Fill in this information to identify the case:

Debtor name Nelson Dermatology, PLLC

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number (if known) 17-11536-BFK

 Check if this is an

amended filing

Official Form 202

Declaration Under Penalty of Perjury for Non-Individual Debtors 12/15

An individual who is authorized to act on behalf of a non-individual debtor, such as a corporation or partnership, must sign and submit this

form for the schedules of assets and liabilities, any other document that requires a declaration that is not included in the document, and any

amendments of those documents. This form must state the individual’s position or relationship to the debtor, the identity of the document,

and the date. Bankruptcy Rules 1008 and 9011.

WARNING -- Bankruptcy fraud is a serious crime. 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 $500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341,

1519, and 3571.

Declaration and signature

I am the president, another officer, or an authorized agent of the corporation; a member or an authorized agent of the partnership; or another

individual serving as a representative of the debtor in this case.

I have examined the information in the documents checked below and I have a reasonable belief that the information is true and correct:

 Schedule A/B: Assets–Real and Personal Property (Official Form 206A/B)

 Schedule D: Creditors Who Have Claims Secured by Property (Official Form 206D)

 Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 206E/F)

 Schedule G: Executory Contracts and Unexpired Leases (Official Form 206G)

 Schedule H: Codebtors (Official Form 206H)

 Summary of Assets and Liabilities for Non-Individuals (Official Form 206Sum)

 Amended Schedule

 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims and Are Not Insiders (Official Form 204)

 Other document that requires a declaration

I declare under penalty of perjury that the foregoing is true and correct.

Executed on June 1, 2017 X /s/ Dr. Jennell E. Nelson

Signature of individual signing on behalf of debtor

Dr. Jennell E. Nelson

Printed name

Managing Member

Position or relationship to debtor

Official Form 202 Declaration Under Penalty of Perjury for Non-Individual Debtors

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 Document Page 1 of 47
Fill in this information to identify the case:

Debtor name Nelson Dermatology, PLLC

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number (if known) 17-11536-BFK

 Check if this is an

amended filing

Official Form 206Sum

Summary of Assets and Liabilities for Non-Individuals 12/15

Part 1: Summary of Assets

1. Schedule A/B: Assets-Real and Personal Property (Official Form 206A/B)

1a. Real property:

 Copy line 88 from Schedule A/B............................................................................................................................. $ 0.00

1b. Total personal property:

 Copy line 91A from Schedule A/B......................................................................................................................... $ 281,949.41

1c. Total of all property:

 Copy line 92 from Schedule A/B........................................................................................................................... $ 281,949.41

Part 2: Summary of Liabilities

2. Schedule D: Creditors Who Have Claims Secured by Property (Official Form 206D)

Copy the total dollar amount listed in Column A, Amount of claim, from line 3 of Schedule D.................................... $ 0.00

3. Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 206E/F)

3a. Total claim amounts of priority unsecured claims:

 Copy the total claims from Part 1 from line 5a of Schedule E/F.......................................................................... $ 68,161.79

3b. Total amount of claims of nonpriority amount of unsecured claims:

 Copy the total of the amount of claims from Part 2 from line 5b of Schedule E/F................................................ +$ 332,232.48

4. Total liabilities .......................................................................................................................................................

Lines 2 + 3a + 3b $ 400,394.27

Official Form 206Sum Summary of Assets and Liabilities for Non-Individuals page 1

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 Document Page 2 of 47
Fill in this information to identify the case:

Debtor name Nelson Dermatology, PLLC

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number (if known) 17-11536-BFK

 Check if this is an

amended filing

Official Form 206A/B

Schedule A/B: Assets - Real and Personal Property 12/15

Disclose all property, real and personal, which the debtor owns or in which the debtor has any other legal, equitable, or future interest.

Include all property in which the debtor holds rights and powers exercisable for the debtor's own benefit. Also include assets and properties

which have no book value, such as fully depreciated assets or assets that were not capitalized. In Schedule A/B, list any executory contracts

or unexpired leases. Also list them on Schedule G: Executory Contracts and Unexpired Leases (Official Form 206G).

Be as complete and accurate as possible. If more space is needed, attach a separate sheet to this form. At the top of any pages added, write

the debtor’s name and case number (if known). Also identify the form and line number to which the additional information applies. If an

additional sheet is attached, include the amounts from the attachment in the total for the pertinent part.

For Part 1 through Part 11, list each asset under the appropriate category or attach separate supporting schedules, such as a fixed asset

schedule or depreciation schedule, that gives the details for each asset in a particular category. List each asset only once. In valuing the

debtor’s interest, do not deduct the value of secured claims. See the instructions to understand the terms used in this form.

Part 1: Cash and cash equivalents

1. Does the debtor have any cash or cash equivalents?

 No. Go to Part 2.

 Yes Fill in the information below.

All cash or cash equivalents owned or controlled by the debtor Current value of

debtor's interest

2. Cash on hand $200.00

3. Checking, savings, money market, or financial brokerage accounts (Identify all)

Name of institution (bank or brokerage firm) Type of account Last 4 digits of account

number

3.1. Everbank Checking 7896 $3,377.00

3.2. Industrial Bank Checking 5238 $500.00

3.3. PNC Checking 1728 $23.37

4. Other cash equivalents (Identify all)

5. Total of Part 1. $4,100.37

Add lines 2 through 4 (including amounts on any additional sheets). Copy the total to line 80.

Part 2: Deposits and Prepayments

6. Does the debtor have any deposits or prepayments?

 No. Go to Part 3.

 Yes Fill in the information below.

7. Deposits, including security deposits and utility deposits

Description, including name of holder of deposit

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 1

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 Document Page 3 of 47
Debtor Nelson Dermatology, PLLC Case number (If known) 17-11536-BFK

Name

7.1. AthenaHealth, Inc. $2,450.00

7.2. Sudley North, LLC (Security Deposit for Rent) $6,159.00

8. Prepayments, including prepayments on executory contracts, leases, insurance, taxes, and rent

Description, including name of holder of prepayment

9. Total of Part 2. $8,609.00

Add lines 7 through 8. Copy the total to line 81.

