Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 1

Notice Required by 11 U.S.C. § 342(b) for 

Individuals Filing for Bankruptcy (Form 2010)

This notice is for you if: 

You are an individual filing for bankruptcy, 

and 

Your debts are 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.”

The types of bankruptcy that are 

available to individuals 

Individuals who meet the qualifications may file 

under one of four different chapters of the 

Bankruptcy Code: 

Chapter 7 — Liquidation 

Chapter 11 — Reorganization 

Chapter 12 — Voluntary repayment plan 

for family farmers or 

fishermen 

Chapter 13 — Voluntary repayment plan 

for individuals with regular 

income 

You should have an attorney review your 

decision to file for bankruptcy and the choice of 

chapter. 

Chapter 7: Liquidation 

 $245 filing fee 

 $75 administrative fee 

+ $15 trustee surcharge 

 $335 total fee 

Chapter 7 is for individuals who have financial 

difficulty preventing them from paying their 

debts and who are willing to allow their nonexempt property to be used to pay their 

creditors. The primary purpose of filing under 

chapter 7 is to have your debts discharged. The 

bankruptcy discharge relieves you after 

bankruptcy from having to pay many of your 

pre-bankruptcy debts. Exceptions exist for 

particular debts, and liens on property may still 

be enforced after discharge. For example, a 

creditor may have the right to foreclose a home 

mortgage or repossess an automobile. 

However, if the court finds that you have 

committed certain kinds of improper conduct 

described in the Bankruptcy Code, the court 

may deny your discharge. 

You should know that even if you file 

chapter 7 and you receive a discharge, some 

debts are not discharged under the law. 

Therefore, you may still be responsible to pay: 

most taxes; 

most student loans; 

domestic support and property settlement 

obligations; 

 

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Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 2

most fines, penalties, forfeitures, and 

criminal restitution obligations; and 

certain debts that are not listed in your 

bankruptcy papers. 

You may also be required to pay debts arising 

from: 

fraud or theft; 

fraud or defalcation while acting in breach 

of fiduciary capacity; 

intentional injuries that you inflicted; and 

death or personal injury caused by 

operating a motor vehicle, vessel, or 

aircraft while intoxicated from alcohol or 

drugs. 

If your debts are primarily consumer debts, the 

court can dismiss your chapter 7 case if it finds 

that you have enough income to repay 

creditors a certain amount. You must file 

Chapter 7 Statement of Your Current Monthly 

Income (Official Form 122A–1) if you are an 

individual filing for bankruptcy under 

chapter 7. This form will determine your 

current monthly income and compare whether 

your income is more than the median income 

that applies in your state. 

If your income is not above the median for 

your state, you will not have to complete the 

other chapter 7 form, the Chapter 7 Means 

Test Calculation (Official Form 122A–2). 

If your income is above the median for your 

state, you must file a second form —the 

Chapter 7 Means Test Calculation (Official 

Form 122A–2). The calculations on the form—

sometimes called the Means Test—deduct 

from your income living expenses and 

payments on certain debts to determine any 

amount available to pay unsecured creditors. If 

your income is more than the median income 

for your state of residence and family size, 

depending on the results of the Means Test, the 

U.S. trustee, bankruptcy administrator, or 

creditors can file a motion to dismiss your case 

under § 707(b) of the Bankruptcy Code. If a 

motion is filed, the court will decide if your 

case should be dismissed. To avoid dismissal, 

you may choose to proceed under another 

chapter of the Bankruptcy Code. 

If you are an individual filing for chapter 7 

bankruptcy, the trustee may sell your property 

to pay your debts, subject to your right to 

exempt the property or a portion of the 

proceeds from the sale of the property. The 

property, and the proceeds from property that 

your bankruptcy trustee sells or liquidates that 

you are entitled to, is called exempt property. 

Exemptions may enable you to keep your 

home, a car, clothing, and household items or 

to receive some of the proceeds if the property 

is sold. 

Exemptions are not automatic. To exempt 

property, you must list it on Schedule C: The 

Property You Claim as Exempt (Official Form 

106C). If you do not list the property, the 

trustee may sell it and pay all of the proceeds 

to your creditors.

Chapter 11: Reorganization 

 $1,167 filing fee 

+ $550 administrative fee 

 $1,717 total fee 

Chapter 11 is often used for reorganizing a 

business, but is also available to individuals. 

The provisions of chapter 11 are too 

complicated to summarize briefly. 

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Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 3

Chapter 12: Repayment plan for family 

farmers or fishermen 

 $200 filing fee 

+ $75 administrative fee 

 $275 total fee 

Similar to chapter 13, chapter 12 permits 

family farmers and fishermen to repay their 

debts over a period of time using future 

earnings and to discharge some debts that are 

not paid. 

Chapter 13: Repayment plan for 

individuals with regular 

income 

 $235 filing fee 

+ $75 administrative fee 

 $310 total fee 

Chapter 13 is for individuals who have regular 

income and would like to pay all or part of 

their debts in installments over a period of time 

and to discharge some debts that are not paid. 

You are eligible for chapter 13 only if your 

debts are not more than certain dollar amounts 

set forth in 11 U.S.C. § 109. 

Under chapter 13, you must file with the court 

a plan to repay your creditors all or part of the 

money that you owe them, usually using your 

future earnings. If the court approves your 

plan, the court will allow you to repay your 

debts, as adjusted by the plan, within 3 years or 

5 years, depending on your income and other 

factors. 

After you make all the payments under your 

plan, many of your debts are discharged. The 

debts that are not discharged and that you may 

still be responsible to pay include: 

domestic support obligations, 

most student loans, 

certain taxes, 

debts for fraud or theft, 

debts for fraud or defalcation while acting 

in a fiduciary capacity, 

most criminal fines and restitution 

obligations, 

certain debts that are not listed in your 

bankruptcy papers, 

certain debts for acts that caused death or 

personal injury, and 

certain long-term secured debts. 

Read These Important Warnings

Because bankruptcy can have serious long-term financial and legal consequences, including loss of 

your property, you should hire an attorney and carefully consider all of your options before you file. 

Only an attorney can give you legal advice about what can happen as a result of filing for bankruptcy 

and what your options are. If you do file for bankruptcy, an attorney can help you fill out the forms 

properly and protect you, your family, your home, and your possessions. 

Although the law allows you to represent yourself in bankruptcy court, you should understand that 

many people find it difficult to represent themselves successfully. The rules are technical, and a 

mistake or inaction may harm you. If you file without an attorney, you are still responsible for knowing 

and following all of the legal requirements. 

You should not file for bankruptcy if you are not eligible to file or if you do not intend to file the 

necessary documents. 

Bankruptcy fraud is a serious crime; you could be fined and imprisoned if you commit fraud in your 

bankruptcy case. 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. 

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Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 4

Bankruptcy crimes have serious 

consequences 

If you knowingly and fraudulently conceal 

assets or make a false oath or statement 

under penalty of perjury—either orally or 

in writing—in connection with a 

bankruptcy case, you may be fined, 

imprisoned, or both. 

All information you supply in connection 

with a bankruptcy case is subject to 

examination by the Attorney General acting 

through the Office of the U.S. Trustee, the 

Office of the U.S. Attorney, and other 

offices and employees of the U.S. 

Department of Justice. 

Make sure the court has your 

mailing address 

The bankruptcy court sends notices to the 

mailing address you list on Voluntary Petition 

for Individuals Filing for Bankruptcy (Official 

Form 101). To ensure that you receive 

information about your case, Bankruptcy 

Rule 4002 requires that you notify the court of 

any changes in your address. 

A married couple may file a bankruptcy case 

together—called a joint case. If you file a joint 

case and each spouse lists the same mailing 

address on the bankruptcy petition, the 

bankruptcy court generally will mail you and 

your spouse one copy of each notice, unless 

you file a statement with the court asking that 

each spouse receive separate copies. 

Understand which services you 

could receive from credit 

counseling agencies 

The law generally requires that you receive a 

credit counseling briefing from an approved 

credit counseling agency. 11 U.S.C. § 109(h). 

If you are filing a joint case, both spouses must 

receive the briefing. With limited exceptions, 

you must receive it within the 180 days before

you file your bankruptcy petition. This briefing 

is usually conducted by telephone or on the 

Internet. 

In addition, after filing a bankruptcy case, you 

generally must complete a financial 

management instructional course before you 

can receive a discharge. If you are filing a joint 

case, both spouses must complete the course. 

You can obtain the list of agencies approved to 

provide both the briefing and the instructional 

course from: 

http://justice.gov/ust/eo/hapcpa/ccde/cc_approved.html. 

In Alabama and North Carolina, go to: 

http://www.uscourts.gov/FederalCourts/Bankruptcy/

BankruptcyResources/ApprovedCredit 

AndDebtCounselors.aspx. 

If you do not have access to a computer, the 

clerk of the bankruptcy court may be able to 

help you obtain the list. 

Warning: File Your Forms on Time

Section 521(a)(1) of the Bankruptcy Code 

requires that you promptly file detailed information 

about your creditors, assets, liabilities, income, 

expenses and general financial condition. The 

court may dismiss your bankruptcy case if you do 

not file this information within the deadlines set by 

the Bankruptcy Code, the Bankruptcy Rules, and 

the local rules of the court. 

For more information about the documents and 

their deadlines, go to: 

http://www.uscourts.gov/bkforms/bankruptcy_form

s.html#procedure. 

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Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 1 

Official Form 101 

Voluntary Petition for Individuals Filing for Bankruptcy 12/17

The bankruptcy forms use you and Debtor 1 to refer to a debtor filing alone. A married couple may file a bankruptcy case together—called a 

joint case—and in joint cases, these forms use you to ask for information from both debtors. For example, if a form asks, “Do you own a car,” 

the answer would be yes if either debtor owns a car. When information is needed about the spouses separately, the form uses Debtor 1 and 

Debtor 2 to distinguish between them. In joint cases, one of the spouses must report information as Debtor 1 and the other as Debtor 2. The 

same person must be Debtor 1 in all of the forms. 

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

information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number 

(if known). Answer every question. 

