Official Form 106A/B

Schedule A/B: Property 12/15 

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

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

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?

 Check if this is an

amended filing

Part 1: Describe Each Residence, Building, Land, or Other Real Estate You Own or Have an Interest In

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.

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:

1.1.

County $661,105.00 

Residential

$661,105.00 

14915 Largo Vista Dr Haymarket, VA 

20169

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.............................................................  $661,105.00 

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.

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





No

Yes

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 1 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

3.1. 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?

Make:

Model:

Year:

Approximate mileage:

Other information:

$19,000.00 $19,000.00 

Ford

F350

2008

160,000

2008 Ford F350 (approx. 160000 

miles)

3.2. 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?

Make:

Model:

Year:

Approximate mileage:

Other information:

$25,000.00 $25,000.00 

Chevrolet

Suburban

2012

79,000

2012 Chevrolet Suburban (approx. 

79000 miles)

3.3. 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?

Make:

Model:

Year:

Approximate mileage:

Other information:

$11,000.00 $11,000.00 

Chevrolet

Corvette

1998

80,000

1998 Chevrolet Corvette (approx. 

80000 miles)

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





No

Yes

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

4.1. 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?

Make:

Model:

Year:

Other information: $3,500.00 $3,500.00 

Pilgrim

Travel Trailer

2006

2006 Pilgrim Travel Trailer

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.............................................................  $58,500.00 

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





No

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

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

See continuation page(s). $1,160.00 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 2 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

7. Electronics





No

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

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

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

Entertainment & Electronics $320.00 

8. Collectibles of value





No

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

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

9. Equipment for sports and hobbies





No

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

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

canoes and kayaks; carpentry tools; musical instruments

See continuation page(s). $150.00 

10. Firearms





No

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

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

11. Clothes





No

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

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

Clothing $400.00 

12. Jewelry





No

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

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

gold, silver

See continuation page(s). $540.00 

13. Non-farm animals





No

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

Examples: Dogs, cats, birds, horses

2 Dogs $1.00 

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





No

Yes. Give specific

did not list

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 the number here.............................................................................................................. .........

$2,571.00 

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





No

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

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

petition

Cash: ........................................... $2.00 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 3 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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





No

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

institution, list each.

Institution name:

17.1. Checking account: BB&T Checking account $200.00 

17.2. Checking account: The Fauquier Bank checking account ending in 7407 $200.00 

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

Name of entity: % of ownership:

information about

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

Artistic Building Concepts Inc. 100% $1.00 

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

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





No

Issuer name:

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

Yes. Give specific

information about

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

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

Type of account: Institution name:

Yes. List each

account separately.

401(k) or similar plan: 403(b) $2,780.65 

Retirement account: Virginia Retirement System Defined Benefit Plan $74,614.44 

22. Security deposits and prepayments

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

companies, or others





No

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

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

23. Annuities (A contract for a specific 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.





No

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

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

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





No

Yes. Give specific

powers exercisable for your benefit

information about them

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 4 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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





No

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

Yes. Give specific

information about them

27. Licenses, franchises, and other general intangibles





No

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

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:

$1.00 

$1.00 

$0.00 

Federal: 2015 Federal Tax Refund - Come & Gone. Amt: 

$1.00

State: 2015 State Tax Refund - Come & Gone. Amt: $1.00

29. Family support





No

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

Yes. Give specific information Alimony:

Maintenance:

Support:

Divorce settlement:

Property settlement:

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

30. Other amounts someone owes you





No

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

Yes. Give specific information

compensation, Social Security benefits; unpaid loans you made to someone else

31. Interests in insurance policies





No

Yes. Name the insurance

Company name: Beneficiary:

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

Surrender or refund value: 

company of each policy

and list its value................

Term Life through work $1.00 

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





No

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

Yes. Give specific information

entitled to receive property because someone has died

Inchoate Inheritance $2.00 

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





No

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

Yes. Describe each claim.............. Regina Jones v. Johnson & Johnson Class Action Unknown 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 5 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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





No

rights to set off claims

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

$77,803.09 

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.

38. Accounts receivable or commissions you already earned





No

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

Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

39. Office equipment, furnishings, and supplies





No

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

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones,

desks, chairs, electronic devices

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





No

Yes. Describe................ Builder/Contractor Tools and ladders $520.00 

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

$520.00 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 6 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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

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.

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

47. Farm animals





No

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

Examples: Livestock, poultry, farm-raised fish

Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

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

$0.00 

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?





No

Yes. Give specific information.

Examples: Season tickets, country club membership

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

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 7 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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.

63. Total of all property on Schedule A/B.

Add lines 56 through 61.................................

Copy personal

property total 

+

+

Add line 55 + line 62.......................................................................................................

$661,105.00 

$58,500.00 

$2,571.00 

$77,803.09 

$520.00 

$0.00 

$0.00 

$139,394.09 $139,394.09 

$800,499.09 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 8 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

6. Household goods and furnishings (details):

Kitchen & Dining Items $370.00 

Living Room Items $310.00 

Bedroom Items $415.00 

Household tools $45.00 

Books $20.00 

9. Equipment for sports and hobbies (details):

Fishing rods $30.00 

Rifle $60.00 

Hand gun $60.00 

12. Jewelry (details):

Watches $40.00 

Wedding and engagement jewelry $400.00 

Costume jewelry $100.00 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 9 of 58
Official Form 106C

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

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).

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)

 Check if this is an

amended filing

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.