Part 3: Accounts receivable

10. Does the debtor have any accounts receivable?

 No. Go to Part 4.

 Yes Fill in the information below.

11. Accounts receivable

11a. 90 days old or less: 44,431.73 - 0.00 = .... $44,431.73

face amount doubtful or uncollectible accounts

11a. 90 days old or less: 36,928.31 - 0.00 = .... $36,928.31

face amount doubtful or uncollectible accounts

11b. Over 90 days old: 2,714.10 - 2,714.10 =.... $0.00

face amount doubtful or uncollectible accounts

11b. Over 90 days old: 9,926.85 - 9,926.85 =.... $0.00

face amount doubtful or uncollectible accounts

12. Total of Part 3. $81,360.04

Current value on lines 11a + 11b = line 12. Copy the total to line 82.

Part 4: Investments

13. Does the debtor own any investments?

 No. Go to Part 5.

 Yes Fill in the information below.

Part 5: Inventory, excluding agriculture assets

18. Does the debtor own any inventory (excluding agriculture assets)?

 No. Go to Part 6.

 Yes Fill in the information below.

General description Date of the last

physical inventory

Net book value of

debtor's interest

(Where available)

Valuation method used

for current value

Current value of

debtor's interest

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 2

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 Document Page 4 of 47
Debtor Nelson Dermatology, PLLC Case number (If known) 17-11536-BFK

Name

19. Raw materials

20. Work in progress

21. Finished goods, including goods held for resale

22. Other inventory or supplies

Skincare Line 5/8/17 $0.00 Recent cost $3,000.00

Medical Supplies $0.00 Recent cost $3,600.00

23. Total of Part 5. $6,600.00

Add lines 19 through 22. Copy the total to line 84.

24. Is any of the property listed in Part 5 perishable?

 No

 Yes

25. Has any of the property listed in Part 5 been purchased within 20 days before the bankruptcy was filed?

 No

 Yes. Book value 0 Valuation method Current Value 3300

26. Has any of the property listed in Part 5 been appraised by a professional within the last year?

 No

 Yes

Part 6: Farming and fishing-related assets (other than titled motor vehicles and land)

27. Does the debtor own or lease any farming and fishing-related assets (other than titled motor vehicles and land)?

 No. Go to Part 7.

 Yes Fill in the information below.

Part 7: Office furniture, fixtures, and equipment; and collectibles

38. Does the debtor own or lease any office furniture, fixtures, equipment, or collectibles?

 No. Go to Part 8.

 Yes Fill in the information below.

General description Net book value of

debtor's interest

(Where available)

Valuation method used

for current value

Current value of

debtor's interest

39. Office furniture

Office Furniture (See Exhibit B38 attached) $589.00 $589.00

Medical Equipment (See Exhibit B38 attached) $382.00 $382.00

40. Office fixtures

41. Office equipment, including all computer equipment and

communication systems equipment and software

Office Equipment (See Exhibit B38 attached) $209.00 $209.00

42. Collectibles Examples: Antiques and figurines; paintings, prints, or other artwork;

books, pictures, or other art objects; china and crystal; stamp, coin, or baseball card

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 3

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 Document Page 5 of 47
Debtor Nelson Dermatology, PLLC Case number (If known) 17-11536-BFK

Name

collections; other collections, memorabilia, or collectibles

43. Total of Part 7. $1,180.00

Add lines 39 through 42. Copy the total to line 86.

44. Is a depreciation schedule available for any of the property listed in Part 7?

 No

 Yes

45. Has any of the property listed in Part 7 been appraised by a professional within the last year?

 No

 Yes

Part 8: Machinery, equipment, and vehicles

46. Does the debtor own or lease any machinery, equipment, or vehicles?

 No. Go to Part 9.

 Yes Fill in the information below.

Part 9: Real property

54. Does the debtor own or lease any real property?

 No. Go to Part 10.

 Yes Fill in the information below.

55. Any building, other improved real estate, or land which the debtor owns or in which the debtor has an interest

Description and location of

property

Include street address or other

description such as Assessor

Parcel Number (APN), and type

of property (for example,

acreage, factory, warehouse,

apartment or office building, if

available.

Nature and

extent of

debtor's interest

in property

Net book value of

debtor's interest

(Where available)

Valuation method used

for current value

Current value of

debtor's interest

55.1. Lease of 7960

Donegan Drive, Suite

217, Manassas, VA

20109 Lease Unknown Unknown

56. Total of Part 9. $0.00

Add the current value on lines 55.1 through 55.6 and entries from any additional sheets.

Copy the total to line 88.

57. Is a depreciation schedule available for any of the property listed in Part 9?

 No

 Yes

58. Has any of the property listed in Part 9 been appraised by a professional within the last year?

 No

 Yes

Part 10: Intangibles and intellectual property

59. Does the debtor have any interests in intangibles or intellectual property?

 No. Go to Part 11.

 Yes Fill in the information below.

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 4

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Debtor Nelson Dermatology, PLLC Case number (If known) 17-11536-BFK

Name

General description Net book value of

debtor's interest

(Where available)

Valuation method used

for current value

Current value of

debtor's interest

60. Patents, copyrights, trademarks, and trade secrets

61. Internet domain names and websites

http://www.nelsonskin.net/ $0.00 $100.00

62. Licenses, franchises, and royalties

63. Customer lists, mailing lists, or other compilations

10,000 Patients / Year $0.00 $30,000.00

64. Other intangibles, or intellectual property

65. Goodwill

Goodwill Professional - Dr. Jennell Nelson $0.00 $130,000.00

Goodwill - Practice - Nelson Dermatology $0.00 $20,000.00

66. Total of Part 10. $180,100.00

Add lines 60 through 65. Copy the total to line 89.

67. Do your lists or records include personally identifiable information of customers (as defined in 11 U.S.C.§§ 101(41A) and 107?

 No

 Yes

68. Is there an amortization or other similar schedule available for any of the property listed in Part 10?

 No

 Yes

69. Has any of the property listed in Part 10 been appraised by a professional within the last year?

 No

 Yes

Part 11: All other assets

70. Does the debtor own any other assets that have not yet been reported on this form?

Include all interests in executory contracts and unexpired leases not previously reported on this form.