Part 1: Identify Yourself

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 

1. Your full name 

Write the name that is on your 

government-issued picture 

identification (for example, 

your driver’s license or 

passport). 

Bring your picture 

identification to your meeting 

with the trustee. 

__________________________________________________ 

First name

__________________________________________________ 

Middle name

__________________________________________________ 

Last name 

___________________________

Suffix (Sr., Jr., II, III)

__________________________________________________ 

First name

__________________________________________________ 

Middle name

__________________________________________________ 

Last name 

___________________________

Suffix (Sr., Jr., II, III) 

2. All other names you 

have used in the last 8 

years 

Include your married or 

maiden names. 

__________________________________________________ 

First name

__________________________________________________ 

Middle name

__________________________________________________ 

Last name 

__________________________________________________ 

First name

__________________________________________________ 

Middle name

__________________________________________________ 

Last name 

__________________________________________________ 

First name

__________________________________________________ 

Middle name

__________________________________________________ 

Last name 

__________________________________________________ 

First name

__________________________________________________ 

Middle name

__________________________________________________ 

Last name 

3. Only the last 4 digits of 

your Social Security 

number or federal 

Individual Taxpayer 

Identification number

(ITIN) 

xxx – xx – ____ ____ ____ ____ 

OR

9 xx – xx – ____ ____ ____ ____ 

xxx – xx – ____ ____ ____ ____ 

OR

9 xx – xx – ____ ____ ____ ____ 

United States Bankruptcy Court for the: 

______________ 

Case number (If known): _________________________ Chapter you are filing under: 

 Chapter 7 

 Chapter 11 

 Chapter 12 

 Chapter 13 

 Fill in this information to identify your case: 

 Check if this is an 

amended filing

	
	
	



 

	


 




	




       

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

 Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 2 

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 

4. Any business names 

and Employer 

Identification Numbers 

(EIN) you have used in 

the last 8 years 

Include trade names and 

doing business as names 

 I have not used any business names or EINs.

_________________________________________________ 

Business name

_________________________________________________ 

Business name

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN

 I have not used any business names or EINs.

_________________________________________________

Business name

_________________________________________________

Business name

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN

5. Where you live 

_________________________________________________ 

Number Street 

_________________________________________________ 

_________________________________________________ 

City State ZIP Code 

_________________________________________________ 

County

If your mailing address is different from the one 

above, fill it in here. Note that the court will send 

any notices to you at this mailing address.

_________________________________________________ 

Number Street 

_________________________________________________ 

P.O. Box

_________________________________________________ 

City State ZIP Code 

If Debtor 2 lives at a different address: 

_________________________________________________

Number Street 

_________________________________________________ 

_________________________________________________

City State ZIP Code 

_________________________________________________

County

If Debtor 2’s mailing address is different from 

yours, fill it in here. Note that the court will send 

any notices to this mailing address.

_________________________________________________

Number Street 

_________________________________________________

P.O. Box

_________________________________________________ 

City State ZIP Code

6. Why you are choosing 

this district to file for 

bankruptcy 

Check one:

 Over the last 180 days before filing this petition, 

I have lived in this district longer than in any 

other district. 

 I have another reason. Explain. 

(See 28 U.S.C. § 1408.) 

________________________________________ 

________________________________________ 

________________________________________ 

________________________________________ 

Check one:

 Over the last 180 days before filing this petition, 

I have lived in this district longer than in any 

other district. 

 I have another reason. Explain. 

(See 28 U.S.C. § 1408.) 

________________________________________ 

________________________________________ 

________________________________________ 

________________________________________




 




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

 Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 3 

Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the 

Bankruptcy Code you 

are choosing to file 

under 

Check one. (For a brief description of each, see Notice Required by 11 U.S.C. § 342(b) for Individuals Filing 

for Bankruptcy (Form 2010)). Also, go to the top of page 1 and check the appropriate box. 

 Chapter 7 

 Chapter 11 

 Chapter 12 

 Chapter 13

8. How you will pay the fee  I will pay the entire fee when I file my petition. Please check with the clerk’s office in your 

local court for more details about how you may pay. Typically, if you are paying the fee 

yourself, you may pay with cash, cashier’s check, or money order. If your attorney is 

submitting your payment on your behalf, your attorney may pay with a credit card or check 

with a pre-printed address. 

 I need to pay the fee in installments. If you choose this option, sign and attach the 

Application for Individuals to Pay The Filing Fee in Installments (Official Form 103A).

 I request that my fee be waived (You may request this option only if you are filing for Chapter 7. 

By law, a judge may, but is not required to, waive your fee, and may do so only if your income is 

less than 150% of the official poverty line that applies to your family size and you are unable to 

pay the fee in installments). If you choose this option, you must fill out the Application to Have the 

Chapter 7 Filing Fee Waived (Official Form 103B) and file it with your petition. 

9. Have you filed for 

bankruptcy within the 

last 8 years?

 No 

 Yes. District __________________________ When _______________ Case number ___________________________

 MM / DD / YYYY

District __________________________ When _______________ Case number ___________________________

 MM / DD / YYYY

 District __________________________ When _______________ Case number ___________________________ 

 MM / DD / YYYY

10. Are any bankruptcy 

cases pending or being 

filed by a spouse who is 

not filing this case with 

you, or by a business 

partner, or by an 

affiliate?

 No

 Yes. Debtor _________________________________________________ Relationship to you _____________________

 District __________________________ When _______________ Case number, if known____________________ 

 MM / DD / YYYY

 Debtor _________________________________________________ Relationship to you _____________________ 

District __________________________ When _______________ Case number, if known____________________

 MM / DD / YYYY

11. Do you rent your 

residence?

 No. Go to line 12.

 Yes. Has your landlord obtained an eviction judgment against you?

 No. Go to line 12.

 Yes. Fill out Initial Statement About an Eviction Judgment Against You (Form 101A) and file it as 

part of this bankruptcy petition.














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

 Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 4 

Part 3: Report About Any Businesses You Own as a Sole Proprietor

12. Are you a sole proprietor 

of any full- or part-time 

business?

A sole proprietorship is a 

business you operate as an 

individual, and is not a 

separate legal entity such as 

a corporation, partnership, or 

LLC. 

If you have more than one 

sole proprietorship, use a 

separate sheet and attach it 

to this petition.

 No. Go to Part 4.

 Yes. Name and location of business

_______________________________________________________________________________________ 

Name of business, if any 

_______________________________________________________________________________________ 

Number Street 

_______________________________________________________________________________________ 

_______________________________________________ _______ __________________________ 

 City State ZIP Code 

Check the appropriate box to describe your business: 

 Health Care Business (as defined in 11 U.S.C. § 101(27A)) 

 Single Asset Real Estate (as defined in 11 U.S.C. § 101(51B)) 

 Stockbroker (as defined in 11 U.S.C. § 101(53A)) 

 Commodity Broker (as defined in 11 U.S.C. § 101(6)) 

 None of the above 

13. Are you filing under 

Chapter 11 of the 

Bankruptcy Code and 

are you a small business 

debtor? 

For a definition of small 

business debtor, see 

11 U.S.C. § 101(51D). 

If you are filing under Chapter 11, the court must know whether you are a small business debtor so that it 

can set appropriate deadlines. If you indicate that you are a small business debtor, you must attach your 

most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or if 

any of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B).

 No. I am not filing under Chapter 11. 

 No. I am filing under Chapter 11, but I am NOT a small business debtor according to the definition in 

the Bankruptcy Code. 

 Yes. I am filing under Chapter 11 and I am a small business debtor according to the definition in the 

Bankruptcy Code. 

Part 4: Report if You Own or Have Any Hazardous Property or Any Property That Needs Immediate Attention

14. Do you own or have any 

property that poses or is 

alleged to pose a threat 

of imminent and 

identifiable hazard to 

public health or safety? 

Or do you own any 

property that needs

immediate attention?

For example, do you own 

perishable goods, or livestock 

that must be fed, or a building 

that needs urgent repairs?

 No 

 Yes. What is the hazard? ________________________________________________________________________

 

 ________________________________________________________________________

If immediate attention is needed, why is it needed? _______________________________________________

 ________________________________________________________________________

 Where is the property? ________________________________________________________________________

 Number Street 

 

 ________________________________________________________________________

________________________________________ _______ ____________________

City State ZIP Code 

 




*





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

 Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 5 

Part 5: Explain Your Efforts to Receive a Briefing About Credit Counseling

15. Tell the court whether 

you have received a 

briefing about credit 

counseling. 

The law requires that you 

receive a briefing about credit 

counseling before you file for 

bankruptcy. You must 

truthfully check one of the 

following choices. If you 

cannot do so, you are not 

eligible to file. 

If you file anyway, the court 

can dismiss your case, you 

will lose whatever filing fee 

you paid, and your creditors 

can begin collection activities 

again. 

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 

You must check one:

 I received a briefing from an approved credit 

counseling agency within the 180 days before I 

filed this bankruptcy petition, and I received a 

certificate of completion. 

Attach a copy of the certificate and the payment 

plan, if any, that you developed with the agency.

 I received a briefing from an approved credit 

counseling agency within the 180 days before I 

filed this bankruptcy petition, but I do not have a 

certificate of completion. 

Within 14 days after you file this bankruptcy petition, 

you MUST file a copy of the certificate and payment 

plan, if any.

 I certify that I asked for credit counseling 

services from an approved agency, but was 

unable to obtain those services during the 7 

days after I made my request, and exigent 

circumstances merit a 30-day temporary waiver 

of the requirement. 

To ask for a 30-day temporary waiver of the 

requirement, attach a separate sheet explaining 

what efforts you made to obtain the briefing, why 

you were unable to obtain it before you filed for 

bankruptcy, and what exigent circumstances 

required you to file this case.

Your case may be dismissed if the court is 

dissatisfied with your reasons for not receiving a 

briefing before you filed for bankruptcy. 

If the court is satisfied with your reasons, you must 

still receive a briefing within 30 days after you file. 

You must file a certificate from the approved 

agency, along with a copy of the payment plan you 

developed, if any. If you do not do so, your case 

may be dismissed. 

Any extension of the 30-day deadline is granted 

only for cause and is limited to a maximum of 15 

days. 