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

Copy the value from

Schedule A/B

Amount of the 

exemption you claim

Check only one box for 

each exemption

Current value of Specific laws that allow exemption

the portion you 

own

Brief description:

Line from Schedule A/B:





1.1

$661,105.00 $2.00

14915 Largo Vista Dr Haymarket, VA 

20169

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





3.1

$19,000.00 $1.00

2008 Ford F350 (approx. 160000 miles)

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





3.2

$25,000.00 $1.00

2012 Chevrolet Suburban (approx. 79000 

miles)

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 1 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 10 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Additional Page

Brief description of the property and line on

Schedule A/B that lists this property

Copy the value from

Schedule A/B

Chad M. Jones 16-11552-BFK

Amount of the 

exemption you claim

Check only one box for 

each exemption

Current value of Specific laws that allow exemption

the portion you 

own

Brief description:

Line from Schedule A/B:





3.3

$11,000.00 $1.00

1998 Chevrolet Corvette (approx. 80000 

miles)

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





4.1

$3,500.00 $3,500.00

2006 Pilgrim Travel Trailer

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





6

$370.00 $370.00

Kitchen & Dining Items

Va. Code Ann. § 34-26(4a)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





6

$310.00 $310.00

Living Room Items

Va. Code Ann. § 34-26(4a)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





6

$415.00 $415.00

Bedroom Items

Va. Code Ann. § 34-26(4a)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





6

$45.00 $45.00

Household tools

Va. Code Ann. § 34-26(4a)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





6

$20.00 $20.00

Books

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





7

$320.00 $320.00

Entertainment & Electronics

Va. Code Ann. § 34-26(4a)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





9

$30.00 $30.00

Fishing rods

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 11 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Additional Page

Brief description of the property and line on

Schedule A/B that lists this property

Copy the value from

Schedule A/B

Chad M. Jones 16-11552-BFK

Amount of the 

exemption you claim

Check only one box for 

each exemption

Current value of Specific laws that allow exemption

the portion you 

own

Brief description:

Line from Schedule A/B:





9

$60.00 $60.00

Rifle 

Va. Code Ann. § 34-26(4b)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





9

$60.00 $60.00

Hand gun

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





11

$400.00 $400.00

Clothing

Va. Code Ann. § 34-26(4)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





12

$40.00 $40.00

Watches

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





12

$400.00 $400.00

Wedding and engagement jewelry

Va. Code Ann. § 34-26(1a)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





12

$100.00 $100.00

Costume jewelry

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





13

$1.00 $1.00

2 Dogs

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





16

$2.00 $2.00

Cash on hand

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





17.1

$200.00 $200.00

BB&T Checking account

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Official Form 106C Schedule C: The Property You Claim as Exempt page 3 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 12 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Additional Page

Brief description of the property and line on

Schedule A/B that lists this property

Copy the value from

Schedule A/B

Chad M. Jones 16-11552-BFK

Amount of the 

exemption you claim

Check only one box for 

each exemption

Current value of Specific laws that allow exemption

the portion you 

own

Brief description:

Line from Schedule A/B:





17.2

$200.00 $200.00

The Fauquier Bank checking account 

ending in 7407

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





19

$1.00 $1.00

Artistic Building Concepts Inc.

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





21

$74,614.44 $74,614.44

Virginia Retirement System Defined 

Benefit Plan

11 U.S.C. § 522(n)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





21

$2,780.65 $2,780.65

403(b)

11 U.S.C. § 522(n)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





28

$1.00 $1.00

2015 Federal Tax Refund - Come & Gone

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





28

$1.00 $1.00

2015 State Tax Refund - Come & Gone

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





31

$1.00 $1.00

Term Life through work

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





32

$2.00 $2.00

Inchoate Inheritance

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





33

Unknown $0.00

Regina Jones v. Johnson & Johnson Class 

Action

(1st exemption claimed for this asset)

Va. Code Ann. § 34-4

100% of fair market 

value, up to any 

applicable statutory 

limit

Official Form 106C Schedule C: The Property You Claim as Exempt page 4 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 13 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Additional Page

Brief description of the property and line on

Schedule A/B that lists this property

Copy the value from

Schedule A/B

Chad M. Jones 16-11552-BFK

Amount of the 

exemption you claim

Check only one box for 

each exemption

Current value of Specific laws that allow exemption

the portion you 

own

Brief description:

Line from Schedule A/B:





33

Unknown $0.00

Regina Jones v. Johnson & Johnson Class 

Action

(2nd exemption claimed for this asset)

Va. Code Ann. § 34-28.1

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





40

$520.00 $520.00

Builder/Contractor Tools and ladders

Va. Code Ann. § 34-26(7)

100% of fair market 

value, up to any 

applicable statutory 

limit

Official Form 106C Schedule C: The Property You Claim as Exempt page 5 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 14 of 58
Official Form 106D

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

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.

 Check if this is an

amended filing

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).

Part 1: List All Secured Claims

2. List all secured claims. If a creditor has more than one secured

Column A Column B Column C

Amount of claim Value of collateral Unsecured

portion

If any

that supports this

claim

Do not deduct the

value of collateral

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.

2.1 Describe the property that

secures the claim:

Creditor's name

Number Street

City State ZIP Code

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

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)

Last 4 digits of account number

BB&T

PO BOX 1847

Wilson NC 27894

$115,158.04 $661,105.00 $115,158.04 

 

14915 Largo Vista Dr 

Haymarket, VA 20169

2nd Mtg

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

$115,158.04 

Add the dollar value of your entries in Column A on this page. Write 

that number here:

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 15 of 58
Part 1:

Additional Page Column A Column B Column C

Amount of claim Value of collateral Unsecured

portion

If any

that supports this

claim

Do not deduct the

value of collateral

Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

After listing any entries on this page, number them

sequentially from the previous page.

2.2 Describe the property that

secures the claim:

Creditor's name

Number Street

City State ZIP Code

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

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)

Last 4 digits of account number

M&T Bank

POB 900

Millsboro DE 19966

$38,406.00 $25,000.00 $13,406.00 

 

2012 Chevy Suburban

Purchase Money

2.3 Describe the property that

secures the claim:

Creditor's name

Number Street

City State ZIP Code

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

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)

Last 4 digits of account number

PWC Employees CU

12715 Ridgefield Vill Dr

Woodbridge VA 22193

$19,933.00 $11,000.00 $8,933.00 

 

Chevy Corvette

Purchase Money

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

$58,339.00 

Add the dollar value of your entries in Column A on this page. Write 

that number here:

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 16 of 58
Part 1:

Additional Page Column A Column B Column C

Amount of claim Value of collateral Unsecured

portion

If any

that supports this

claim

Do not deduct the

value of collateral

Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

After listing any entries on this page, number them

sequentially from the previous page.

