f. Student loans 6f. $ 0.00

Total

claims

from Part 2 6g. Obligations arising out of a separation agreement or divorce that

you did not report as priority claims 6g. $ 0.00

6h. Debts to pension or profit-sharing plans, and other similar debts 6h. $ 0.00

6i. Other. Add all other nonpriority unsecured claims. Write that amount

here.

6i.

$ 3,307.00

6j. Total Nonpriority. Add lines 6f through 6i. 6j. $ 3,307.00

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 5 of 5

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Case 16-13801-RGM Doc 14 Filed 12/13/16 Entered 12/13/16 15:58:17 Desc Main

 Document Page 24 of 37
Fill in this information to identify your case:

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801

(if known)  Check if this is an

amended filing

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 contacts of leases are listed on Schedule A/B:Property (Official Form 106 A/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

Name, Number, Street, City, State and ZIP Code

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

Official Form 106G Schedule G: Executory Contracts and Unexpired Leases Page 1 of 1

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

Case 16-13801-RGM Doc 14 Filed 12/13/16 Entered 12/13/16 15:58:17 Desc Main

 Document Page 25 of 37
Fill in this information to identify your case:

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801

(if known)  Check if this is an

amended filing

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?

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

Name, Number, Street, City, State and ZIP Code

Column 2: The creditor to whom you owe the debt

Check all schedules that apply:

3.1  Schedule D, line

Name  Schedule E/F, line

 Schedule G, line

Number Street

City State ZIP Code

3.2  Schedule D, line

Name  Schedule E/F, line

 Schedule G, line

Number Street

City State ZIP Code

Official Form 106H Schedule H: Your Codebtors Page 1 of 1

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Case 16-13801-RGM Doc 14 Filed 12/13/16 Entered 12/13/16 15:58:17 Desc Main

 Document Page 26 of 37
Fill in this information to identify your case:

Debtor 1 Teresa S Rose

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA

DIVISION)

Case number 16-13801 Check if this is:

(If known)  An amended filing

 A supplement showing postpetition chapter

13 income as of the following date:

Official Form 106I MM / DD/ YYYY

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. Debtor 1 Debtor 2 or non-filing spouse

If you have more than one job,

attach a separate page with

information about additional

employers.

Include part-time, seasonal, or

self-employed work.

Occupation may include student

or homemaker, if it applies.

Employment status

 Employed

 Not employed

 Employed

 Not employed

Occupation

Employer's name Burlington Coat Factory

Employer's address 1830 Route 130 North

Burlington, NJ 08016

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. $ 4,679.72 $ N/A

3. Estimate and list monthly overtime pay. 3. +$ 0.00 +$ N/A

4. Calculate gross Income. Add line 2 + line 3. 4. $ 4,679.72 $ N/A

Official Form 106I Schedule I: Your Income page 1

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 Document Page 27 of 37
Debtor 1 Teresa S Rose Case number (if known) 16-13801

For Debtor 1 For Debtor 2 or

non-filing spouse

Copy line 4 here 4. $ 4,679.72 $ N/A

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a. $ 669.33 $ N/A

5b. Mandatory contributions for retirement plans 5b. $ 0.00 $ N/A

5c. Voluntary contributions for retirement plans 5c. $ 0.00 $ N/A

5d. Required repayments of retirement fund loans 5d. $ 0.00 $ N/A

5e. Insurance 5e. $ 490.45 $ N/A

5f. Domestic support obligations 5f. $ 0.00 $ N/A

5g. Union dues 5g. $ 0.00 $ N/A

5h. Other deductions. Specify: 5h.+ $ 0.00 + $ N/A

6. Add the payroll deductions. Add lines 5a+5b+5c+5d+5e+5f+5g+5h. 6. $ 1,159.78 $ N/A

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $ 3,519.94 $ N/A

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. $ 0.00 $ N/A

8b. Interest and dividends 8b. $ 0.00 $ N/A

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

regularly receive

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

settlement, and property settlement. 8c. $ 0.00 $ N/A

8d. Unemployment compensation 8d. $ 0.00 $ N/A

8e. Social Security 8e. $ 0.00 $ N/A

8f. Other government assistance that you regularly receive

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

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

Nutrition Assistance Program) or housing subsidies.