 I am not required to receive a briefing about 

credit counseling because of:

 Incapacity. I have a mental illness or a mental 

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me 

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so. 

 Active duty. I am currently on active military 

duty in a military combat zone. 

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court. 

You must check one:

 I received a briefing from an approved credit 

counseling agency within the 180 days before I 

filed this bankruptcy petition, and I received a 

certificate of completion. 

Attach a copy of the certificate and the payment 

plan, if any, that you developed with the agency.

 I received a briefing from an approved credit 

counseling agency within the 180 days before I 

filed this bankruptcy petition, but I do not have a 

certificate of completion. 

Within 14 days after you file this bankruptcy petition, 

you MUST file a copy of the certificate and payment 

plan, if any.

 I certify that I asked for credit counseling 

services from an approved agency, but was 

unable to obtain those services during the 7 

days after I made my request, and exigent 

circumstances merit a 30-day temporary waiver 

of the requirement. 

To ask for a 30-day temporary waiver of the 

requirement, attach a separate sheet explaining 

what efforts you made to obtain the briefing, why 

you were unable to obtain it before you filed for 

bankruptcy, and what exigent circumstances 

required you to file this case. 

Your case may be dismissed if the court is 

dissatisfied with your reasons for not receiving a 

briefing before you filed for bankruptcy. 

If the court is satisfied with your reasons, you must 

still receive a briefing within 30 days after you file. 

You must file a certificate from the approved 

agency, along with a copy of the payment plan you 

developed, if any. If you do not do so, your case 

may be dismissed. 

Any extension of the 30-day deadline is granted 

only for cause and is limited to a maximum of 15 

days. 

 I am not required to receive a briefing about 

credit counseling because of: 

 Incapacity. I have a mental illness or a mental 

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me 

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so. 

 Active duty. I am currently on active military 

duty in a military combat zone. 

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.




 

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

 Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 6 

Part 6: Answer These Questions for Reporting Purposes

16. What kind of debts do 

you have?

16a. Are your debts 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.”

 No. Go to line 16b. 

 Yes. Go to line 17. 

16b. Are your debts primarily business debts? Business debts are debts that you incurred to obtain 

money for a business or investment or through the operation of the business or investment. 

 No. Go to line 16c. 

 Yes. Go to line 17. 

16c. State the type of debts you owe that are not consumer debts or business debts. 

_______________________________________________________________ 

17. Are you filing under 

Chapter 7? 

Do you estimate that after 

any exempt property is 

excluded and 

administrative expenses 

are paid that funds will be 

available for distribution 

to unsecured creditors? 

 No. I am not filing under Chapter 7. Go to line 18. 

 Yes. I am filing under Chapter 7. Do you estimate that after any exempt property is excluded and 

administrative expenses are paid that funds will be available to distribute to unsecured creditors? 

 No 

 Yes 

18. How many creditors do 

you estimate that you 

owe? 

 1-49 

 50-99 

 100-199 

 200-999 

 1,000-5,000 

 5,001-10,000 

 10,001-25,000 

 25,001-50,000 

 50,001-100,000 

 More than 100,000

19. How much do you 

estimate your assets to 

be worth? 

 $0-$50,000 

 $50,001-$100,000 

 $100,001-$500,000 

 $500,001-$1 million 

 $1,000,001-$10 million 

 $10,000,001-$50 million 

 $50,000,001-$100 million 

 $100,000,001-$500 million 

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

20. How much do you 

estimate your liabilities 

to be? 

 $0-$50,000 

 $50,001-$100,000 

 $100,001-$500,000 

 $500,001-$1 million 

 $1,000,001-$10 million 

 $10,000,001-$50 million 

 $50,000,001-$100 million 

 $100,000,001-$500 million 

 $500,000,001-$1 billion 

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

Part 7: Sign Below

For you I have examined this petition, and I declare under penalty of perjury that the information provided is true and 

correct. 

If I have chosen to file under Chapter 7, I am aware that I may proceed, if eligible, under Chapter 7, 11,12, or 13 

of title 11, United States Code. I understand the relief available under each chapter, and I choose to proceed 

under Chapter 7.

If no attorney represents me and I did not pay or agree to pay someone who is not an attorney to help me fill out 

this document, I have obtained and read the notice required by 11 U.S.C. § 342(b).

I request relief in accordance with the chapter of title 11, United States Code, specified in this petition.

I understand making a false statement, concealing property, or obtaining money or property by fraud in connection 

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

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

______________________________________________ _____________________________ Signature of Debtor 1 Signature of Debtor 2

Executed on _________________ Executed on __________________ 

MM / DD / YYYY MM / DD / YYYY 
















++ ++

"+,+" "+,+"

Warren Artis Liane Mae Artis

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 10 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

 Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 7 

For your attorney, if you are 

represented by one 

If you are not represented 

by an attorney, you do not 

need to file this page.

I, the attorney for the debtor(s) named in this petition, declare that I have informed the debtor(s) about eligibility 

to proceed under Chapter 7, 11, 12, or 13 of title 11, United States Code, and have explained the relief 

available under each chapter for which the person is eligible. I also certify that I have delivered to the debtor(s) 

the notice required by 11 U.S.C. § 342(b) and, in a case in which § 707(b)(4)(D) applies, certify that I have no 

knowledge after an inquiry that the information in the schedules filed with the petition is incorrect. 

_________________________________ Date _________________ Signature of Attorney for Debtor MM / DD / YYYY 

_________________________________________________________________________________________________ 

Printed name 

_________________________________________________________________________________________________ 

Firm name 

_________________________________________________________________________________________________ 

Number Street 

_________________________________________________________________________________________________ 

______________________________________________________ ____________ ______________________________ 

City State ZIP Code 

Contact phone _____________________________________ Email address ______________________________ 

______________________________________________________ ____________ 

Bar number State 

 




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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 11 of 81
Capital One

P.O. Box 30285

Salt Lake City,UT 84130

Dothins

Carrington Mortgage

P.O. Box 5001

Westfield,IN 46074

Dothins

Cavalry Portfolio Svcs

500 Summit Lake Drive, #4A

Valhalla,NY 10595

Dothins

Cavalry SPV I, LLC

500 Summit Lake Drive, Suite 400

Valhalla,NY 10595

Dothins

Comcast Corporation

1701 JFK Boulevard

Philadelphia,PA 19103

Dothins

Comenity Bank

Bankruptcy Department

P.O. Box 182125

Columbus,OH 43218

Dothins

Country Door

1515 S 21st STreet

Clinton,IA 52732

Dothins

Credit Acceptance Corporation

25505 W 12 Mile Road

Southfield,MI 48034

Dothins

Discover Financial Services LLC

P.O. Box 15316

Wilmington,DE 19850

Dothins

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 12 of 81
DSNB/Macy's

P.O. Box 8218

Mason,OH 45050

Dothins

EOS CCA

P.O. Box 981008

Boston,MA 02298

Dothins

Exeter Finance LLC

P.O. Box 166097

Irving,TX 75016

Dothins

Glasser and Glasser

580 East Main Street, #600

Norfolk,VA 23510

Dothins

Glasser and Glasser, PLC

P.O. Box 3400

Norfolk,VA 23514

Dothins

Jefferson Capital System

16 McLeland Road

Saint Cloud,MN 56303

Dothins

Jefferson Capital Systems, LLC

P.O. Box 17210

Golden,CO 80402

Dothins

Joseph AC Synan

101 Lafayette Boulevard

Fredericksburg,VA 22401

Dothins

Kohl's Department Store

P.O. Box 3115

Milwaukee,WI 53201

Dothins

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 13 of 81
Mary Washington Healthcare

2300 Fall Hill Avenue, #101

Fredericksburg,VA 22401

Dothins

Mary Washington Hospital

2300 Fall Hill Avenue, #313

Fredericksburg,VA 22401

Dothins

McLaughlin, Timothy J. and Rebecca N.

12308 Catharines Furnace Court

Spotsylvania,VA 22553

Dothins

Medical Imaging of Fredericksburg

2300 Fall Hill Avenue, #314

Fredericksburg,VA 22401

Dothins

Merrick Bank

P.O. Box 9201

Old Bethpage,NY 11804

Dothins

Midland Funding LLC

P.O. Box 939069

San Diego,CA 92193

Dothins

Monroe & Main

1515 S 21st Street

Clinton,IA 52732

Dothins

NextCare Urgent Care VA

2550 N. Thunderbird Circle #123

Mesa,AZ 85215

Dothins

ODC Recovery Services

2300 Fall Hill Avenue, #314

Fredericksburg,VA 22401

Dothins

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 14 of 81
Peter Heindel, Esq.

6802 Paragon Place, #410

Richmond,VA 23230

Dothins

Phyllis D. Artis

11908 Falcon Ridge Drive

Fredericksburg,VA 22407

Dothins

Portfolio Recovery Associates LLC

P.O. Box 41067

Norfolk,VA 23541

Dothins

Regional Acceptance Corporation

1424 E. Firetower Road

Greenville,NC 27858

Dothins

Select Portfolio Servicing

10401 Deerwood Park Boulevard

Jacksonville,FL 32256

Dothins

SW Credit Systems L.P.

4120 International Parkway, #1100

Carrollton,TX 75007

Dothins

SW Credit Systems L.P.

41200 International Parkway, #1100

Carrollton,TX 75007

Dothins

SYNCB/JC Penney

Attn: Bankruptcy Dept.

P.O. Box 965064

Orlando,FL 32896

Dothins

SYNCB/Lowes

Attn: Bankruptcy Dept.

P.O. Box 965060

Orlando,FL 32896

Dothins

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 15 of 81
SYNCB/Regency Furniture

Attn: Bankruptcy Dept.

P.O. Box 965064

Orlando,FL 32896

Dothins

SYNCB/Walmart

Attn: Bankruptcy Dept.

P.O. Box 965060

Orlando,FL 32896

Dothins

Synchrony Bank

Attn: Bankruptcy Dept.

P.O. Box 965060

Orlando,FL 32896

Dothins

T-Mobile Bankruptcy Team

P.O. Box 53410

Bellevue,WA 98015

Dothins

Total Card, Inc.