2.4 Describe the property that

secures the claim:

Creditor's name

Number Street

City State ZIP Code

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

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)

Last 4 digits of account number

Specialized Loan Svc

POB 266005

Littleton CO 80163

$682,623.67 $661,105.00 $21,518.67 

 

14915 Largo Vista Dr 

Haymarket, VA 20169

1st Mtg

2.5 Describe the property that

secures the claim:

Creditor's name

Number Street

City State ZIP Code

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

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)

Last 4 digits of account number

Tower FCU

7901 Sandy Spring Rd

Laurel MD 20707

$28,714.00 $19,000.00 $9,714.00 

 

2008 Ford F350

Purchase Money

Official Form 106D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page 3 

$711,337.67 

$884,834.71 

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:

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 17 of 58
Official Form 106E/F

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

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





No. Go to Part 2.

Yes.

 Check if this is an

amended filing

on Schedule A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases

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).

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

Part 1: List All of Your PRIORITY Unsecured Claims

(Official Form 106G).

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

Total claim Priority

amount

Nonpriority

amount

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

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 

more space is needed for 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.

2.1

Last 4 digits of account number 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

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

Other. Specify

intoxicated

Prince William Circuit Court

9311 Lee Ave

Manassas VA 20110

Unknown Unknown Unknown 

 

Administrative Priority

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 18 of 58
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 you other schedules.

Yes

Part 2: List All of Your NONPRIORITY Unsecured Claims

Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim.

Total 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 more space is needed for nonpriority unsecured claims, fill out the Continuation Page of Part 2.

4.1

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Advance America

8368 Sudley Rd

Manassas VA 20109

$623.50 

 

Payday Loan

4.2

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Barclay's Bank Delaware

700 Prides Xing

Newark DE 19713

$2,639.35 

 

Credit Card

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 2 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 19 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.3

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Capital One

POB 30285

Salt Lake City UT 84130

$1,113.00 

6 9 8 9

Credit Card

4.4

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Capital One

POB 30285

Salt Lake City UT 84130

$1,145.00 

5 2 7 1

Credit Card

4.5

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Capital One

POB 30285

Salt Lake City UT 84130

$883.00 

9 2 6 6

Credit Card

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 3 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 20 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.6

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Capital One

POB 30285

Salt Lake City UT 84130

$1,131.00 

 

Credit Card

4.7

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Capital One

POB 30285

Salt Lake City UT 84130

$1,000.00 

 

Credit Card

4.8

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Federal Loan Svcing Credit

POB 60610

Harrisburg PA 17106

$78,881.00 

 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 4 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 21 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.9

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

First Premier Bank

601 S Minnesota Ave

Sioux Falls SD 57104

$559.00 

5 4 4 0

Credit Card

4.10

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

First Premier Bank

601 S Minnesota Ave

Sioux Falls SD 57104

$625.00 

 

Credit Card

4.11

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

First Premier Bank

601 S Minnesota Ave

Sioux Falls SD 57104

$400.00 

 

Credit Card

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 22 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.12

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Kohls/Cap 1

PO BOX 3115

Milwaukee WI 53201

$689.00 

 

Credit Card

4.13

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Mariner Finance of Virginia LLC

4118 Leonard Dr Ste 200

Fairfax VA 22030

$3,100.00 

 

Credit Card

4.14

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Michael & Nancy Gleysteen

14428 Chamberry Cir

Haymarket VA 20169

$63,934.44 

 

Misc

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 6 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 23 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.15

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Peter Martin

7014 Old Carolina Rd

Gainesville VA 20155

$8,300.00 

 

Misc

4.16

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

PWC Employees CU

12715 Ridgefield Vill Dr

Woodbridge VA 22193

$7,995.00 

 

Loan

4.17

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

PWC Employees CU

12715 Ridgefield Vill Dr

Woodbridge VA 22193

$2,741.00 

 

Loan

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 7 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 24 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.18

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

PWC Employees CU

12715 Ridgefield Vill Dr

Woodbridge VA 22193

$9,906.00 

 

Loan

4.19

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Reico Kitchen & Bath

6790 Commercial Dr

Springfield VA 22151

$48,000.00 

 

Misc

4.20

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Springleaf Fin Svcs

POB 59

Evansville IN 47701

$5,535.00 

 

Loan

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 8 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 25 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.21

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

SYNCB/Amazon

POB 965015

Orlando FL 32896

$750.00 

 

Credit Card

4.22

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

SYNCB/Ashley Furniture

POB 960061

Orlando FL 32896

$2,984.00 

 

Credit Card

4.23

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

SYNCB/Paypal Smart Conn

POB 965005

Orlando FL 32896

$300.00 

 

Credit Card

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 9 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 26 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.24

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

SYNCB/Walmart

POB 965024

Orlando FL 32896

$600.00 

 

Credit Card

4.25

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

Target Corp

PO Box 673

Minneapolis MN 55440

$700.00 

 

Credit Card

4.26

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

The Fauquier Bank

10 Courthouse Square

Warrenton VA 20186

$1,000.00 

 

Loan

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 10 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 27 of 58
Debtor 1

First Name Middle Name Last Name

Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the

previous page.

Chad M. Jones 16-11552-BFK

4.27

Last 4 digits of account number

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

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

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

Other. Specify

that you did not report as priority claims

The Fauquier Bank

10 Courthouse Square

Warrenton VA 20186

$5,000.00 

 

Loan

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 11 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 28 of 58
Part 3: List Others to Be Notified About a Debt That You Already Listed

5.

Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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 parties 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

David D. Armistead III Esq/Gleysteen

2750 Killarney Dr Ste 203

Woodbridge VA 22192

 

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

Jeremy S. Tishler, Esq

9842 Business Way

Manassas VA 20110

4.15

 

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

Prince William Circuit Ct/M & N Gleystee

9311 Lee Ave

Manassas VA 20110

5 9 0 0

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

Prince William County GDC/Peter Martin

9311 Lee Ave

Manassas VA 20110

7 7 0 0

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

Prince William GDC/PWC Employees CU

9311 Lee Ave

Manassas VA 20110

7 1 0 0

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 12 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 29 of 58
Part 4: Add the Amounts for Each Type of Unsecured Claim

6.

6a. Domestic support obligations

6b. Taxes and certain other debts you owe the government

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

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

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

6a.

Total claim

6b.

6c.

6d.

6d.

+ 

6f. Student loans

6g. Obligations arising out of a separation agreement or divorce

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

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

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

6f.

Total claim

6g.

6h.

6i.

6j.