Specify: 8f. $ 0.00 $ N/A

8g. Pension or retirement income 8g. $ 0.00 $ N/A

8h. Other monthly income. Specify: Part time Job 8h.+ $ 450.00 + $ N/A

Daughter's contribution to car payments $ 268.00 $ N/A

Tax refund (prorated) $ 208.00 $ N/A

9. Add all other income. Add lines 8a+8b+8c+8d+8e+8f+8g+8h. 9. $ 926.00 $ N/A

10. Calculate monthly income. Add line 7 + line 9. 10. $ 4,445.94 + $ N/A = $ 4,445.94

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

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

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

other friends or relatives.

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

Specify: 11. +$ 0.00

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

12. $ 4,445.94

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

applies

Combined

monthly income

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

 No.

 Yes. Explain:

Official Form 106I Schedule I: Your Income page 2

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 Document Page 28 of 37
Fill in this information to identify your case:

Debtor 1 Teresa S Rose Check if this is:

 An amended filing

Debtor 2  A supplement showing postpetition chapter

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

(ALEXANDRIA DIVISION)

MM / DD / YYYY

Case number 16-13801

(If known)

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

2. Do you have dependents?  No

Do not list Debtor 1 and

Debtor 2.

 Yes. Fill out this information for

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

Dependent’s relationship to

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent

live with you?

Do not state the

dependents names. Daughter 22

 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 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. $ 1,567.00

If not included in line 4:

4a. Real estate taxes 4a. $ 0.00

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

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

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

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

Official Form 106J Schedule J: Your Expenses page 1

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 Document Page 29 of 37
Debtor 1 Teresa S Rose Case number (if known) 16-13801

6. Utilities:

6a. Electricity, heat, natural gas 6a. $ 200.00

6b. Water, sewer, garbage collection 6b. $ 30.00

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

6d. Other. Specify: Cellphones 6d. $ 200.00

7. Food and housekeeping supplies 7. $ 350.00

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

9. Clothing, laundry, and dry cleaning 9. $ 70.00

10. Personal care products and services 10. $ 70.00

11. Medical and dental expenses 11. $ 45.00

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

Do not include car payments. 12. $ 250.00

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $ 70.00

14. Charitable contributions and religious donations 14. $ 0.00

15. Insurance.

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

15a. Life insurance 15a. $ 0.00

15b. Health insurance 15b. $ 0.00

15c. Vehicle insurance 15c. $ 135.00

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

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

Specify: Property taxes 16. $ 30.00

17. Installment or lease payments:

17a. Car payments for Vehicle 1 17a. $ 268.00

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

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

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

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

deducted from your pay on line 5, Schedule I, Your Income (Official Form 106I). 18. $ 0.00

19. Other payments you make to support others who do not live with you. $ 810.00

Specify: Daughter's expenses in college (rent and food) 19.

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

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

20b. Real estate taxes 20b. $ 0.00

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

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

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

21. Other: Specify: 21. +$ 0.00

22. Calculate your monthly expenses

22a. Add lines 4 through 21. $ 4,145.00

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. $ 4,145.00

23. Calculate your monthly net income.

23a. Copy line 12 (your combined monthly income) from Schedule I. 23a. $ 4,445.94

23b. Copy your monthly expenses from line 22c above. 23b. -$ 4,145.00

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

The result is your monthly net income. 23c. $ 300.94

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: Daughter graduates from college in May, 2016. Debtor's disposable income will increase then.

Official Form 106J Schedule J: Your Expenses page 2

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 Document Page 30 of 37
Fill in this information to identify your case:

Debtor 1 Teresa S Rose

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA (ALEXANDRIA DIVISION)

Case number 16-13801

(if known)  Check if this is an

amended filing

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.

X /s/ Teresa S Rose X

Teresa S Rose Signature of Debtor 2

Signature of Debtor 1

Date December 13, 2016 Date

Official Form 106Dec Declaration About an Individual Debtor's Schedules

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 Document Page 31 of 37
Fill in this information to identify your case: Check as directed in lines 17 and 21:

According to the calculations required by this

Statement:

 1. Disposable income is not determined under

11 U.S.C. § 1325(b)(3).

 2. Disposable income is determined under 11

U.S.C. § 1325(b)(3).