 No. Go to Part 12.

 Yes Fill in the information below.

Current value of

debtor's interest

71. Notes receivable

Description (include name of obligor)

72. Tax refunds and unused net operating losses (NOLs)

Description (for example, federal, state, local)

73. Interests in insurance policies or annuities

The Hartford - Commercial and General Liability and

Excess $0.00

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 5

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Debtor Nelson Dermatology, PLLC Case number (If known) 17-11536-BFK

Name

Accident Fund Insurance Co. - Workers Compensation $0.00

Norcal Mutual - Medical Malpractice for Dr. Arrington $0.00

United HealthCare - Employee Health Insurance $0.00

The Medical Protective - Medical Malpractice for Dr.

Nelson $0.00

74. Causes of action against third parties (whether or not a lawsuit

has been filed)

Claim against David C. Jones, Jr. Unknown

Nature of claim Legal Services Paid for and Not

Received, breach of contract

Amount requested $2,500.00

75. Other contingent and unliquidated claims or causes of action of

every nature, including counterclaims of the debtor and rights to

set off claims

76. Trusts, equitable or future interests in property

77. Other property of any kind not already listed Examples: Season tickets,

country club membership

78. Total of Part 11. $0.00

Add lines 71 through 77. Copy the total to line 90.

79. Has any of the property listed in Part 11 been appraised by a professional within the last year?

 No

 Yes

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 6

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 Document Page 8 of 47
Debtor Nelson Dermatology, PLLC Case number (If known) 17-11536-BFK

Name

Part 12: Summary

In Part 12 copy all of the totals from the earlier parts of the form

Type of property Current value of

personal property

Current value of real

property

80. Cash, cash equivalents, and financial assets.

Copy line 5, Part 1 $4,100.37

81. Deposits and prepayments. Copy line 9, Part 2. $8,609.00

82. Accounts receivable. Copy line 12, Part 3. $81,360.04

83. Investments. Copy line 17, Part 4. $0.00

84. Inventory. Copy line 23, Part 5. $6,600.00

85. Farming and fishing-related assets. Copy line 33, Part 6. $0.00

86. Office furniture, fixtures, and equipment; and collectibles.

Copy line 43, Part 7. $1,180.00

87. Machinery, equipment, and vehicles. Copy line 51, Part 8. $0.00

88. Real property. Copy line 56, Part 9.........................................................................................> $0.00

89. Intangibles and intellectual property. Copy line 66, Part 10. $180,100.00

90. All other assets. Copy line 78, Part 11. + $0.00

91. Total. Add lines 80 through 90 for each column $281,949.41 + 91b. $0.00

92. Total of all property on Schedule A/B. Add lines 91a+91b=92 $281,949.41

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 7

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 Document Page 9 of 47
Fill in this information to identify the case:

Debtor name Nelson Dermatology, PLLC

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number (if known) 17-11536-BFK

 Check if this is an

amended filing

Official Form 206D

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

Be as complete and accurate as possible.

1. Do any creditors have claims secured by debtor's property?

 No. Check this box and submit page 1 of this form to the court with debtor's other schedules. Debtor has nothing else to report on this form.

 Yes. Fill in all of the information below.

Official Form 206D Schedule D: Creditors Who Have Claims Secured by Property page 1 of 1

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Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 10 of 47
Fill in this information to identify the case:

Debtor name Nelson Dermatology, PLLC

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number (if known) 17-11536-BFK

 Check if this is an

amended filing

Official Form 206E/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 unsecured claims and Part 2 for creditors with NONPRIORITY unsecured 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: Assets - Real and

Personal Property (Official Form 206A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 206G). Number the entries in Parts 1 and

2 in the boxes on the left. If more space is needed for Part 1 or Part 2, fill out and attach the Additional Page of that Part included in this form.

Part 1: List All Creditors with PRIORITY Unsecured Claims

1. Do any creditors have priority unsecured claims? (See 11 U.S.C. § 507).

 No. Go to Part 2.

 Yes. Go to line 2.

2. List in alphabetical order all creditors who have unsecured claims that are entitled to priority in whole or in part. If the debtor has more than 3 creditors

with priority unsecured claims, fill out and attach the Additional Page of Part 1.

Total claim Priority amount

2.1 Priority creditor's name and mailing address As of the petition filing date, the claim is: $1,147.67 $1,147.67

County of Prince William

1 County Complex Ct

Woodbridge, VA 22192

Check all that apply.

 Contingent

 Unliquidated

 Disputed

Date or dates debt was incurred Basis for the claim:

Taxes

Last 4 digits of account number

Specify Code subsection of PRIORITY

unsecured claim: 11 U.S.C. § 507(a) (8)

Is the claim subject to offset?

 No

 Yes

2.2 Priority creditor's name and mailing address As of the petition filing date, the claim is: $60,816.02 $55,316.12

Internal Revenue Service

PO Box 7346

Philadelphia, PA 19101-7346

Check all that apply.

 Contingent

 Unliquidated

 Disputed

Date or dates debt was incurred Basis for the claim:

Taxes 2016 and 2017

Last 4 digits of account number 8425

Specify Code subsection of PRIORITY

unsecured claim: 11 U.S.C. § 507(a) (8)

Is the claim subject to offset?

 No

 Yes

Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of 10

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

2.3 Priority creditor's name and mailing address As of the petition filing date, the claim is: $1,469.10 $1,469.10

VA Dept. Taxation-Sales Tax

PO Box 1115

Richmond, VA 23218-1115

Check all that apply.

 Contingent

 Unliquidated

 Disputed

Date or dates debt was incurred Basis for the claim:

Sales Tax

Last 4 digits of account number

Specify Code subsection of PRIORITY

unsecured claim: 11 U.S.C. § 507(a) (8)

Is the claim subject to offset?

 No

 Yes

2.4 Priority creditor's name and mailing address As of the petition filing date, the claim is: $4,729.00 $4,729.00

Virginia Commonwealth

PO Box 1115

Richmond, VA 23218-1115

Check all that apply.