+ 

that you did not report as priority claims

debts

Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$78,881.00 

$0.00 

$0.00 

$171,653.29 

$250,534.29 

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 claims 

from Part 1

Total claims 

from Part 2

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 13 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 30 of 58
Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15 

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

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

 Check if this is an

amended filing

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

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).

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

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 31 of 58
Official Form 106H

Schedule H: Your Codebtors 12/15 

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

1. Do you have any codebtors?





No

Yes

 Check if this is an

amended filing

(If you are filing a joint case, do not list either spouse as a codebtor.)

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.

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

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:

Official Form 106H Schedule H: Your Codebtors page 1 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 32 of 58
Official Form 106I

Schedule I: Your Income 12/15 

Part 1: Describe Employment

1.

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

 An amended filing

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

Fill in your employment

Check if this is:

 A supplement showing postpetition

chapter 13 income as of the following date:

MM / DD / YYYY

information.

Employment status

Occupation

Employer's name

Employer's address

How long employed there?

Debtor 1 Debtor 2 or non-filing spouse

Employed

 Not employed

Employed

 Not employed

Number Street Number Street

City State Zip Code City State Zip Code

Leadman

Pendleton Homes

McLean, VA

2 mos

Admin Coord

Prince William County Public Schools

15000 Graduation Dr

Haymarket, VA

18 yrs

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.

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.

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.

2. List monthly gross wages, salary, and commissions

For Debtor 1 For Debtor 2 or

non-filing spouse

(before all

payroll deductions). If not paid monthly, calculate what the monthly wage

2. $3,357.50 $7,943.82 

would be.

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.

3. Estimate and list monthly overtime pay. 3. + $0.00 $0.00 

4. Calculate gross income. Add line 2 + line 3. 4. $3,357.50 $7,943.82 

Official Form 106I Schedule I: Your Income page 1 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 33 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

Copy line 4 here ...................................................................................................................

For Debtor 1 For Debtor 2 or

non-filing spouse

 4. $3,357.50 $7,943.82 

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.

5h. Other deductions.

Specify: +

$427.85 $1,534.20 

$0.00 $834.96 

$0.00 $0.00 

$0.00 

$0.00 

$0.00 

$317.60 

$0.00 

$234.48 

$0.00 $0.00 

$0.00 $0.00 

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e + 5f + 6. $427.85 $2,921.24 

5g + 5h.

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $2,929.65 $5,022.58 

8. List all other income regularly received:

8a. 8a.

8b. Interest and dividends 8b.

8c. 8c.

8d. Unemployment compensation 8d.

8f.

8f.

8e. Social Security 8e.

Other government assistance that you regularly receive

Specify:

8h.

8h.

8g. Pension or retirement income 8g.

Other monthly income.

Specify: +

$0.00 $0.00 

$0.00 $0.00 

$0.00 $0.00 

$0.00 $0.00 

$0.00 $0.00 

$0.00 $0.00 

$0.00 $0.00 

AVG TAX REFUND $583.00 $0.00 

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.

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.

Include cash assistance and the value (if known) or any noncash assistance that you receive, such as food stamps 

(benefits under the Supplemental Nutrition Assistance Program) 

or housing subsidies.

9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f + 8g + 8h. 9. $583.00 $0.00 

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

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

$3,512.65 $5,022.58 + = $8,535.23 

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

Specify: 11. + $0.00 

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.

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

income. Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information,

Combined

monthly income

$8,535.23 

if it applies.

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

No.

Yes. Explain:





None.

Official Form 106I Schedule I: Your Income page 2 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 34 of 58
Official Form 106J

Schedule J: Your Expenses 12/15 

Part 1: Describe Your Household

1.

 An amended filing

Is this a joint case?

Check if this is:

 A supplement showing postpetition

chapter 13 expenses as of the

following date:

MM / DD / YYYY

 No. Go to line 2.

Yes.

No

 Yes. Debtor 2 must file Official Form 106J-2, Expenses for Separate Household of Debtor 2.

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

Does Debtor 2 live in a separate household?

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.

2. Do you have dependents? 



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

Son

Son

Son

13

10

6

Do not list Debtor 1 and 

Debtor 2.

Do not state the dependents' 

names.

3. 



No

Yes

Do your expenses include 

expenses of people other than 

yourself and your dependents?

Part 2: Estimate Your Ongoing Monthly Expenses

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

4b. Property, homeowner's, or renter's insurance

4c. Home maintenance, repair, and upkeep expenses

4d. Homeowner's association or condominium dues

4a.

4b.

4c.

4d.

$2,746.33 

$75.00 

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.)

Official Form 106J Schedule J: Your Expenses page 1 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 35 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

Your expenses

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

6. Utilities:

6a. Electricity, heat, natural gas

6b. Water, sewer, garbage collection

6c. Telephone, cell phone, Internet, satellite, and 

6d. Other. Specify:

6a.

6b.

6c.

6d.

$700.00 

$270.00 

Cell Phones $350.00 

cable services

7. Food and housekeeping supplies 7. $800.00 

8. Childcare and children's education costs 8. $375.00 

9. Clothing, laundry, and dry cleaning 9. $120.00 

10. Personal care products and services 10. $110.00 

11. Medical and dental expenses 11. $200.00 

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

fare. Do not include car payments.

$400.00 

13. Entertainment, clubs, recreation, newspapers, 13. $100.00 

magazines, and books

14. Charitable contributions and religious donations 14. $40.00 

15. Insurance.

15a. Life insurance

15b. Health insurance

15c. Vehicle insurance

15d. Other insurance. Specify:

15a.

15b.

15c.

15d.

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

$235.00 

16. Taxes.

Specify: 16.

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

Car Tax $40.00 

17. Installment or lease payments:

17a. Car payments for Vehicle 1

17b. Car payments for Vehicle 2

17c. Other. Specify:

17d. Other. Specify:

17a.

17b.

17c.

17d.

M&T Bank - Suburban $790.00 

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

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

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

20a. Mortgages on other property

20b. Real estate taxes

20c. Property, homeowner's, or renter's insurance

20d. Maintenance, repair, and upkeep expenses

20a.

20b.

20c.

20d.

Schedule I: Your Income.

20e. Homeowner's association or condominium dues 20e.

Official Form 106J Schedule J: Your Expenses page 2 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 36 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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. 22c.

$7,351.33 

$7,351.33 

22a.