 3. The commitment period is 3 years.

 4. The commitment period is 5 years.

Debtor 1 Teresa S Rose

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the:

Eastern District of Virginia

(Alexandria Division)

Case number 16-13801

(if known)

 Check if this is an amended filing

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). $ 4,827.85 $

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

Column B is filled in. $ 0.00 $

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

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

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

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

filled in. Do not include payments you listed on line 3. $ 0.00 $

5. Net income from operating a business,

profession, or farm Debtor 1

Gross receipts (before all deductions) $ 0.00

Ordinary and necessary operating expenses -$ 0.00

Net monthly income from a business, profession, or farm $ 0.00 Copy here -> $ 0.00 $

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

Gross receipts (before all deductions) $ 0.00

Ordinary and necessary operating expenses -$ 0.00

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

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

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Debtor 1 Teresa S Rose Case number (if known) 16-13801

Column A

Debtor 1

Column B

Debtor 2 or

non-filing spouse

7. Interest, dividends, and royalties $ 0.00 $

8. Unemployment compensation $ 0.00 $

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

the Social Security Act. Instead, list it here:

For you $ 0.00

For your spouse $

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

benefit under the Social Security Act. $ 0.00 $

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

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

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

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

total below.

Part time job $ 361.68 $

$ 0.00 $

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

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

each column. Then add the total for Column A to the total for Column B. $ 5,189.53 + $ = $ 5,189.53

Total average

monthly income

Part 2: Determine How to Measure Your Deductions from Income

12. Copy your total average monthly income from line 11. $ 5,189.53

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 $ 0.00 Copy here=> - 0.00

14. Your current monthly income. Subtract line 13 from line 12. $ 5,189.53

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

15a. Copy line 14 here=> $

5,189.53

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. ........................................... $ 62,274.36

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

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 Document Page 33 of 37
Debtor 1 Teresa S Rose Case number (if known) 16-13801

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

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

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

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

70,976.00

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

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

17. How do the lines compare?

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

11 U.S.C. § 1325(b)(3). Go to Part 3. Do NOT fill out Calculation of Your 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 Your 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 . $ 5,189.53

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. -$ 0.00

19b. Subtract line 19a from line 18. $ 5,189.53

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

20a. Copy line 19b $

5,189.53

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 $ 62,274.36

20c. Copy the median family income for your state and size of household from line 16c $ 70,976.00

21. How do the lines compare?

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

period is 3 years. Go to Part 4.

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

commitment period is 5 years. Go to Part 4.

Part 4: Sign Below

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

X /s/ Teresa S Rose

Teresa S Rose

Signature of Debtor 1

Date December 13, 2016

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.

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

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

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ChexSystems

Attn: Consumer Relations

7805 Hudson Rd., Suite 100

Saint Paul, MN 55125

Equifax Check Services

PO Box 30272

Tampa, FL 33630-3272

Telecheck Services, Inc.

5251 Westheimer

Houston, TX 77056

TransUnion

P.O. Box 2000

Chester, PA 19022

Experian

475 Anton Blvd

Costa Mesa, CA 92626

Internal Revenue Service - VA

Centralized Insolvency

P.O. Box 7346

Philadelphia, PA 19101-7346

Virginia Department of Taxatio

PO Box 2156

Richmond, VA 23218-2156

Early Warning Services

16552 N 90th St.

Scottsdale, AZ 85255

AMCB

P.O. Box 37007

Baltimore, MD 21297

Arcadia Recovery Bureau

PO BOX 70256

Philadelphia, PA 19176

Capital One

Po Box 30285

Salt Lake City, UT 84130

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Client Services, Inc

3451 Harry Truman Blvd

Saint Charles, MO 63301-4047

EMA

20010 Century Blvd

Ste 200

Germantown, MD 20874-1118

Franklin Collection Service, Inc

Po Box 3910

Tupelo, MS 38801

Inova

PO Box 37013

Baltimore, MD 21297

INOVA Health Care Services

c/o Golinowski & Colarusso

4015 Chain Bridge Road

Fairfax, VA 22030

Novant Heath Haymarket Med Ctr

PO Box 7428

Merrifield, VA 22116

Ocwen Loan Servicing Llc

Attn: Research Dept

1661 Worthintong Rd Ste 100

West Palm Beach, FL 33409

Stellar Recovery Inc

Attn: Bankruptcy

4500 Salisbury Road Ste 105

Jackonville, FL 32216

US Department of HUD

Housing Finance and Operations

451 7th Street, S.W. Room 1012

Washington, DC 20410

Wells Fargo Dealer Services

Po Box 3569

Rancho Cucamonga, CA 91729

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Wffnb Dual L

Po Box 94498

Las Vegas, NV 89193

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