 Contingent

 Unliquidated

 Disputed

Date or dates debt was incurred Basis for the claim:

Tax Withholdings

Last 4 digits of account number

Specify Code subsection of PRIORITY

unsecured claim: 11 U.S.C. § 507(a) (8)

Is the claim subject to offset?

 No

 Yes

Part 2: List All Creditors with NONPRIORITY Unsecured Claims

3. List in alphabetical order all of the creditors with nonpriority unsecured claims. If the debtor has more than 6 creditors with nonpriority unsecured claims, fill

out and attach the Additional Page of Part 2.

Amount of claim

3.1 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,175.62

4Imprint

101 Commerce Street

PO Box 320

Oshkosh, WI 54901

Date(s) debt was incurred 

Last 4 digits of account number 2182 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.2 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $593.40

Artisan Laser Skin Care Center

12713 Galveston Court

Manassas, VA 20112

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: 

Is the claim subject to offset?  No  Yes

3.3 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,100.00

BJ Kane and Company, P.C.

7006 Little River Turnpike

Suite L

Annandale, VA 22003

Date(s) debt was incurred 

Last 4 digits of account number 0001 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Accounting Services 

Is the claim subject to offset?  No  Yes

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 2 of 10

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

3.4 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $12,177.50

Brown, Mobley & Way P.C.

Attn: Jackie Way

9161 Liberia Ave #100

Manassas, VA 20110

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Accounting Services 

Is the claim subject to offset?  No  Yes

3.5 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $420.23

Caldwell Consultants

209 Midshipman Circle

Stafford, VA 22554

Date(s) debt was incurred 4/3/2017 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: IT Services 

Is the claim subject to offset?  No  Yes

3.6 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $777.63

Capital Document Solutions

12115 Parklawn Drive

Rockville, MD 20852

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.7 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $656.38

Comcast Business

PO Box 37601

Philadelphia, PA 19101-0601

Date(s) debt was incurred 

Last 4 digits of account number 2748 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Communication Services 

Is the claim subject to offset?  No  Yes

3.8 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $5,200.11

Dell Financial Services

Po Box 81577

Austin, TX 78708-1577

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.9 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $20,104.19

Delta Locum Tenems, LLC

Four Hickory Centre

1755 Willington Place, Ste 175

Dallas, TX 75234

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.10 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,000.00

Denise Hovington CPA

PO Box 1018

Woodbridge, VA 22195-1018

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Accounting Services 

Is the claim subject to offset?  No  Yes

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 3 of 10

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Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

3.11 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $982.46

Dr. Susan K. Fitzgerald M.D.

8100 Ashton Avenue

Suite 207

Manassas, VA 20109

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Lease 

Is the claim subject to offset?  No  Yes

3.12 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $10,603.66

Everbank Commercial Finance

c/o Johnson, Morgan & White

6800 Broken Sound Parkway

Boca Raton, FL 33487

Date(s) debt was incurred 

Last 4 digits of account number 3990 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Equipment Lease 

Is the claim subject to offset?  No  Yes

3.13 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $7,000.00

Foundation Care Pharmacy

4010 Wedgeway Court

Earth City, MO 63045

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.14 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $2,088.85

Iconnect - RxPc

21630 Ridgetop Circle

Suite 120

Sterling, VA 20166

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Professional Services 

Is the claim subject to offset?  No  Yes

3.15 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $7,672.32

Kaiser Foundation Health

of the MID

2101 E Jefferson Street

Rockville, MD 20852

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Medical Insurance for Employees 

Is the claim subject to offset?  No  Yes

3.16 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $257.90

Laboratory Corp of America

PO Box 2240

Burlington, NC 27216-2240

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.17 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,878.73

McKesson Distribution

(Galderma Laboratories LP)

401 Mason Road

LaVergne, TN 37086

Date(s) debt was incurred 

Last 4 digits of account number 5979 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 4 of 10

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 Document Page 14 of 47
Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

3.18 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $110.87

McKesson Medical-Surgical

aka McKesson Specialty Care

401 Mason Road

LaVergne, TN 37086

Date(s) debt was incurred 

Last 4 digits of account number 3434 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.19 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $8,458.95

McKesson Medical-Surgical Minn

Supply Inc. Successor to Next

Successor to Next Day Medical

LaVergne, TN 37086

Date(s) debt was incurred 

Last 4 digits of account number 3968 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.20 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $3,171.40

Merz Aesthetics

Merz North America, Inc

PO Box 912073

Denver, CO 80291-2073

Date(s) debt was incurred 

Last 4 digits of account number 1490 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.21 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $35.00

Millenium Systems Intl

28 Eastmans Road

Parsippanny, NJ 07054

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade Debt 

Is the claim subject to offset?  No  Yes

3.22 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $500.00

Miraca Life Sciences

PO Box 843829

Dallas, TX 75284

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: 

Is the claim subject to offset?  No  Yes

3.23 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $3,653.56

Nixon Uniform Service & Med

500 Centerpoint Blvd

New Castle, DE 19720

Date(s) debt was incurred 

Last 4 digits of account number 4771 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.24 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $450.00

Northern Virginia Magazine

14104 Newbrook Drive

Suite 100

Chantilly, VA 20151

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: 

Is the claim subject to offset?  No  Yes

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 5 of 10

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Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 15 of 47
Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

3.25 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $845.00

Onstage Publications

1612 Prosser Avenue

Dayton, OH 45409

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade Debt 

Is the claim subject to offset?  No  Yes

3.26 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $651.25

Paramount Service Corp.

aka Paramount Mechanical Corp.

7053 Gateway Court

Manassas, VA 20109

Date(s) debt was incurred 

Last 4 digits of account number 4131 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.27 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $191,966.14

Piedmont Medical Real Estate

c/o Doumar Martin PLLC

1530 Wilson Boulevard, Ste 430

Arlington, VA 22209

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Lease 

Is the claim subject to offset?  No  Yes

3.28 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $938.16

Pitney Bowes Inc.