2700 S. Lorraine Place

Sioux Falls,SD 57106

Dothins

US Bank RMS CC

P.O. Box 108

Saint Louis,MO 63166

Dothins

Van Ru Credit Corporation

4839 N Elston Avenue

Chicago,IL 60630

Dothins

Verizon Wireless Bankruptcy Administrati

500 Technology Drive, #550

Weldon Spring,MO 63304

Dothins

Villages of Salem Station HOA

3190 Fairview Park Drive, #300

Falls Church,VA 22042

Dothins

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 16 of 81
Webbank/Fingerhut

6250 Ridgewood Road

Saint Cloud,MN 56303

Dothins

Whiteford, Taylor & Preston L.L.P.

3190 Fairview Park Drive, #300

Falls Church,VA 22042

Dothins

William A. Hamilton, MD

619 Jefferson Davis Highway

Fredericksburg,VA 22401

Dothins

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 17 of 81
UNITED STATES BANKRUPTCY COURT

In re:

Debtors

Case No.

Chapter

VERIFICATION OF CREDITOR MATRIX

The above named debtor(s), or debtor’s attorney if applicable, do hereby certify under penalty of perjury that the 

Local Bankruptcy Rules and I/we assume all responsibility for errors and omissions.

Dated: Signed: 

Dated: Signed: 

attached Master Mailing List of creditors is complete, correct and consistent with the debtor's schedules pursuant to

	
		

	


					



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Warren Artis

Liane Mae Artis

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 18 of 81
 Official Form 106A/B Schedule A/B: Property page 1

Official Form 106A/B 

Schedule A/B: Property 12/15

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

category where you think it fits best. Be as complete and accurate as possible. If two married people are filing together, both are equally 

responsible for supplying correct information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, 

write your name and case number (if known). Answer every question. 

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

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

 No. Go to Part 2. 

 Yes. Where is the property?



1.1. _________________________________________ 

Street address, if available, or other description

_________________________________________ 

_________________________________________ 

City State ZIP Code 

_________________________________________ 

County

What is the property? Check all that apply.

 Single-family home 

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$_______________ 

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

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

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

__________________________________________

 Check if this is community property 

(see instructions)

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

property identification number: _______________________________

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

1.2. ________________________________________ 

Street address, if available, or other description 

________________________________________ 

________________________________________ 

City State ZIP Code 

________________________________________ 

County

What is the property? Check all that apply.

 Single-family home 

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$_________________ 

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

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

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

__________________________________________

 Check if this is community property 

(see instructions)

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

property identification number: _______________________________

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: ______________________________________ 

Case number ___________________________________________ 

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

 Check if this is an 

amended filing

 

  

	
	
	





		

 

 

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 19 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

1.3. ________________________________________ 

Street address, if available, or other description 

________________________________________ 

________________________________________ 

City State ZIP Code 

________________________________________ 

County

What is the property? Check all that apply.

 Single-family home 

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$_________________ 

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

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

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

__________________________________________

 Check if this is community property 

(see instructions)

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

property identification number: _______________________________

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

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

Part 2: Describe Your Vehicles 

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

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

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

 No

 Yes

3.1. Make: ______________ 

Model: ______________ 

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

 Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________ 

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

3.2. Make: ______________ 

Model: ______________ 

Year: ____________ 

Approximate mileage: ____________ 

Other information:

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

 Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________ 

 





*

+ 

,



- -



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//

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 20 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

3.3. Make: ______________ 

Model: ______________ 

Year: ____________ 

Approximate mileage: ____________ 

Other information:

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

 Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________ 

3.4. Make: ______________ 

Model: ______________ 

Year: ____________ 

Approximate mileage: ____________ 

Other information:

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

 Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________ 

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

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

 No

 Yes

4.1. Make: ____________________ 

Model: ____________________ 

Year: ____________ 

Other information: 

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

 Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________ 

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

4.2. Make: ____________________ 

Model: ____________________ 

Year: ____________ 

Other information:

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only 

At least one of the debtors and another 

 Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________ 

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

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

 





Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 21 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 3: Describe Your Personal and Household Items 

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

portion you own?

Do not deduct secured claims 

or exemptions. 

6. Household goods and furnishings 

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

 No

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

7. Electronics 

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

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

 No

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

8. Collectibles of value 

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

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

 No

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

9. Equipment for sports and hobbies 

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

and kayaks; carpentry tools; musical instruments 

 No

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

10.Firearms 

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

 No

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

11. Clothes

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

 No

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

12. Jewelry 

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

gold, silver 

 No

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

13. Non-farm animals 

Examples: Dogs, cats, birds, horses

 No

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

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

 No 

 Yes. Give specific 

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

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

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

 

 		

	0

 

	1	2	&	1	 







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 3 		1	2		9#: 





-

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 22 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 4: Describe Your Financial Assets

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

portion you own?

Do not deduct secured claims 

or exemptions.

16. Cash

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

 No 

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

17. Deposits of money 

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

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

 No 

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

17.1. Checking account: _________________________________________________________ 

17.2. Checking account: _________________________________________________________ 

17.3. Savings account: _________________________________________________________ 

17.4. Savings account: _________________________________________________________ 

17.5. Certificates of deposit: _________________________________________________________ 

17.6. Other financial account: _________________________________________________________ 

17.7. Other financial account: _________________________________________________________ 

17.8. Other financial account: _________________________________________________________ 

17.9. Other financial account: _________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

18. Bonds, mutual funds, or publicly traded stocks 

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

 No

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

_________________________________________________________________________________________ 

_________________________________________________________________________________________ 

_________________________________________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

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

an LLC, partnership, and joint venture 

 No 

Yes. Give specific 

information about 

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

Name of entity: % of ownership: 

_____________________________________________________________________ ___________% 

_____________________________________________________________________ ___________% 

_____________________________________________________________________ ___________% 

$__________________ 

$__________________ 

$__________________ 

 

 



;	+	0/3	/3+	0-	<=> 





Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 23 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

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

 No 

Yes. Give specific 

information about 

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

Issuer name: 

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

21. Retirement or pension accounts 

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

 No

 Yes. List each 

account separately. . Type of account: Institution name: 

401(k) or similar plan: ___________________________________________________________________ 

Pension plan: ___________________________________________________________________ 

IRA: ___________________________________________________________________ 

Retirement account: ___________________________________________________________________ 

Keogh: ___________________________________________________________________ 

Additional account: ___________________________________________________________________ 

Additional account: ___________________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

22.Security deposits and prepayments 

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

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

companies, or others 

 No

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

Electric: ______________________________________________________________________ 

Gas: ______________________________________________________________________ 

Heating oil: ______________________________________________________________________ 

Security deposit on rental unit: _____________________________________________________________ 

Prepaid rent: ______________________________________________________________________ 

Telephone: ______________________________________________________________________ 

Water: ______________________________________________________________________ 

Rented furniture: ______________________________________________________________________ 

Other: ______________________________________________________________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________

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

 No

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

_______________________________________________________________________________________

_______________________________________________________________________________________ 

_______________________________________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

 









Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 24 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

 No

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

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

 $_________________ 

$_________________ 

$_________________ 

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

exercisable for your benefit 

 No 

 Yes. Give specific 

information about them. .. $__________________ 

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

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

 No 

 Yes. Give specific 

information about them. .. $__________________ 

27. Licenses, franchises, and other general intangibles 

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

 No 

 Yes. Give specific 

information about them. .. $__________________

Money or property owed to you? Current value of the 

portion you own?

Do not deduct secured 

claims or exemptions.

28.Tax refunds owed to you

 No 

 Yes. Give specific information 

about them, including whether 

you already filed the returns 

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

Federal: $_________________

State: $_________________

Local: $_________________

29. Family support 

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

 No

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

Alimony: 

Maintenance:

Support: 

Divorce settlement: 

Property settlement: 

$________________

$________________ 

$________________ 

$________________ 

$________________

30. Other amounts someone owes you 

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

Social Security benefits; unpaid loans you made to someone else 

 No 

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

$______________________ 

 









 	.	
 









Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 25 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

31. Interests in insurance policies 

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

 No 

 Yes. Name the insurance company 

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

___________________________________________ ____________________________ 

___________________________________________ ____________________________ 

___________________________________________ ____________________________ 

Surrender or refund value: 

$__________________ 

$__________________ 

$__________________

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

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

property because someone has died.

 No 

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

$_____________________ 

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

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

 No 

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

$______________________ 

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

to set off claims 

 No 

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

$_____________________ 

35. Any financial assets you did not already list 

 No 

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

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

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

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

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

 No. Go to Part 6. 

 Yes. Go to line 38.

Current value of the 

portion you own? 

Do not deduct secured claims 

or exemptions.

38. Accounts receivable or commissions you already earned 

 No 

 Yes. Describe .......

$_____________________ 

39. Office equipment, furnishings, and supplies 

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

 No 

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

 



















Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 26 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

 No 

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

41. Inventory 

 No 

 Yes. Describe .......

 

$_____________________ 

42. Interests in partnerships or joint ventures 

 No 

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

______________________________________________________________________ ________% 

______________________________________________________________________ ________% 

______________________________________________________________________ ________%

$_____________________ 

$_____________________ 

$_____________________ 

43. Customer lists, mailing lists, or other compilations 

 No

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

 No

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

$____________________ 

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

 No

 Yes. Give specific 

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

______________________________________________________________________________________ $____________________ 

______________________________________________________________________________________ $____________________ 

______________________________________________________________________________________ $____________________ 

______________________________________________________________________________________ $____________________ 

______________________________________________________________________________________ $____________________ 

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

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

Part 6: Describe Any Farm- and Commercial Fishing-Related Property You Own or Have an Interest In. If you own or have an interest in farmland, list it in Part 1.

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

 No. Go to Part 7.

 Yes. Go to line 47. 

Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

47. Farm animals 

Examples: Livestock, poultry, farm-raised fish 

 No

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

$___________________ 

 



















Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 27 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

48. Crops—either growing or harvested 

 No 

 Yes. Give specific 

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

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

 No

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

$___________________ 

50.Farm and fishing supplies, chemicals, and feed 

 No

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

$___________________ 

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

 No 

 Yes. Give specific 

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

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

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

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

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

Examples: Season tickets, country club membership

 No 

 Yes. Give specific 

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

$________________ 

$________________ 

$________________ 

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

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

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

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

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

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

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

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

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

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

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

 

















-









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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 28 of 81
	








	



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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 29 of 81
Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __ 

	
 106C 

Schedule C: The Property You Claim as Exempt 

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

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

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

your name and case number (if known). 

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

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

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

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

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

would be limited to the applicable statutory amount. 

Part 1: Identify the Property You Claim as Exempt

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

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

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

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

Brief description of the property and line on 

Schedule A/B that lists this property 

Current value of the 

portion you own 

Copy the value from 

Schedule A/B

Amount of the exemption you claim 

Check only one box for each exemption. 

Specific laws that allow exemption

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: _________________________ 

$________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ 

Line from 

Schedule A/B: ______ 

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

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

No

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

No

Yes

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: __________ District of __________ 

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

Check if this is an

amended filing

____________________________________



  

	




  

  



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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 30 of 81
____________________________ 

____________________________ 

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

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

Part 2: Additional Page

Brief description of the property and line 

on Schedule A/B that lists this property 

Current value of the 

portion you own 

Copy the value from 

Schedule A/B

Amount of the exemption you claim 

Check only one box for each exemption

Specific laws that allow exemption

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ 

$________________ $ ____________ 

100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 



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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 31 of 81
 Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___ 

Official Form 106D 

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

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

information. If more space is needed, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any 

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

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

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

 Yes. Fill in all of the information below. 

Part 1: List All Secured Claims 

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

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

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

Column A 

Amount of claim 

Do not deduct the 

value of collateral.

Column B 

Value of collateral 

that supports this 

claim

Column C 

Unsecured 

portion

If any

2.1 

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

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

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

 Contingent 

 Unliquidated 

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

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

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim relates to a 

community debt

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

2.2 

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

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

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

 Contingent 

 Unliquidated 

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

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

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim relates to a 

community debt

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

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: ______________________________________ 

Case number ___________________________________________ 

 (If known) 

 Fill in this information to identify your case: 

 Check if this is an 

amended filing





	




 	
  


				



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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 32 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 1: 

Additional Page 

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

by 2.4, and so forth.

Column A 

Amount of claim 

Do not deduct the 

value of collateral.

Column B 

Value of collateral 

that supports this 

claim

Column C 

Unsecured 

portion

If any

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

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

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

 Contingent 

 Unliquidated 

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

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

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim relates to a 

community debt

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

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

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

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

 Contingent 

 Unliquidated 

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

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

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim relates to a 

community debt

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

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

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

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

 Contingent 

 Unliquidated 

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

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

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim relates to a 

community debt

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

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

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

Write that number here: $_________________ 

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 33 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 1: 

Additional Page 

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

by 2.4, and so forth.

Column A 

Amount of claim 

Do not deduct the 

value of collateral.

Column B 

Value of collateral 

that supports this 

claim

Column C 

Unsecured 

portion

If any

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

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

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

 Contingent 

 Unliquidated 

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

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

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim relates to a 

community debt

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

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

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

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

 Contingent 

 Unliquidated 

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

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

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim relates to a 

community debt

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

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

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

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

 Contingent 

 Unliquidated 

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

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

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim relates to a 

community debt

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

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

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

Write that number here: $_________________ 

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 34 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

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

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

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

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code 

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

Last 4 digits of account number ___ ___ ___ ___ 

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code 

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

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

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

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

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

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

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

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

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

Last 4 digits of account number ___ ___ ___ ___ 

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 35 of 81
	








	


 	  



Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 36 of 81
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___ 

Official Form 106E/F 

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

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

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

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

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

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

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

Part 1: List All of Your PRIORITY Unsecured Claims 

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

 No. Go to Part 2. 

 Yes.

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

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

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

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

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

Total claim Priority 

amount 

Nonpriority 

amount

2.1 ____________________________________________ 

Priority Creditor’s Name

____________________________________________ 

Number Street 

____________________________________________ 

____________________________________________ 

City State ZIP Code

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

When was the debt incurred? ____________

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

 Contingent 

 Unliquidated 

 Disputed 

Type of PRIORITY unsecured claim:

 Domestic support obligations 

 Taxes and certain other debts you owe the government 

 Claims for death or personal injury while you were 

intoxicated 

 Other. Specify _________________________________ 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset?

 No 

 Yes 

2.2 ____________________________________________ 

Priority Creditor’s Name

____________________________________________ 

Number Street 

____________________________________________ 

____________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of PRIORITY unsecured claim:

 Domestic support obligations 

 Taxes and certain other debts you owe the government 

 Claims for death or personal injury while you were 

intoxicated 

 Other. Specify _________________________________

$_____________ $___________ $____________ 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: ______________________________________ 

Case number ___________________________________________ 

 (If known) 

 Fill in this information to identify your case: 

 Check if this is an 

amended filing

 

  

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 37 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: List All of Your NONPRIORITY Unsecured Claims 

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

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

 Yes

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

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

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

fill out the Continuation Page of Part 2. 

Total claim

4.1 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________ 

Number Street 

_____________________________________________________________ 

City State ZIP Code

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

When was the debt incurred? ____________

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim: 

 Student loans 

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims 

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

 Other. Specify ______________________________________

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

4.2 _____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________ 

Number Street 

_____________________________________________________________ 

City State ZIP Code

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

When was the debt incurred? ____________

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim: 

 Student loans 

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims 

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

 Other. Specify ______________________________________

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

4.3 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________ 

Number Street 

_____________________________________________________________ 

City State ZIP Code

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

When was the debt incurred? ____________

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim: 

 Student loans 

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims 

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

 Other. Specify ______________________________________

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

 




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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 38 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

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

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 39 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

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

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 40 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

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

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 41 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

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

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 42 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

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

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

 


    
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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 43 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

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

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 44 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

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

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 45 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page 

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

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

_____________________________________________________________ 

Nonpriority Creditor’s Name

_____________________________________________________________

 Number Street 

_____________________________________________________________

City State ZIP Code 

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another 

 Check if this claim is for a community debt 

Is the claim subject to offset? 

 No 

 Yes

Last 4 digits of account number ___ ___ ___ ___ 

When was the debt incurred? ____________ 

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

 Contingent 

 Unliquidated 

 Disputed 

Type of NONPRIORITY unsecured claim:

 Student loans 

 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

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

 Other. Specify________________________________

$____________ 

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 46 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

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

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

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

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 47 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

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

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

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

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 48 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

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

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

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

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________ 

Name

_____________________________________________________ 

Number Street 

_____________________________________________________ 

_____________________________________________________ 

City State ZIP Code

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

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

  Part 2: Creditors with Nonpriority Unsecured 

Claims

Last 4 digits of account number ___ ___ ___ ___

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 49 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

Add the amounts for each type of unsecured claim. 

Total claim 

Total claims 

from Part 1

6a. Domestic support obligations 6a. $_________________________ 

6b. Taxes and certain other debts you owe the 

government 6b. $_________________________ 

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

intoxicated 6c. $_________________________ 

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

 Write that amount here. 6d. +$_________________________ 

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

$_________________________ 

Total claim 

Total claims 

from Part 2

6f. Student loans 6f.

 $_________________________ 

6g. Obligations arising out of a separation agreement 

or divorce that you did not report as priority 

claims 6g. $_________________________ 

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

similar debts 6h. $_________________________ 

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

 Write that amount here. 6i. + $_________________________

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

$_________________________ 

 


















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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 50 of 81
Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___ 

Official Form 106G 

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

information. If more space is needed, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any 

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

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

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

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

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

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

unexpired leases.

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

2.1 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code 

2.2 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code 

2.3 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code 

2.4 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code 

2.5 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code 

Debtor __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

(Spouse If filing) First Name Middle Name Last Name

United States Bankruptcy Court for the:______________________________________

Case number ___________________________________________ 

 (If known) 

 Fill in this information to identify your case: 

 Check if this is an 

amended filing

	


		




	
				





Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 51 of 81
Official Form 106H Schedule H: Your Codebtors page 1 of ___ 

Official Form 106H 

Schedule H: Your Codebtors 12/15

Codebtors are people or entities who are also liable for any debts you may have. Be as complete and accurate as possible. If two married people 

are filing together, both are equally responsible for supplying correct information. If more space is needed, copy the Additional Page, fill it out, 

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

case number (if known). Answer every question. 

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

 No 

 Yes 

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

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

 No. Go to line 3.

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

 No

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

______________________________________________________________________ 

Name of your spouse, former spouse, or legal equivalent 

______________________________________________________________________ 

Number Street 

______________________________________________________________________ 

City State ZIP Code 

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

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

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

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

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

Check all schedules that apply: 

3.1 ________________________________________________________________________________ 

Name 

________________________________________________________________________________ 

Number Street 

________________________________________________________________________________ 

City State ZIP Code

 Schedule D, line ______ 

 Schedule E/F, line ______ 

 Schedule G, line ______ 

3.2 ________________________________________________________________________________ 

Name 

________________________________________________________________________________ 

Number Street 

________________________________________________________________________________ 

City State ZIP Code

 Schedule D, line ______ 

 Schedule E/F, line ______ 

 Schedule G, line ______ 

3.3 ________________________________________________________________________________ 

Name 

________________________________________________________________________________ 

Number Street 

________________________________________________________________________________ 

City State ZIP Code

 Schedule D, line ______ 

 Schedule E/F, line ______ 

 Schedule G, line ______ 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the:_______________________________________

Case number ____________________________________________ 

 (If known) 

 Fill in this information to identify your case: 

 Check if this is an 

amended filing

	


		




	
				





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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 52 of 81
Official Form 106I Schedule I: Your Income page 1

Official Form 106I 

Schedule I: Your Income 12/15

Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for 

supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your spouse. 

If you are separated and your spouse is not filing with you, do not include information about your spouse. If more space is needed, attach a 

separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question. 

Part 1: Describe Employment 

1. Fill in your employment 

information.