22b.

23. Calculate your monthly net income.

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

23b. Copy your monthly expenses from line 22c above.

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

23a.

23b.

The result is your monthly net income. 23c.

–

$8,535.23 

$7,351.33 

$1,183.90 

24. Do you expect an increase or decrease in your expenses within the year after you file this form?





No.

Yes. Explain here:

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?

Ongoing medicals

Official Form 106J Schedule J: Your Expenses page 3 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 37 of 58
Official Form 106Sum

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

Part 1: Summarize Your Assets

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

1a.

1b.

1c.

Copy line 55, Total real estate, from Schedule A/B.....................................................................................................................

Copy line 62, Total personal property, from Schedule A/B...........................................................................................................................................................

Copy line 63, Total of all property on Schedule A/B.....................................................................................................................................................................

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK  Check if this is an

amended filing

$661,105.00 

$139,394.09 

$800,499.09 

Your assets

Value of what you own

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 2: Summarize Your Liabilities

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

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.

3b.

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

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

Your total liabilities

2a. $884,834.71 

$0.00 

$250,534.29 

$1,135,369.00 

Your liabilities

Amount you owe

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 22c of Schedule J.........................................................................................................

$8,535.23 

$7,351.33 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 38 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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.

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. $9,482.31 

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.

9b.

Domestic support obligations. (Copy line 6a.)

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.

$0.00 

$0.00 

$0.00 

$78,881.00 

$0.00 

$0.00 

$78,881.00 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 39 of 58
Official Form 106Dec

Declaration About an Individual Debtor's Schedules 12/15 

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK  Check if this is an

amended filing

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).

X /s/ Chad M. Jones X /s/ Regina B. Jones

Chad M. Jones, Debtor 1 Regina B. Jones, Debtor 2

Date

MM / DD / YYYY

Date

MM / DD / YYYY

06/14/2016 06/14/2016

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.

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.

Official Form 106Dec Declaration About an Individual Debtor's Schedules page 1 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 40 of 58
Official Form 107

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK

1. What is your current marital status?





Married

Not married

 Check if this is an

amended filing

Part 1: Give Details About Your Marital Status and Where You Lived Before

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.

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.

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





No

Yes. Make sure you fill out

(Community property states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas,

Washington, and Wisconsin.)

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?





No

Yes. Fill in the details.

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.



 Operating a business

For the last calendar year:

(January 1 to December 31,

YYYY

)



Operating a business



Operating a business

For the calendar year before that:

(January 1 to December 31,

YYYY

)



 Operating a business



 Operating a business



 Operating a business

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

2015

2014

$9,460.50 

$11,000.00 

$22,000.00 

$31,775.32 

$75,000.00 

$72,000.00 

Wages, commissions, 

bonuses, tips

From January 1 of the current year until 

the date you filed for bankruptcy:

Wages, commissions, 

bonuses, tips

Wages, commissions, 

bonuses, tips

Wages, commissions, 

bonuses, tips

Wages, commissions, 

bonuses, tips

Wages, commissions, 

bonuses, tips

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 41 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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





No

Yes. Fill in the details.

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 in 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.

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.

* 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 $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.

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.

 Mortgage

Car

 Credit card

 Loan repayment

 Suppliers or vendors

 Other

Creditor's name

Number Street

City State ZIP Code

M&T Bank

POB 900

Millsboro DE 19966

$2,370.00 $38,406.00

Dates of

payment

Total amount Amount you Was this payment for...

paid still owe

Monthly

 Mortgage

Car

 Credit card

 Loan repayment

 Suppliers or vendors

 Other

Creditor's name

Number Street

City State ZIP Code

Tower FCU

7901 Sandy Spring Rd

Laurel MD 20707

$2,250.00 $28,714.00

Dates of

payment

Total amount Amount you Was this payment for...

paid still owe

Monthly

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 42 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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;





No

Yes. List all payments to an insider.

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.

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?





No

Yes. List all payments that benefited an insider.

Include payments on debts guaranteed or cosigned by an insider.

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?





No

Yes. Fill in the details.

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

modifications, and contract disputes.

Case title

Pending

 On appeal

Case number  Concluded

Court Name

Number Street

City State ZIP Code

GV16001477-00

Prince William General District Court

9311 Lee Avenue

Manassas VA 20110

Nature of the case Court or agency Status of the case

Warrant in Debt

Hrg: 9/22/2016

Peter Martin v. Artistic Building 

Concepts Inc. and Chad Jones

Case title

Pending

 On appeal

Case number  Concluded

Court Name

Number Street

City State ZIP Code

GV16005471-00

Prince William General District Court

9311 Lee Avneue

Manassas VA 20110

Nature of the case Court or agency Status of the case

Warrant in Debt

Hearing 6/28/2016

PWC Employees CU v. Chad 

Jones

Case title

Pending

 On appeal

Case number  Concluded

Court Name

Number Street

City State ZIP Code

CL16001559-00

Prince William County Circuit Court

9311 Lee Avenue

Manassas VA 20110

Nature of the case Court or agency Status of the case

Nancy & Michael Gleysteen v. Contract Action

Artistic Building Concepts Inc, 

Chad Jones, and Regina Jones

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

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Document Page 43 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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





No. Go to line 11.

Yes. Fill in the information below.

seized, or levied?

Check all that apply and fill in the details below.

11.





No

Yes. Fill in the details.

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?

12.





No

Yes

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?

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.

14.





No

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

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?

Part 6: List Certain Losses

15.





No

Yes. Fill in the details.

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?

Part 7: List Certain Payments or Transfers

16.





No

Yes. Fill in the details.

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

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?

Description and value of any property transferred Date payment

or transfer was

Amount of

Person Who Was Paid

Number Street

City State ZIP Code

Email or website address

Person Who Made the Payment, if Not You

payment Law Offices of Robert R. Weed

45575 Shepard Drive, Suite #201

Sterling VA 20164

05/02/2016 $2,500.00

made

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

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Document Page 44 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

Description and value of any property transferred Date payment

or transfer was

Amount of

Person Who Was Paid

Number Street

City State ZIP Code

Email or website address

Person Who Made the Payment, if Not You

payment Moneysharp.org

$20.00

made

17.





No

Yes. Fill in the details.