PO Box 371896

Pittsburgh, PA 15250-7896

Date(s) debt was incurred 

Last 4 digits of account number 6297 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Lease of Rental Equipment 

Is the claim subject to offset?  No  Yes

3.29 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $101.18

Pitney Bowes, Inc.

PO Box 371896

Pittsburgh, PA 15250-7896

Date(s) debt was incurred 

Last 4 digits of account number 9223 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Lease of Rental Equipment 

Is the claim subject to offset?  No  Yes

3.30 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $9,372.31

PNC Bank Credit Card

Manassas Crossroads

7800 Sudley Road

Manassas, VA 20108-2804

Date(s) debt was incurred 

Last 4 digits of account number 8240 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Credit card purchases 

Is the claim subject to offset?  No  Yes

3.31 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $2,757.84

Professional Media Corporation

t/a Your Health Magazine

4201 Northview Drive, Ste 102

Bowie, MD 20716

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 6 of 10

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

3.32 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,219.08

Quill

PO Box 37600

Philadelphia, PA 19019-0600

Date(s) debt was incurred 

Last 4 digits of account number 4296 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.33 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,500.00

Randi Kopf

110 N. Washington Street

Suite 408

Rockville, MD 20850

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.34 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,186.26

Roberts Oxygen Company, Inc.

15830 Redland Road

PO Box 5507

Rockville, MD 20855

Date(s) debt was incurred 

Last 4 digits of account number 1370 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.35 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $13,079.56

Solor, Inc.

1021 Shoal Creek Way

Easley, SC 29642

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.36 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $379.00

Solutionreach

2912 Executive Parkway

Suite 300

Lehi, UT 84043

Date(s) debt was incurred 

Last 4 digits of account number 1788 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.37 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $159.22

Stericycle

PO Box 6582

Carol Stream, IL 60197-6582

Date(s) debt was incurred 

Last 4 digits of account number 8644 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.38 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $6,675.02

Sudley North, LLC

9101 Gaither Road

Gaithersburg, MD 20877

Date(s) debt was incurred 

Last 4 digits of account number 330 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Lease 

Is the claim subject to offset?  No  Yes

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 7 of 10

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

3.39 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $197.22

Summers Laboratories

103i G.P Clement Drive

Collegeville, PA 19426-2044

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.40 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $474.00

Tangible Solutions

PO Box 488

Matthews, NC 28106

Date(s) debt was incurred 

Last 4 digits of account number 4717 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.41 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,318.91

Teltek Systems, Inc.

11521 Cronridge Drive

Suite A

Owings Mills, MD 21117

Date(s) debt was incurred 9/26/2016 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.42 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $0.00

TrueShred

PO Box 980

Gainesville, VA 20156

Date(s) debt was incurred 

Last 4 digits of account number 0730 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.43 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,211.40

United Healthcare

PO Box 7082

Bridgeport, CT 06610-7082

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Insurance 

Is the claim subject to offset?  No  Yes

3.44 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $929.23

Universal Companies, Inc.

18260 Oak Park Drive

Abingdon, VA 24210

Date(s) debt was incurred 

Last 4 digits of account number 1385 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.45 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $6,957.11

Valeant Pharmaceuticals

3701 Concorde Pkwy

#800

Chantilly, VA 20151

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 8 of 10

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

3.46 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. Unknown

Weisco Signs

9073 Liberia Avenue

Manassas, VA 24210

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

3.47 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $245.83

ZirMed, Inc.

Attn: Accounting Dept.

888 W. Market Street, Ste 400

Louisville, KY 40202

Date(s) debt was incurred 4/12/2017 

Last 4 digits of account number 6382 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Trade debt 

Is the claim subject to offset?  No  Yes

Part 3: List Others to Be Notified About Unsecured Claims

4. List in alphabetical order any others who must be notified for claims listed in Parts 1 and 2. Examples of entities that may be listed are collection agencies,

assignees of claims listed above, and attorneys for unsecured creditors.

If no others need to be notified for the debts listed in Parts 1 and 2, do not fill out or submit this page. If additional pages are needed, copy the next page.

Name and mailing address On which line in Part1 or Part 2 is the

related creditor (if any) listed?

Last 4 digits of

account number, if

any

4.1 A.R.M. Solutions, Inc

PO Box 2929

Camarillo, CA 93011-2929

Line 3.37 

 Not listed. Explain 

 

4.2 Allen Maxwell & Silver

PO Box 540

Fair Lawn, NJ 07410

Line 3.29 

 Not listed. Explain 

 8593 

4.3 Allen Maxwell & Silver

PO Box 540

Fair Lawn, NJ 07410

Line 3.28 

 Not listed. Explain 

 8593 

4.4 American Recovery Service, Inc

555 St. Charles Drive

Suite 100

Thousand Oaks, CA 91360

Line 3.8 

 Not listed. Explain 

 1557 

4.5 Andersen, Randall & Richards

Attn: Pamela J. Bim

5151 E. Broadway Blvd

Tucson, AZ 85711

Line 3.45 

 Not listed. Explain 

 

4.6 Credit Mediators, Inc.

PO Box 456

Upper Darby, PA 19082-0456

Line 3.23 

 Not listed. Explain 

 

4.7 David Straube

Tsarouhis Law Group

21 S. 9th Street Ste 200

Allentown, PA 18102

Line 3.15 

 Not listed. Explain 

 

4.8 Galderma Laboratories

14501 N. Freeway

Fort Worth, TX 76177

Line 3.17 

 Not listed. Explain 

 5979 

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 9 of 10

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 Document Page 19 of 47
Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK Name

Name and mailing address On which line in Part1 or Part 2 is the

related creditor (if any) listed?