If you have more than one job, 

attach a separate page with 

information about additional 

employers. 

Include part-time, seasonal, or 

self-employed work. 

Occupation may Include student 

or homemaker, if it applies.

Debtor 1 Debtor 2 or non-filing spouse 

Employment status  Employed

 Not employed 

 Employed

 Not employed 

Occupation __________________________________ __________________________________ 

Employer’s name __________________________________ __________________________________ 

Employer’s address _______________________________________ 

Number Street 

_______________________________________ 

_______________________________________ 

_______________________________________ 

City State ZIP Code 

________________________________________ 

Number Street 

________________________________________ 

________________________________________ 

________________________________________ 

City State ZIP Code 

How long employed there? _______ _______ 

Part 2: Give Details About Monthly Income 

Estimate monthly income as of the date you file this form. If you have nothing to report for any line, write $0 in the space. Include your non-filing 

spouse unless you are separated. 

If you or your non-filing spouse have more than one employer, combine the information for all employers for that person on the lines 

below. If you need more space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or 

non-filing spouse 

2. List monthly gross wages, salary, and commissions (before all payroll 

deductions). If not paid monthly, calculate what the monthly wage would be. 2. $___________ $____________

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

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

Debtor 1 ____________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ____________________________________________________________________ 

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

United States Bankruptcy Court for the: ___________________________________________ Case number ___________________________________________ 

 (If known) 

 Fill in this information to identify your case: 

Check if this is: 

 An amended filing 

 A supplement showing post-petition 

chapter 13 income as of the following date: 

________________ 

MM / DD / YYYY 

	


		




	
				

 



Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 53 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

 Official Form 106I Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or 

non-filing spouse

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

5. List all payroll deductions: 

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

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

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

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

5e. Insurance 5e. $____________ $_____________ 

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

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

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

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

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

8. List all other income regularly received: 

 8a. Net income from rental property and from operating a business, 

profession, or farm 

Attach a statement for each property and business showing gross 

receipts, ordinary and necessary business expenses, and the total 

monthly net income. 8a. $____________ $_____________ 

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

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

regularly receive 

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

settlement, and property settlement. 8c. $____________ $_____________ 

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

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

8f. Other government assistance that you regularly receive 

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

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

Nutrition Assistance Program) or housing subsidies. 

Specify: ___________________________________________________ 8f. 

$____________ $_____________ 

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

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

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

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

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

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

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

friends or relatives. 

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

Specify: _______________________________________________________________________________ 11. + $_____________ 

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

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

Combined 

monthly income 

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

 No. 

 Yes. Explain: 

	























 





 




 








Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 54 of 81
 Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J 

Schedule J: Your Expenses 12/15 

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

information. If more space is needed, attach another sheet to this form. On the top of any additional pages, write your name and case number 

(if known). Answer every question. 

Part 1: Describe Your Household

1. Is this a joint case? 

 No. Go to line 2. 

 Yes. Does Debtor 2 live in a separate household? 

 No 

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

2. Do you have dependents? 

Do not list Debtor 1 and 

Debtor 2. 

Do not state the dependents’ 

names. 

 No 

 Yes. Fill out this information for 

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

Dependent’s relationship to 

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent live 

with you?

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

3. Do your expenses include 

expenses of people other than 

yourself and your dependents? 

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

Estimate your expenses as of your bankruptcy filing date unless you are using this form as a supplement in a Chapter 13 case to report 

expenses as of a date after the bankruptcy is filed. If this is a supplemental Schedule J, check the box at the top of the form and fill in the 

applicable date. 

Include expenses paid for with non-cash government assistance if you know the value of 

such assistance and have included it on Schedule I: Your Income (Official Form B 106I.) Your expenses 

4. The rental or home ownership expenses for your residence. Include first mortgage payments and 

any rent for the ground or lot. 4. $_____________________ 

If not included in line 4: 

4a. Real estate taxes 4a. $_____________________ 

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

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

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

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: ______________________________________ 

Case number ___________________________________________ 

 (If known) 

 Fill in this information to identify your case:

Check if this is: 

 An amended filing 

 A supplement showing post-petition chapter 13 

expenses as of the following date: 

________________ 

MM / DD / YYYY 

	


	

























Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 55 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

 Official Form 106J Schedule J: Your Expenses page 2

Your expenses

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

6. Utilities: 

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

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

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

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

7. Food and housekeeping supplies 7. $_____________________ 

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

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

10. Personal care products and services 10. $_____________________ 

11. Medical and dental expenses 11. $_____________________ 

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

Do not include car payments. 12. $_____________________ 

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

14. Charitable contributions and religious donations 14. $_____________________ 

15. Insurance. 

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

1

15a. Life insurance 15a. $_____________________ 

15b. Health insurance 15b. $_____________________ 

15c. Vehicle insurance 15c. $_____________________ 

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

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

Specify: ________________________________________________________ 16.

$_____________________ 

17. Installment or lease payments: 

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

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

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

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

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

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

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

Specify:_______________________________________________________ 19. $_____________________ 

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

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

20b. Real estate taxes 20b. $_____________________ 

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

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

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

	


































































Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 56 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

 Official Form 106J Schedule J: Your Expenses page 3

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

22. Calculate your monthly expenses. 

22a. Add lines 4 through 21. 

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

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

$_____________________

$_____________________

$_____________________

23. Calculate your monthly net income. 

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

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

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

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

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

For example, do you expect to finish paying for your car loan within the year or do you expect your 

mortgage payment to increase or decrease because of a modification to the terms of your mortgage?

 No. 

 Yes. Explain here: 

	








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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 57 of 81
Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2 

Official Form 106Sum 

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

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

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

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

Part 1: Summarize Your Assets 

Your assets

Value of what you own 

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

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

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

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

Part 2: Summarize Your Liabilities 

Your liabilities

Amount you owe

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

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

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

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

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

Your total liabilities $ ________________

Part 3: Summarize Your Income and Expenses 

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

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

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

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

 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: ______________________________________ 

Case number ___________________________________________ 

 (If known) 

 Fill in this information to identify your case: 

 Check if this is an 

amended filing

 


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 58 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 4: Answer These Questions for Administrative and Statistical Records

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

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

 Yes

7. What kind of debt do you have?

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

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

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

this form to the court with your other schedules. 

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

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

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

Total claim

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

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

$_____________________

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

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

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

$_____________________ 

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

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

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

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

 






	

















Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 59 of 81
Official Form 106Dec Declaration About an Individual Debtor’s Schedules page 1 

Official Form 106Dec 

Declaration About an Individual Debtor’s Schedules 12/15

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

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

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

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

Sign Below

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

No 

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

Signature (Official Form 119).

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

that they are true and correct. 

______________________________________________ _____________________________ Signature of Debtor 1 Signature of Debtor 2 

Date _________________ Date _________________ 

MM / DD / YYYY MM / DD / YYYY

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: _______________________________________ 

Case number ___________________________________________ 

 (If known) 

 Fill in this information to identify your case: 

 Check if this is an 

amended filing

	





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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 60 of 81
 Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

Official Form 107 

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

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

information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case 

number (if known). Answer every question. 

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

1. What is your current marital status? 

 Married 

 Not married 

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

 No 

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

Debtor 1: Dates Debtor 1 

lived there 

Debtor 2: Dates Debtor 2 

lived there 

__________________________________________ 

Number Street 

__________________________________________ 

__________________________________________ 

City State ZIP Code

From ________

To ________

 Same as Debtor 1 

___________________________________________ 

Number Street 

___________________________________________ 

___________________________________________ 

City State ZIP Code 

 Same as Debtor 1

From ________

To ________

__________________________________________ 

Number Street 

 __________________________________________ 

__________________________________________ 

City State ZIP Code

From ________

To ________

 Same as Debtor 1 

___________________________________________ 

Number Street 

___________________________________________ 

___________________________________________ 

City State ZIP Code 

 Same as Debtor 1

From ________

To ________

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

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

 No

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

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: ____________________________________________

 

Case number ___________________________________________ 

 (If known) 

 Fill in this information to identify your case: 

 Check if this is an 

amended filing

 

  



	

	

	

 



  

	

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 61 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Explain the Sources of Your Income 

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

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

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

 No 

 Yes. Fill in the details.

Debtor 1 Debtor 2 

Sources of income 

Check all that apply.

Gross income 

(before deductions and 

exclusions)

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy:

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________ 

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________ 

For last calendar year: 

(January 1 to December 31, _________) YYYY

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________ 

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________ 

For the calendar year before that: 

(January 1 to December 31, _________) YYYY

 Wages, commissions, 

bonuses, tips

 Operating a business $________________ 

 Wages, commissions, 

bonuses, tips

 Operating a business $________________ 

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

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

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

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

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

 No 

 Yes. Fill in the details.

Debtor 1 Debtor 2 

Sources of income

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

Sources of income 

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy: 

__________________ 

__________________ 

__________________ 

$_________________ 

$_________________ 

$_________________ 

_____________________ 

_____________________ 

_____________________ 

$_________________ 

$_________________ 

$_________________

For last calendar year: 

(January 1 to December 31, ______) YYYY

__________________ 

__________________ 

__________________ 

$_________________ 

$_________________ 

$_________________ 

_____________________ 

_____________________ 

_____________________ 

$_________________ 

$_________________ 

$_________________ 

For the calendar year before that: 

(January 1 to December 31, ______) YYYY

__________________ 

__________________ 

__________________ 

$_________________ 

$_________________ 

$_________________ 

_____________________ 

_____________________ 

_____________________ 

$_________________ 

$_________________ 

$_________________



	

	


   

	  


   

	  




  



Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 62 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	
 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3

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

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

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

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

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

No. Go to line 7.

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

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

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

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

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

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

No. Go to line 7.

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

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

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

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Dates of 

payment

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

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________



	

	

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 63 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

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

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

such as child support and alimony. 

 No 

 Yes. List all payments to an insider. 

____________________________________________ 

Insider’s Name

____________________________________________ 

Number Street 

____________________________________________ 

____________________________________________ 

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

_________ 

_________ 

_________ 

$____________ $____________ 

____________________________________________ 

Insider’s Name

____________________________________________ 

Number Street 

____________________________________________ 

____________________________________________ 

City State ZIP Code

_________ 

_________ 

_________ 

$____________ $____________ 

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

an insider? 