Do not include any payment or transfer that you listed on line 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 who promised to help you deal with your creditors or to make payments to your creditors?

18.





No

Yes. Fill in the details.

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 granting of a security interest or mortgage on your property).

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

Description and value of any Date transfer

was made

Person Who Received Transfer

Number Street

City State ZIP Code

property transferred

Describe any property or payments

received or debts paid in exchange Dealership

2014

Person's relationship to you None

Chevrolet Acadia traded in for 

Chevrolet Suburban

Description and value of any Date transfer

was made

Person Who Received Transfer

Number Street

City State ZIP Code

property transferred

Describe any property or payments

received or debts paid in exchange Chad Jones

12/2015

Person's relationship to you Spouse

Debtor wife transferred truck 

from her name to Debtor 

husband's name.

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 45 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

19.





No

Yes. Fill in the details.

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.)

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

20.





No

Yes. Fill in the details.

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.

21.





No

Yes. Fill in the details.

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?

22.





No

Yes. Fill in the details.

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

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

23.





No

Yes. Fill in the details.

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.

Part 10: Give Details About Environmental Information





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

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

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

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

Environmental law

Site

Hazardous material

hazardous or toxic substance, 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.

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

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

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

24.





No

Yes. Fill in the details.

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

law?

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 46 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

25.





No

Yes. Fill in the details.

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

26.





No

Yes. Fill in the details.

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

orders.

27.

 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)

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

 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.

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

business?

Business Name

Number Street

City State ZIP Code

Describe the nature of the business Employer Identification number

Name of accountant or bookkeeper

Do not include Social Security number or ITIN.

EIN: –

Dates business existed

From To

Artistic Building Concepts

2008 2016

Contractor/Builder

Debtor

28.





No

Yes. Fill in the details below.

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.

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

X /s/ Chad M. Jones X /s/ Regina B. Jones

Chad M. Jones, Debtor 1 Regina B. Jones, Debtor 2

Date Date

Did you attach additional pages toYour 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).

06/14/2016 06/14/2016

that 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.

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 47 of 58
Official Form 122C-1

Chapter 13 Statement of Your Current Monthly Income

12/15 

Part 1: Calculate Your Average Monthly Income

1.

 Check if this is an amended filing

What is your marital and filing status? Check one only.

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK





Not married.

Married.

Fill out Column A, lines 2-11.

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

Check as directed in lines 17 and 21:







1.

2.

3.

and Calculation of Commitment Period

4.

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).

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.

Disposable income is not determined 

under 11 U.S.C. § 1325(b)(3).

Disposable income is determined 

under 11 U.S.C. § 1325(b)(3).

The commitment period is 3 years.

According to the calculations required by this 

Statement:

The commitment period is 5 years.

Column B

Debtor 2 or

Column A

Debtor 1

non-filing spouse

2. Your gross wages, salary, tips, bonuses, overtime, and commissions

(before all payroll deductions).

$1,528.58 $7,953.73 

3. Alimony and maintenance payments. Do not include payments from a spouse. $0.00 $0.00 

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

expenses of you or your dependents, including child support. Include

$0.00 $0.00 

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

Gross receipts (before all

Ordinary and necessary operating

Net monthly income from a business,

Copy

here $0.00 $0.00 

$0.00 

$0.00 

$0.00 

– 

Debtor 1 Debtor 2

$0.00 

– 

$0.00 

$0.00 

expenses

profession, or farm

deductions)

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 48 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

Column B

Debtor 2 or

Column A

Debtor 1

non-filing spouse

6. Net income from rental and other real property

Gross receipts (before all

Ordinary and necessary operating

Net monthly income from rental or

Copy

here

$0.00 

$0.00 

$0.00  $0.00 $0.00 

– 

Debtor 1 Debtor 2

$0.00 

$0.00 

$0.00 

– 

expenses

other real property

deductions)

7. Interest, dividends, and royalties $0.00 $0.00 

8. Unemployment compensation

For you............................................................................................................................

For your spouse..............................................................................................................

$0.00 

$0.00 

$0.00 $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: .......................................  ........

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

was a benefit under the Social Security Act.

$0.00 $0.00 

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

Total amounts from separate pages, if any. + + 

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.

11. Calculate your total average monthly income.

+ =

Total average

monthly income

Add lines 2 through 10 for each column. $1,528.58 $7,953.73 $9,482.31 

Then add the total for Column A to the total for Column B.

Part 2: Determine How to Measure Your Deductions from Income

12. Copy your total average monthly income from line 11. .............................................................................................................................................. $9,482.31 

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.

Total...................................................................................................................... Copy here  $0.00 

+ 

$0.00 – 

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.

14. Your current monthly income. Subtract the total in line 13 from line 12. $9,482.31 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 49 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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

15a. Copy line 14 here  $9,482.31 

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. ....................................................................... $113,787.72 ................

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

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

Fill in the state in which you live.

Fill in the number of people in your household.

Fill in the median family income for your state and size of household....................................................................................$101,133.00 ..................................

Virginia

5

16a.

16b.

16c.

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,

Go to Part 3.

Disposable income is not determined

17b. Line 15b is more than line 16c. On the top of page 1 of this form, check box 2,

Go to Part 3 and fill out Calculation of Your Disposable Income (Official Form 122C-2).

Disposable income is determined under

under 11 U.S.C. § 1325(b)(3). Do NOT fill out Calculation of Your Disposable Income (Official Form 122C-2).

11 U.S.C. § 1325(b)(3).

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. .............................................................................................................................................. $9,482.31 

19. Deduct the marital adjustment if it applies. If you are married, your spouse is not filing with you, and you contend

If the marital adjustment does not apply, fill in 0 on line 19a. ....................................................................................................................... – $0.00 

Subtract line 19a from line 18. $9,482.31 

19a.

19b.

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.

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

20a. Copy line 19b $9,482.31 

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. $113,787.72 

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

20c. Copy the median family income for your state and size of household from line 16c. ....................................................... $101,133.00 

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,

The commitment period is 3 years.

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

The commitment period is 5 years.

Go to Part 4.

of this form, check box 4,

check box 3,

Go to Part 4.

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

Date Date

X X

Chad M. Jones, Debtor 1 Regina B. Jones, Debtor 2

6/14/2016 6/14/2016

/s/ Chad M. Jones /s/ Regina B. Jones

Part 4: Sign Below

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.