Last 4 digits of

account number, if

any

4.9 GB Collects

145 Bradford Drive

W. Berlin, NJ 08091

Line 3.15 

 Not listed. Explain 

 

4.10 John Ellington

Altus Global Trade Solutions

2400 Veterans Blvd Ste 300

Kenner, LA 70062

Line 3.12 

 Not listed. Explain 

 

4.11 Jonathan A. Nelson

Juris Day, PLLC

10521 Judicial Drive, Ste 200

Fairfax, VA 22030

Line 3.9 

 Not listed. Explain 

 

4.12 Law Offices of Joel Cardis, LL

2006Swede Road

Suite 100

E. Norriton, PA 19401

Line 3.14 

 Not listed. Explain 

 

4.13 Legum Law, PLC

Attn: Terry C. Legum, Esquire

4004 Williamsburg Court

Fairfax, VA 22032

Line 3.19 

 Not listed. Explain 

 2001 

4.14 Michael J. Smith

Dycio & Biggs

10533 Main Street

Fairfax, VA 22030

Line 3.27 

 Not listed. Explain 

 

Part 4: Total Amounts of the Priority and Nonpriority Unsecured Claims

5. Add the amounts of priority and nonpriority unsecured claims.

Total of claim amounts

5a. Total claims from Part 1 5a. $ 68,161.79

5b. Total claims from Part 2 5b. + $ 332,232.48

5c. Total of Parts 1 and 2

 Lines 5a + 5b = 5c. 5c. $ 400,394.27

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 10 of 10

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Fill in this information to identify the case:

Debtor name Nelson Dermatology, PLLC

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number (if known) 17-11536-BFK

 Check if this is an

amended filing

Official Form 206G

Schedule G: Executory Contracts and Unexpired Leases 12/15

Be as complete and accurate as possible. If more space is needed, copy and attach the additional page, number the entries consecutively.

1. Does the debtor have any executory contracts or unexpired leases?

 No. Check this box and file this form with the debtor's other schedules. There is nothing else to report on this form.

 Yes. Fill in all of the information below even if the contacts of leases are listed on Schedule A/B: Assets - Real and Personal Property

(Official Form 206A/B).

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

2.1. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

AARP

601 E. Street NW

Washington, DC 20049

State the term remaining

List the contract number of any

government contract

2.2. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

AARP Health

PO Box 740819

Atlanta, GA 30374-0819

State the term remaining

List the contract number of any

government contract

2.3. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance - Workers

Compensation

Accident Fund

National Insurance Company

PO Box 77000 Dept. 77125

Detroit, MI 48277-0125

State the term remaining

List the contract number of any

government contract 0002

2.4. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Aetna, Inc.

PO Box 981104

El Paso, TX 79998-1104

State the term remaining

List the contract number of any

government contract

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 1 of 15

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Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

2.5. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Aetna, Inc.

PO Box 14079

Lexington, KY 40512-4079

State the term remaining

List the contract number of any

government contract

2.6. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Medical

Supplies

Allergan

12975 Collections Center Drive

Chicago, IL 60693-0129

State the term remaining

List the contract number of any

government contract 4265

2.7. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Amerigroup

PO Box 5446

Richmond, VA 23220

State the term remaining

List the contract number of any

government contract

2.8. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Anthem BCBS

PO 27401

Richmond, VA 23261-7401

State the term remaining

List the contract number of any

government contract

2.9. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Anthem Health Keepers Plus

PO Box 27401

Richmond, VA 23261-7401

State the term remaining

List the contract number of any

government contract

2.10. State what the contract or

lease is for and the nature of

the debtor's interest

Record and Billing

Services

AthenaHealth

311 Arsenal Street

Watertown, MA 02472

State the term remaining

List the contract number of any

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 2 of 15

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Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 22 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

government contract

2.11. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Bankers Life and Casualty

PO Box 1935

Carmel, IN 46082-1935

State the term remaining

List the contract number of any

government contract

2.12. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Blue Cross Blue Shield

PO Box 27401

Richmond, VA 23261-7401

State the term remaining

List the contract number of any

government contract

2.13. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Care Credit

PO Box 965068

Orlando, FL 32896-5068

State the term remaining

List the contract number of any

government contract

2.14. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Carefirst

PO Box 981633

El Paso, TX 79998-1633

State the term remaining

List the contract number of any

government contract

2.15. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Carefirst Administrators

PO Box 981608

El Paso, TX 79998-1608

State the term remaining

List the contract number of any

government contract

2.16. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Carefirst BCBS

PO Box 981608

El Paso, TX 22038

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 3 of 15

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

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 Document Page 23 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

State the term remaining

List the contract number of any

government contract

2.17. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Carefirst BCBS

PO Box 14416

Lexington, KY 40512-4416

State the term remaining

List the contract number of any

government contract

2.18. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

CareFirst Blue Choice

PO Box 14115

Lexington, KY 40512-4416

State the term remaining

List the contract number of any

government contract

2.19. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Carefirst Blue Choice

PO Box 804

Owings Mill, MD 21170-0804

State the term remaining

List the contract number of any

government contract

2.20. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Center for Medicaid & Medicare

7500 Security Boulevard

Baltimore, MD 21244

State the term remaining

List the contract number of any

government contract

2.21. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

CHAMPVA

PO 469064

Denver, CO 80246-9064

State the term remaining

List the contract number of any

government contract

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 4 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 24 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

2.22. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Cigna

PO Box 5200

Scranton, PA 18505-5200

State the term remaining

List the contract number of any

government contract

2.23. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Cigna

PO Box 182223

Chattanooga, TN 37422-7223

State the term remaining

List the contract number of any

government contract

2.24. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Cigna

PO Box 5909

Scranton, PA 18505-5909

State the term remaining

List the contract number of any

government contract

2.25. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Cigna

PO Box 188061

Chattanooga, TN 18505-8061

State the term remaining

List the contract number of any

government contract

2.26. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Cigna

PO Box 188050

Chattanooga, TN 18505-8050

State the term remaining

List the contract number of any

government contract

2.27. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Cigna

PO Box 188004

Chattanooga, TN 18505-8004

State the term remaining

List the contract number of any

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 5 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 25 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

government contract

2.28. State what the contract or

lease is for and the nature of

the debtor's interest

Communications

Services

Comcast Business

PO Box 37601

Philadelphia, PA 19101-0601

State the term remaining

List the contract number of any

government contract 2748

2.29. State what the contract or

lease is for and the nature of

the debtor's interest

Communications

Services

Comcast Communications

PO Box 3005

Southeastern, PA 19398-3005

State the term remaining

List the contract number of any

government contract 9011

2.30. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Compass Rose Health Plan

PO Box 6430

Annapolis, MD 21401

State the term remaining

List the contract number of any

government contract

2.31. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

CoreSource

PO Box 2920

Clinton, IA 52733-2920

State the term remaining

List the contract number of any

government contract

2.32. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Medical

Supplies

Delasco

608 13th Avenue

Counsel Bluffs, IA 51501

State the term remaining

List the contract number of any

government contract

2.33. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

DMAS

PO Box 27444

Richmond, VA 23261-7444

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 6 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 26 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

State the term remaining

List the contract number of any

government contract

2.34. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Medical

Supplies

DUSA Pharmaceuticals, Inc.