Include payments on debts guaranteed or cosigned by an insider. 

 No 

 Yes. List all payments that benefited an insider. 

____________________________________________ 

Insider’s Name

____________________________________________ 

Number Street 

____________________________________________ 

____________________________________________ 

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

Include creditor’s name

_________ 

_________ 

_________ 

$____________ $____________ 

____________________________________________ 

Insider’s Name

____________________________________________ 

Number Street 

____________________________________________ 

____________________________________________ 

City State ZIP Code

_________ 

_________ 

_________ 

$____________ $____________ 



	

	

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 64 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

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

and contract disputes. 

 No 

 Yes. Fill in the details.

Case title_____________________________ 

____________________________________ 

Case number ________________________ 

Nature of the case Court or agency Status of the case 

________________________________________ 

Court Name

________________________________________ 

Number Street 

________________________________________ 

City State ZIP Code

 Pending 

 On appeal 

 Concluded

Case title_____________________________ 

____________________________________ 

Case number ________________________

________________________________________ 

Court Name

________________________________________ 

Number Street 

________________________________________ 

City State ZIP Code

 Pending 

 On appeal 

 Concluded

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

Check all that apply and fill in the details below.

 No. Go to line 11. 

 Yes. Fill in the information below. 

_________________________________________ 

Creditor’s Name

_________________________________________ 

Number Street 

_________________________________________ 

_________________________________________ 

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

 Property was repossessed. 

 Property was foreclosed. 

 Property was garnished. 

 Property was attached, seized, or levied.

_________________________________________ 

Creditor’s Name

_________________________________________ 

Number Street 

_________________________________________ 

_________________________________________ 

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened 

 Property was repossessed. 

 Property was foreclosed. 

 Property was garnished. 

 Property was attached, seized, or levied.



	


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 65 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

 No 

 Yes. Fill in the details. 

______________________________________ 

Creditor’s Name

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code 

Describe the action the creditor took Date action 

was taken

Amount

____________ $________________

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

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

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

 No 

 Yes

Part 5: List Certain Gifts and Contributions 

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

 No 

 Yes. Fill in the details for each gift. 

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________ 

Person to Whom You Gave the Gift 

______________________________________ 

______________________________________ 

______________________________________ 

City State ZIP Code

Person’s relationship to you ______________ 

_________

_________ 

$_____________ 

$_____________ 

Gifts with a total value of more than $600 

per person 

Describe the gifts Dates you gave 

the gifts 

Value 

______________________________________ 

Person to Whom You Gave the Gift 

______________________________________ 

______________________________________ 

______________________________________ 

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________ 

$_____________ 



	

	

	

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 66 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

 No 

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

Gifts or contributions to charities 

that total more than $600

Describe what you contributed Date you 

contributed

Value 

_____________________________________ 

Charity’s Name

_____________________________________ 

_____________________________________ 

_____________________________________ 

City State ZIP Code

_________

_________

$_____________ 

$_____________ 

Part 6: List Certain Losses 

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

or gambling? 

 No 

 Yes. Fill in the details.

Describe the property you lost and how 

the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending insurance 

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

Date of your loss Value of property 

lost

_________ $_____________ 

Part 7: List Certain Payments or Transfers 

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

consulted about seeking bankruptcy or preparing a bankruptcy petition?

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

 No 

 Yes. Fill in the details.

___________________________________ 

Person Who Was Paid 

___________________________________ 

Number Street 

___________________________________

___________________________________ 

City State ZIP Code 

____________________________________________ 

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of payment 

_________

_________

$_____________ 

$_____________ 

___________________________________ 

Person Who Made the Payment, if Not You



	

	

	


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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 67 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

____________________________________ 

Person Who Was Paid 

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code 

________________________________________________ 

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of 

payment

_________

_________

$_____________ 

$_____________ 

___________________________________ 

Person Who Made the Payment, if Not You

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

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

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

 No 

 Yes. Fill in the details. 

____________________________________ 

Person Who Was Paid 

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code 

Description and value of any property transferred Date payment or 

transfer was made 

Amount of payment 

_________

_________

$____________ 

$____________ 

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

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

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

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

 No 

 Yes. Fill in the details.

___________________________________ 

Person Who Received Transfer 

___________________________________ 

Number Street 

___________________________________

___________________________________ 

City State ZIP Code 

Description and value of property 

transferred

Describe any property or payments received 

or debts paid in exchange

Date transfer 

was made

_________ 

Person’s relationship to you _____________

___________________________________ 

Person Who Received Transfer 

___________________________________ 

Number Street 

___________________________________

___________________________________ 

City State ZIP Code 

_________ 

Person’s relationship to you _____________




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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 68 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

 No 

 Yes. Fill in the details.

Name of trust __________________________ 

______________________________________ 

Description and value of the property transferred Date transfer 

was made 

_________ 

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

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

closed, sold, moved, or transferred? 

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

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

 No 

 Yes. Fill in the details.

____________________________________ 

Name of Financial Institution 

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code 

Last 4 digits of account number Type of account or 

instrument

Date account was 

closed, sold, moved, 

or transferred 

Last balance before 

closing or transfer 

XXXX–___ ___ ___ ___ Checking 

 Savings 

 Money market 

 Brokerage 

 Other__________

_________ $___________ 

____________________________________ 

Name of Financial Institution 

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code

XXXX–___ ___ ___ ___ Checking 

 Savings 

 Money market 

 Brokerage 

 Other__________

_________ $___________ 

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

securities, cash, or other valuables? 

 No 

 Yes. Fill in the details.

____________________________________ 

Name of Financial Institution 

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code

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

have it? 

_______________________________________ 

Name 

_______________________________________ 

Number Street 

_______________________________________ 

City State ZIP Code

 No 

 Yes 





	

	

	

	

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 69 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

 No 

 Yes. Fill in the details.

___________________________________ 

Name of Storage Facility

___________________________________ 

Number Street 

___________________________________

___________________________________ 

City State ZIP Code

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

have it? 

_______________________________________ 

Name 

_______________________________________ 

Number Street 

_______________________________________ 

City State ZIP Code

 No 

 Yes 



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

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

or hold in trust for someone. 

 No 

 Yes. Fill in the details.

___________________________________ 

Owner’s Name

___________________________________ 

Number Street 

___________________________________

___________________________________ 

City State ZIP Code

Where is the property? Describe the property Value

_________________________________________ 

Number Street 

_________________________________________ 

_________________________________________ 

City State ZIP Code

$__________ 

Part 10: Give Details About Environmental Information 

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

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

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

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

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

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

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

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

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

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

 No 

 Yes. Fill in the details.

____________________________________ 

Name of site

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code

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

_______________________________ 

Governmental unit

_______________________________ 

Number Street 

_______________________________ 

City State ZIP Code

_________ 



	

	

	

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 70 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

 No 

 Yes. Fill in the details.

____________________________________ 

Name of site

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code

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

_______________________________ 

Governmental unit

_______________________________ 

Number Street 

_______________________________ 

City State ZIP Code

_________ 

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

 No 

 Yes. Fill in the details.

Case title______________________________ 

______________________________________ 

______________________________________ 

Case number

Court or agency Nature of the case Status of the 

case 

________________________________ 

Court Name

________________________________ 

Number Street 

________________________________ 

City State ZIP Code

 Pending 

 On appeal 

Concluded



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

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

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

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

 A partner in a partnership 

 An officer, director, or managing executive of a corporation 

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

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

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

____________________________________ 

Business Name

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN. 

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

Name of accountant or bookkeeper Dates business existed 

From _______ To _______ 

____________________________________ 

Business Name

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN. 

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

Name of accountant or bookkeeper Dates business existed

From _______ To _______ 



	

	

	

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 71 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

____________________________________ 

Business Name

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN. 

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

Name of accountant or bookkeeper Dates business existed

From _______ To _______ 

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

institutions, creditors, or other parties. 

 No 

 Yes. Fill in the details below. 

____________________________________ 

Name

____________________________________ 

Number Street 

____________________________________

____________________________________ 

City State ZIP Code

Date issued

____________ 

MM / DD / YYYY

Part 12: Sign Below 

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

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

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

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

______________________________________________ _____________________________ Signature of Debtor 1 Signature of Debtor 2 

Date ________________ Date _________________

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

 No 

 Yes

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

 No 

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

Declaration, and Signature (Official Form 119).



	

 



	

	

Warren Artis Liane Mae Artis

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 72 of 81

	


	


















 




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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 73 of 81
Official Form 108 Statement of Intention for Individuals Filing Under Chapter 7 page 1 

Official Form 108 

Statement of Intention for Individuals Filing Under Chapter 7 12/15

If you are an individual filing under chapter 7, you must fill out this form if: 

creditors have claims secured by your property, or 

you have leased personal property and the lease has not expired. 

You must file this form with the court within 30 days after you file your bankruptcy petition or by the date set for the meeting of creditors, 

whichever is earlier, unless the court extends the time for cause. You must also send copies to the creditors and lessors you list on the form. 

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

Both debtors must sign and date the form. 

Be as complete and accurate as possible. 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). 

Part 1: List Your Creditors Who Hold Secured Claims 

1. For any creditors that you listed in Part 1 of Schedule D: Creditors Who Hold Claims Secured by Property (Official Form 106D), fill in the 

information below. 

Identify the creditor and the property that is collateral What do you intend to do with the property that 

secures a debt?

Did you claim the property 

as exempt on Schedule C?

Creditor’s 

name:  Surrender the property. 

 Retain the property and redeem it. 

 Retain the property and enter into a 

Reaffirmation Agreement. 

 Retain the property and [explain]: __________ 

______________________________________ 

 No 

 Yes 

Description of 

property 

securing debt: 

Creditor’s 

name:  Surrender the property. 

 Retain the property and redeem it. 

 Retain the property and enter into a 

Reaffirmation Agreement. 

 Retain the property and [explain]: __________ 

______________________________________ 

 No 

 Yes 

Description of 

property 

securing debt: 

Creditor’s 

name:  Surrender the property. 