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 50 of 58
Official Form 122C-2

Chapter 13 Calculation of Your Disposable Income 04/16 

Part 1: Calculate Your Deductions from Your Income

Check if this is an amended filing

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Chad M. Jones

Regina B. Jones

EASTERN DISTRICT OF VIRGINIA

16-11552-BFK



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

Calculation of Commitment Period (Official Form 122C-1).

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

accurate. If more space is needed, attach a separate sheet to this form. Include the line number to which the additional 

information applies. On the top of any additional pages, write your name and case number (if known).

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

5

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

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

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

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

actual expenses if they are higher than the standards. Do not include any operating expenses that you subtracted from income in lines 5 

and 6 of Form 122C-1, and do not deduct any amounts that you subtracted from your spouse's income in line 13 of Form 122C-1.

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

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

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

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

be different from the number of people in your household.

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

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

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

$1,850.00 

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

People who are under 65 years of age

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

7b. Number of people who are under 65 X

7c. Subtotal. Multiply line 7a by line 7b. here

Copy



People who are 65 years of age or older

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

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

7f. Subtotal. Multiply line 7d by line 7e. here

Copy



7g. Total. Add lines 7c and 7f................................................................................................................................

+ Copy

here 

$54.00 

5 

$270.00 

$130.00 

$0.00 

$270.00 

$270.00 

$0.00 

$270.00 

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

under 65 and people who are 65 or older--because older people have a higher IRS allowance for health care costs. If 

your actual expenses are higher than this IRS amount, you may deduct the additional amount on line 22.

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 1 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 51 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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





Housing and utilities -- Insurance and operating expenses

Housing and utilities -- Mortgage or rent expenses

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

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

$657.00 

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

for bankruptcy purposes into two parts:

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

the link specified in the separate instructions for this form. This chart may also be available at the 

bankruptcy clerk's office.

9. Housing and utilities -- Mortgage or rent expenses:

9a.

Name of the creditor

9b.

Average monthly

payment

+ 

9b. Total average monthly payment

Copy

here  – 

9c.

Copy

here  $0.00 

$2,251.00 

$3,294.12 

$0.00 

$3,294.12 

BB&T

Specialized Loan Svc

$547.79 

$2,746.33 

Using the number of people you entered in line 5, fill in the dollar amount listed 

for your county for mortgage or rent expenses.

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

your home.

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

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

bankruptcy. Next divide by 60.

Repeat this 

amount on 

line 33a.

Net mortgage or rent expense.

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

rent expense). If this number is less than $0, enter $0.

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

and affects the calculation of your monthly expenses, fill in any additional amount you claim.

Explain

why:

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







0. Go to line 14.

1. Go to line 12.

2 or more. Go to line 12.

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

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

$500.00 

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 52 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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

Vehicle 1 Describe Vehicle 1:

13a.

13b.

Ownership or leasing costs using IRS Local Standard. ...........................................................................

Name of each creditor for Vehicle 1 Average monthly

payment

Copy

here  – 

13c. expense

here 

Vehicle 1

Copy net

$471.00 

$0.00 $0.00 

$640.10 

M&T Bank $640.10 

+ 

Total average monthly payment $640.10 

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

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

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

2012 Chevy Suburban

Average monthly payment for all debts secured by Vehicle 1.

Do not include costs for leased vehicles.

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

amounts that are contractually due to each secured creditor in the 60 months 

after you file for bankruptcy. Then divide by 60.

Repeat this 

amount on 

line 33b.

Net Vehicle 1 ownership or lease expense.

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

Vehicle 2 Describe Vehicle 2:

13d.

13e.

Ownership or leasing costs using IRS Local Standard. ...........................................................................

Name of each creditor for Vehicle 2 Average monthly

payment

Copy

here  – 

13f. expense

here 

Vehicle 2

Copy net

$471.00 

$138.78 $138.78 

$332.22 

PWC Employees CU $332.22 

Total average monthly payment $332.22 

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

Chevy Corvette

Average monthly payment for all debts secured by Vehicle 2. Do not include 

costs for leased vehicles.

Repeat this 

amount on 

line 33c.

Net Vehicle 2 ownership or lease expense.

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

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

Transportation expense allowance regardless of whether you use public transportation.

$0.00 

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

also deduct a public transportation expense, you may fill in what you believe is the appropriate expense, but you may

$0.00 

not claim more than the IRS Local Standard for Public Transportation.

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 53 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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

following IRS categories.

16. Taxes: The total monthly amount that you actually pay for federal, state and local taxes, such as income taxes, self- $1,795.30 

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

your pay for these taxes. However, if you expect to receive a tax refund, you must divide the expected refund by 12 

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

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

17. Involuntary deductions: The total monthly payroll deductions that your job requires, such as retirement contributions, $317.76 

union dues, and uniform costs.

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

18. Life insurance: The total monthly premiums that you pay for your own term life insurance. If two married people are $0.00 

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

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

form of life insurance other than term.

19. Court-ordered payments: The total monthly amount that you pay as required by the order of a court or administrative $0.00 

agency, such as spousal or child support payments.

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

20. Education: The total monthly amount that you pay for education that is either required: $0.00 





as a condition for your job, or

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

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

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

$375.00 

22. Additional health care expenses, excluding insurance costs: The monthly amount that you pay for health care that $0.00 

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

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

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

23. Optional telephones and telephone services: The total monthly amount that you pay for telecommunication services + $49.00 

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

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

of income, if it is not reimbursed by your employer.

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

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

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

Add lines 6 through 23. $5,952.84 

Additional Expense Deductions These are additional deductions allowed by the Means Test.

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

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

Health insurance

Disability insurance

Health savings account

Total Copy total here 

+ 

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

Do you actually spend this total amount?





No. How much do you actually spend?

Yes

$811.92 

$23.04 

$0.00 

$834.96 $834.96 

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

spouse, or your dependents.

26. Continued contributions to the care of household or family members. The actual monthly expenses that you $0.00 

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

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

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

27. Protection against family violence. The reasonably necessary monthly expenses that you incur to maintain the $0.00 

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

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

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

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 54 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

28. Additional home energy costs. Your home energy costs are included in your insurance and operating expenses $764.00 

on line 8.