25 Upton Drive

Wilmington, MA 01887

State the term remaining

List the contract number of any

government contract

2.35. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

GEHA

PO Box 4665

Independence, MO 64051-4665

State the term remaining

List the contract number of any

government contract

2.36. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

GEHA

PO Box 30783

Salt Lake City, UT 84130-0783

State the term remaining

List the contract number of any

government contract

2.37. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Humana

PO Box 14601

Lexington, KS 40512-4601

State the term remaining

List the contract number of any

government contract

2.38. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Humana Choice

PO Box 14601

Lexington, KY 40512-4601

State the term remaining

List the contract number of any

government contract

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 7 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 27 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

2.39. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

IHC Health Solutions

PO Box 21456

Saint Paul, MN 55121-1456

State the term remaining

List the contract number of any

government contract

2.40. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Innovation Health Insurance

PO Box 981106

El Paso, TX 79998-1106

State the term remaining

List the contract number of any

government contract

2.41. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

INTOTAL Health

PO Box 61010

Virginia Beach, VA 23466-1010

State the term remaining

List the contract number of any

government contract

2.42. State what the contract or

lease is for and the nature of

the debtor's interest

 Medical Malpractice

Insurance

Medical Protective

23257 Network Place

Chicago, IL 60673-1232

State the term remaining

List the contract number of any

government contract

2.43. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Meritain Health

PO Box 853921

Richardson, TX 75085

State the term remaining

List the contract number of any

government contract

2.44. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

MHBP

PO 8402

London, KY 40742

State the term remaining

List the contract number of any

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 8 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 28 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

government contract

2.45. State what the contract or

lease is for and the nature of

the debtor's interest

Medispa Software

Millenium Systems Intl

28 Eastmans Road

Parsippanny, NJ 07054

State the term remaining

List the contract number of any

government contract

2.46. State what the contract or

lease is for and the nature of

the debtor's interest

Medical Malpractice

Insurance for Dr.

Arrington

Norcal Group

PO Box 398054

San Francisco, CA 94139-8054

State the term remaining

List the contract number of any

government contract

2.47. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Palmetto GBA

Mail Code AG600

Columbia, SC 29201

State the term remaining

List the contract number of any

government contract

2.48. State what the contract or

lease is for and the nature of

the debtor's interest

Lease of Rental

Equipment

Pitney Bowes

PO Box 371896

Pittsburgh, PA 15250-7896

State the term remaining

List the contract number of any

government contract

2.49. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Medical

Supplies

Roberts Oxygen Company, Inc.

15830 Redland Road

PO Box 5507

Rockville, MD 20855

State the term remaining

List the contract number of any

government contract

2.50. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Selman & Company

PO Box 2610

Rockville, MD 20847

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 9 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 29 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

State the term remaining

List the contract number of any

government contract

2.51. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Biohazard

Material Services

Sharps Compliance, Inc.

PO Box 52792

Lafayette, LA 70505-2792

State the term remaining

List the contract number of any

government contract

2.52. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Records &

Billing Services.

Solor, Inc.

1021 Shoal Creek Way

Easley, SC 29642

State the term remaining

List the contract number of any

government contract

2.53. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Sofware

Services

Solutionreach

2912 Executive Parkway

Suite 300

Lehi, UT 84043

State the term remaining

List the contract number of any

government contract

2.54. State what the contract or

lease is for and the nature of

the debtor's interest

Lease for Rent

Sudley North, LLC

9101 Gaither Road

Gaithersburg, VA 20877

State the term remaining

List the contract number of any

government contract

2.55. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Records &

Billing Services.

Tangible Solutions

PO Box 488

Matthews, NC 28106

State the term remaining

List the contract number of any

government contract

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 10 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 30 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

2.56. State what the contract or

lease is for and the nature of

the debtor's interest

Business / Commercial

and General Liability

Insurance

The Hartford Insurance

2060 West Whispering Wind Dr.

#267

Phoenix, AR 85085

State the term remaining

List the contract number of any

government contract 4806

2.57. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

TrailBlazer

PO Box 650208

Dallas, TX 25262

State the term remaining

List the contract number of any

government contract

2.58. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Tricare

PO Box 870140

Surfside Beach, SC 29587-9740

State the term remaining

List the contract number of any

government contract

2.59. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Tricare Champ VA Supplement

PO Box 2510

Rockville, MD 20847

State the term remaining

List the contract number of any

government contract

2.60. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Tricare for Life

PO Box 7890

Madison, WI 53707

State the term remaining

List the contract number of any

government contract

2.61. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

UMR

PO Box 30541

Salt Lake City, UT 84130-0451

State the term remaining

List the contract number of any

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 11 of 15

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

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 Document Page 31 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

government contract

2.62. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

UMR

PO Box 8095

Wausau, WI 54402-8095

State the term remaining

List the contract number of any

government contract

2.63. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 7082

Bridgeport, CT 06610-7082

State the term remaining

List the contract number of any

government contract

2.64. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 740825

Atlanta, GA 30374-0825

State the term remaining

List the contract number of any

government contract

2.65. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 30557

Salt Lake City, UT 84130-0557

State the term remaining

List the contract number of any

government contract

2.66. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 31362

Salt Lake City, UT 84130-0362

State the term remaining

List the contract number of any

government contract

2.67. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 30555

Salt Lake City, UT 84130-0555

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 12 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 32 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