 Retain the property and redeem it. 

 Retain the property and enter into a 

Reaffirmation Agreement. 

 Retain the property and [explain]: __________ 

______________________________________ 

 No 

 Yes 

Description of 

property 

securing debt: 

Creditor’s 

name:  Surrender the property. 

 Retain the property and redeem it. 

 Retain the property and enter into a 

Reaffirmation Agreement. 

 Retain the property and [explain]: __________ 

______________________________________ 

 No 

 Yes 

Description of 

property 

securing debt: 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: _______________________________________ 

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

 Check if this is an 

amended filing

6





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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 74 of 81
Your name ______________________________________________________ Case number (If known)_____________________________________ First Name Middle Name Last Name

 Official Form 108 Statement of Intention for Individuals Filing Under Chapter 7 page 2 

Part 2: List Your Unexpired Personal Property Leases 

For any unexpired personal property lease that you listed in Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G), 

fill in the information below. Do not list real estate leases. Unexpired leases are leases that are still in effect; the lease period has not yet 

ended. You may assume an unexpired personal property lease if the trustee does not assume it. 11 U.S.C. § 365(p)(2).

Describe your unexpired personal property leases Will the lease be assumed? 

Lessor’s name:  No 

 Yes Description of leased 

property: 

Lessor’s name:  No 

 Yes Description of leased 

property: 

Lessor’s name:  No 

Description of leased  Yes

property: 

Lessor’s name:  No 

 Yes

Description of leased 

property: 

Lessor’s name:  No 

 Yes

Description of leased 

property: 

Lessor’s name:  No 

 Yes

Description of leased 

property: 

Lessor’s name:  No 

 Yes

Description of leased 

property: 

Part 3: Sign Below

Under penalty of perjury, I declare that I have indicated my intention about any property of my estate that secures a debt and any 

personal property that is subject to an unexpired lease. 

___________________________________________ ___________________________________________ 

Signature of Debtor 1 Signature of Debtor 2 

Date _________________ Date _________________ MM / DD / YYYY MM / DD / YYYY

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/.*0.*/1 /.*0.*/1

Warren Artis Liane Mae Artis

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 75 of 81
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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 76 of 81
Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 1

Official Form 122A─1 

Chapter 7 Statement of Your Current Monthly Income 12/15

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

space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any 

additional pages, write your name and case number (if known). If you believe that you are exempted from a presumption of abuse because you 

do not have primarily consumer debts or because of qualifying military service, complete and file Statement of Exemption from Presumption of 

Abuse Under § 707(b)(2) (Official Form 122A-1Supp) with this form. 

Part 1: Calculate Your Current Monthly Income

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

 Not married. Fill out Column A, lines 2-11. 

Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11. 

 Married and your spouse is NOT filing with you. You and your spouse are: 

 Living in the same household and are not legally separated. Fill out both Columns A and B, lines 2-11. 

 Living separately or are legally separated. Fill out Column A, lines 2-11; do not fill out Column B. By checking this box, you declare 

under penalty of perjury that you and your spouse are legally separated under nonbankruptcy law that applies or that you and your 

spouse are living apart for reasons that do not include evading the Means Test requirements. 11 U.S.C. § 707(b)(7)(B). 

Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this 

bankruptcy case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through 

August 31. If the amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6. 

Fill in the result. Do not include any income amount more than once. For example, if both spouses own the same rental property, put the 

income from that property in one column only. If you have nothing to report for any line, write $0 in the space. 

Column A 

Debtor 1

Column B 

Debtor 2 or 

non-filing spouse 

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

(before all payroll deductions). $_________ $__________ 

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

Column B is filled in. $_________ $__________ 

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

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

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

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

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

5. Net income from operating a business, profession, 

or farm Debtor 1 Debtor 2

Gross receipts (before all deductions) $______ $______

Ordinary and necessary operating expenses – $______ – $______

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

here $_________ $__________ 

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

Gross receipts (before all deductions) $______ $______

Ordinary and necessary operating expenses – $______ – $______

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

Copy 

here $_________ $__________ 

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

 Check if this is an amended filing

 1. There is no presumption of abuse. 

 2. The calculation to determine if a presumption of 

abuse applies will be made under Chapter 7 

Means Test Calculation (Official Form 122A–2). 

 3. The Means Test does not apply now because of 

qualified military service but it could apply later. 

Check one box only as directed in this form and in 

Form 122A-1Supp: 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: ____________________________________________

Case number ___________________________________________ 

(If known) 

Fill in this information to identify your case: 

-	(



	



	
	





 

 

 

   

   

 

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 77 of 81
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 2

Column A 

Debtor 1

Column B 

Debtor 2 or 

non-filing spouse 

8. Unemployment compensation $__________ $___________ 

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

under the Social Security Act. Instead, list it here: ................................ 

For you .................................................................................... $______________ 

For your spouse .................................................................... $______________

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

benefit under the Social Security Act. $__________ $___________ 

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

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

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

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

______________________________________ $_________ $___________ 

______________________________________ $_________ $___________ 

Total amounts from separate pages, if any. + $_________ + $___________ 

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

column. Then add the total for Column A to the total for Column B. $_________ + $___________ = $__________

Total current 

monthly income

Part 2: Determine Whether the Means Test Applies to You

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

12a. Copy your total current monthly income from line 11. ..................................................................................... Copy line 11 here $__________ 

 Multiply by 12 (the number of months in a year). x 12

12b. The result is your annual income for this part of the form. 12b. $__________ 

13. 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. ................................................................................................. 13.

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.

$__________ 

14. How do the lines compare?

14a.  Line 12b is less than or equal to line 13. On the top of page 1, check box 1, There is no presumption of abuse.

Go to Part 3. 

14b.  Line 12b is more than line 13. On the top of page 1, check box 2, The presumption of abuse is determined by Form 122A-2. 

Go to Part 3 and fill out Form 122A–2.

Part 3: Sign Below

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

__________________________________________________________ ______________________________________ Signature of Debtor 1 Signature of Debtor 2 

Date _________________ Date _________________ 

MM / DD / YYYY MM / DD / YYYY 

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 78 of 81
B2030 (Form 2030) (12/15)

UnitedStatesBankruptcyCourt

In re

Case No. ___________________

Debtor Chapter ____________________

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

1. Pursuant to 11 U .S.C. § 329(a) and Fed. Bankr. P. 2016(b), I certify that I am the attorney for the above

named debtor(s) and that compensation paid to me within one year before the filing of the petition in

bankruptcy, or agreed to be paid to me, for services rendered or to be rendered on behalf of the debtor(s) in

contemplation of or in connection with the bankruptcy case is as follows:

For legal services, I have agreed to accept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________

Prior to the filing of this statement I have received . . . . . . . . . . . . . . . . . . . . . . . . $______________

Balance Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________

2. The source of the compensation paid to me was:

Debtor Other (specify)

3. The source of compensation to be paid to me is:

Debtor Other (specify)

4. I have not agreed to share the above-disclosed compensation with any other person unless they are

members and associates of my law firm.

I have agreed to share the above-disclosed compensation with a other person or persons who are not

members or associates of my law firm. A copy of the agreement, together with a list of the names of the

people sharing in the compensation, is attached.

5. In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy

case, including:

a. Analysis of the debtor' s financial situation, and rendering advice to the debtor in determining whether to

file a petition in bankruptcy;

b. Preparation and filing of any petition, schedules, statements of affairs and plan which may be required;

c. Representation of the debtor at the meeting of creditors and confirmation hearing, and any adjourned

hearings thereof;

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 79 of 81
B2030 (Form 2030) (12/15)

d. Representation of the debtor in adversary proceedings and other contested bankruptcy matters;

e. [Other provisions as needed]

6. By agreement with the debtor(s), the above-disclosed fee does not include the following services:

CERTIFICATION

I certify that the foregoing is a complete statement of any agreement or arrangement for payment to

me for representation of the debtor(s) in this bankruptcy proceeding.

______________________

Date Signature of Attorney

Name of law firm

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Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 80 of 81
UNITED STATES BANKRUPTCY COURT

EASTERN DISTRICT OF VIRGINIA

RICHMOND DIVISION

In re 

Warren Artis and Liane Mae Artis

Debtors. Dothins

Dothins

Chapter 7

Case No. 

Dothins

STATEMENT OF MONTHLY Net INCOME

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

Income:

Dothins Dothins

Debtor

Dothins Dothins Dothins

Joint Debtor

Dothins

Six months ago

Dothins

$ Dothins2,668.58

Dothins Dothins

$ Dothins4,221.00

Dothins

Five months ago

Dothins

$ Dothins2,668.58

Dothins Dothins

$ Dothins0.00

Dothins

Four months ago

Dothins

$ Dothins2,668.58

Dothins Dothins

$ Dothins0.00

Dothins

Three months ago

Dothins

$ Dothins2,608.52

Dothins Dothins

$ Dothins0.00

Dothins

Two months ago

Dothins

$ Dothins2,608.52

Dothins Dothins

$ Dothins0.00

Dothins

Last month

Dothins

$ Dothins2,608.52

Dothins Dothins

$ Dothins0.00

Dothins

Total Net income for 

six months preceding filing

Dothins

$ Dothins15,831.30

Dothins

Dothins

$ Dothins4,221.00

Dothins

Average Monthly Net 

Income

Dothins

$ Dothins2,638.55

Dothins

Dothins

$ Dothins703.50

Dothins

Dated:

Dothins

January 23, 2019 

Dothins Dothins Dothins

Dothins Dothins Dothins

/s/Warren Artis Dothins

Dothins Dothins Dothins

Warren Artis Dothins

Dothins Dothins Dothins

Debtor Dothins

Dothins Dothins Dothins Dothins

Dothins Dothins Dothins

/s/Liane Mae Artis Dothins

Dothins Dothins Dothins

Liane Mae Artis Dothins

Dothins Dothins Dothins

Joint Debtor Dothins

Case 19-30377-KRH Doc 1 Filed 01/24/19 Entered 01/24/19 15:43:04 Desc Main

 Document Page 81 of 81