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

line 8, then fill in the excess amount of home energy costs.

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

amount claimed is reasonable and necessary.

29. Education expenses for dependent children who are younger than 18. The monthly expenses (not more than $0.00 

$160.42* per child) that you pay for your dependent children who are younger than 18 years old to attend a private or 

public elementary or secondary school.

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

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

* Subject to adjustment on 4/01/19, and every 3 years after that for cases begun on or after the date of adjustment.

30. Additional food and clothing expense. The monthly amount by which your actual food and clothing expenses are $64.00 

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

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

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

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

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

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

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

$40.00 

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

+ 

32. Add all of the additional expense deductions.

Add lines 25 though 31.

$1,702.96 

Deductions for Debt Payment

33.

Mortgages on your home

33a. Copy line 9b here........................................................................................................................................ $3,294.12 

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

Loans on your first two vehicles

33b. Copy line 13b here....................................................................................................................................... $640.10 .....................................................

33c. Copy line 13e here....................................................................................................................................... $332.22 .....................................................

Copy total

here  $4,266.44 

Name of each creditor for

other secured debt

Identify property that

secures the debt





No

Yes

Does payment

include taxes or

insurance?





No

Yes





No

Yes

+ 

33e. Total average monthly payment. Add lines 33a through 33d.............................................$4,266.44 ..................







33d. List other secured debts:

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

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

To calculate the total average monthly payment, add all amounts that are contractually due to each secured creditor in 

the 60 months after you file for bankruptcy. Then divide by 60.

Average monthly

payment

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 5 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 55 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

34.

 No.

Yes.

Go to line 35.

Name of the creditor Identify property that

secures the debt

Total cure

amount

÷ 60 =

÷ 60 =

÷ 60 = + 

Copy total

Total $463.33 here  $463.33 

Monthly cure

amount

Specialized Loan Svc 14915 Largo Vista Dr Haymarket, VA 20169 $27,800.00 $463.33 

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

necessary for your support or the support of your dependents?

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

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

35.

No.

 Yes.

Go to line 36.

Total amount of all past-due priority claims...................................................................................... $0.00 

Do you owe any priority claims--such as a priority tax, child support, or

11 U.S.C. § 507.

alimony--that are past due as of the filing date of your bankruptcy case?

÷ 60 =

Fill in the total amount of all of these priority claims. Do not include 

current or ongoing priority claims, such as those you listed in line 19.

36. Projected monthly Chapter 13 plan payment

Average monthly administrative expense

$1.00 

X 7 

Copy total

$0.07 here  $0.07 

%

Current multiplier for your district as stated on the list issued by the Administrative 

Office of the United States Courts (for districts in Alabama and North Carolina) or 

by the Executive Office for United States Trustees (for all other districts).

To find a list of district multipliers that includes your district, go online using the link 

specified in the separate instructions for this form. This list may also be available 

at the bankruptcy clerk's office.

37. Add all of the deductions for debt payment.

Add lines 33g through 36. $4,729.84 

Total Deductions from Income

38. Add all of the allowed deductions.

Copy line 24, All of the expenses allowed under IRS expense allowances.............................................. $5,952.84 

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

Copy line 32, All of the additional expense deductions...............................................................$1,702.96 

Copy line 37, All of the deductions for debt payment..................................................... + $4,729.84 

Total deductions $12,385.64 $12,385.64 

Copy total

here 

Part 2: Determine Your Disposable Income Under 11 U.S.C. § 1325(b)(2)

39. Copy your total current monthly income from line 14 of Form 122C-1, Chapter 13

Statement of Your Current Monthly Income and Calculation of Commitment Period. $9,482.31 

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

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

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Document Page 56 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

40. Fill in any reasonably necessary income you receive for support of dependent children.

The monthly average of any child support payments, foster care payments, or 

disability payments for a dependent child, reported in Part 1 of Form 122C-1, that 

you received in accordance with applicable nonbankruptcy law to the extent 

reasonably necessary to be expended for such child.

41. Fill in all qualified retirement deductions.

$234.48 

The monthly total of all amounts that

your employer withheld from wages as contributions for qualified retirement 

plans, as specified in 11 U.S.C. § 541(b)(7) plus all required repayments of loans 

from retirement plans, as specified in 11 U.S.C. § 362(b)(19).

42. Total of all deductions allowed under 11 U.S.C. § 707(b)(2)(A).

Copy line 38 here.......................................................................................................................................................  $12,385.64 

43. Deduction for special circumstances. If special circumstances justify additional

Describe the special circumstances Amount of expense

+ 

Total

Copy

$0.00 here  + $0.00 

expenses and you have no reasonable alternative, describe the special 

circumstances and their expenses. You must give your case trustee a detailed 

explanation of the special circumstances and documentation for the expenses.

44. Total adjustments. Add lines 40 through 43...............................................................................  $12,620.12 

............................................... $12,620.12 

Copy

here  – 

45. Calculate your monthly disposable income under § 1325(b)(2). Subtract line 44 from line 39. ($3,137.81) 

Part 3: Change in Income or Expenses

46. Change in income or expenses. If the income in Form 122C-1 or the expenses you reported in this form have changed or are

Form Line Reason for change Date of change Increase or Amount of change

decrease?





122C-1

122C-2

 Increase

 Decrease





122C-1

122C-2

 Increase

 Decrease





122C-1

122C-2

 Increase

 Decrease





122C-1

122C-2

 Increase

 Decrease

virtually certain to change after the date you filed your bankruptcy petition and during the time your case will be open, fill in the 

information below. For example, if the wages reported increased after you filed your petition, check 122C-1 in the first column, enter 

line 2 in the second column, explain why the wages increased, fill in when the increase occurred, and fill in the amount of the 

increase.

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 7 

Case 16-11552-BFK Doc 17 Filed 06/14/16 Entered 06/14/16 10:40:06 Desc Main

Document Page 57 of 58
Debtor 1

First Name Middle Name Last Name

Chad M. Jones Case number (if known) 16-11552-BFK

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

Date Date

X X

Chad M. Jones, Debtor 1 Regina B. Jones, Debtor 2

6/14/2016 6/14/2016

/s/ Chad M. Jones /s/ Regina B. Jones

Part 4: Sign Below

MM / DD / YYYY MM / DD / YYYY

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 8 

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