State the term remaining

List the contract number of any

government contract

2.68. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 30995

Salt Lake City, UT 84130-0995

State the term remaining

List the contract number of any

government contract

2.69. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 30884

Salt Lake City, UT 84130-0802

State the term remaining

List the contract number of any

government contract

2.70. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 740802

Atlanta, GA 30374

State the term remaining

List the contract number of any

government contract

2.71. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 740800

Atlanta, GA 30374-0800

State the term remaining

List the contract number of any

government contract

2.72. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

United Health Care

PO Box 740809

Atlanta, GA 30374-0809

State the term remaining

List the contract number of any

government contract

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 13 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 33 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

2.73. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance - Employee

Healthcare

United Healthcare

12018 Sunrise Valley Drive

# 400

Reston, VA 20191

State the term remaining

List the contract number of any

government contract

2.74. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

VA Financial Service

PO Box 149344

Austin, TX 74714-9344

State the term remaining

List the contract number of any

government contract

2.75. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for

Communications

Services

Verizon

455 Duke Drive

Franklin, TN 37067

State the term remaining

List the contract number of any

government contract

2.76. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Veterans Choice Program

PO Box 2748

Virginia Beach, VA 23450

State the term remaining

List the contract number of any

government contract

2.77. State what the contract or

lease is for and the nature of

the debtor's interest

Insurance Receivables

Wellnet

PO Box 270226

Minneapolis, MN 55427-0226

State the term remaining

List the contract number of any

government contract

2.78. State what the contract or

lease is for and the nature of

the debtor's interest

Contract for Software

Services

ZocDoc

568 Broadway

New York, NY 30000

State the term remaining

List the contract number of any

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 14 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 34 of 47
Debtor 1 Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK First Name Middle Name Last Name

Additional Page if You Have More Contracts or Leases

2. List all contracts and unexpired leases State the name and mailing address for all other parties with

whom the debtor has an executory contract or unexpired

lease

government contract

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 15 of 15

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 35 of 47
Fill in this information to identify the case:

Debtor name Nelson Dermatology, PLLC

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number (if known) 17-11536-BFK

 Check if this is an

amended filing

Official Form 206H

Schedule H: Your Codebtors 12/15

Be as complete and accurate as possible. If more space is needed, copy the Additional Page, numbering the entries consecutively. Attach the

Additional Page to this page.

1. Do you have any codebtors?

 No. Check this box and submit this form to the court with the debtor's other schedules. Nothing else needs to be reported on this form.

 Yes

2. In Column 1, list as codebtors all of the people or entities who are also liable for any debts listed by the debtor in the schedules of

creditors, Schedules D-G. Include all guarantors and co-obligors. In Column 2, identify the creditor to whom the debt is owed and each schedule

on which the creditor is listed. If the codebtor is liable on a debt to more than one creditor, list each creditor separately in Column 2.

Column 1: Codebtor Column 2: Creditor

Name Mailing Address Name Check all schedules

that apply:

2.1 Dr. Jennell

Nelson

8974 Yellowleg Court

Gainesville, VA 20155

Sudley North, LLC  D 

 E/F 3.38 

 G 

2.2 Ernesto Flores 15645 Turtle Point Dr.

Gainesville, VA 20155

PNC Bank Credit

Card

 D 

 E/F 3.30 

 G 

Official Form 206H Schedule H: Your Codebtors Page 1 of 1

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

Case 17-11536-BFK Doc 43 Filed 06/01/17 Entered 06/01/17 17:28:29 Desc Main

 Document Page 36 of 47
Fill in this information to identify the case:

Debtor name Nelson Dermatology, PLLC

United States Bankruptcy Court for the: EASTERN DISTRICT OF VIRGINIA

Case number (if known) 17-11536-BFK

 Check if this is an

amended filing

Official Form 207

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

The debtor must answer every question. If more space is needed, attach a separate sheet to this form. On the top of any additional pages,

write the debtor’s name and case number (if known).

Part 1: Income

1. Gross revenue from business

 None.

Identify the beginning and ending dates of the debtor’s fiscal year,

which may be a calendar year

Sources of revenue

Check all that apply

Gross revenue

(before deductions and

exclusions)

From the beginning of the fiscal year to filing date:

From 1/01/2017 to Filing Date

 Operating a business $175,404.04

 Other

For prior year:

From 1/01/2016 to 12/31/2016

 Operating a business $502,587.00

 Other

For year before that:

From 1/01/2015 to 12/31/2015

 Operating a business $453,251.00

 Other

2. Non-business revenue

Include revenue regardless of whether that revenue is taxable. Non-business income may include interest, dividends, money collected from lawsuits,

and royalties. List each source and the gross revenue for each separately. Do not include revenue listed in line 1.

 None.

Description of sources of revenue Gross revenue from

each source

(before deductions and

exclusions)

Part 2: List Certain Transfers Made Before Filing for Bankruptcy

3. Certain payments or transfers to creditors within 90 days before filing this case

List payments or transfers--including expense reimbursements--to any creditor, other than regular employee compensation, within 90 days before

filing this case unless the aggregate value of all property transferred to that creditor is less than $6,425. (This amount may be adjusted on 4/01/19

and every 3 years after that with respect to cases filed on or after the date of adjustment.)

 None.

Creditor's Name and Address Dates Total amount of value Reasons for payment or transfer

Check all that apply

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 1

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

Creditor's Name and Address Dates Total amount of value Reasons for payment or transfer

Check all that apply

3.1. Odin, Feldman & Pittleman, PC

1775 Wiehle Avenue

Suite 400

Reston, VA 20190

February 8,

2017

$1,000.00  Secured debt

 Unsecured loan repayments

 Suppliers or vendors

 Services

 Other Legal Services 

3.2. Odin, Feldman & Pittleman P.C.

1775 Wiehle Avenue

Suite 400

Reston, VA 20190

April 10,

2017

$1,000.00  Secured debt

 Unsecured loan repayments

 Suppliers or vendors

 Services

 Other Legal Services 

3.3. Odin, Feldman & Pittleman P.C.

1775 Wiehle Avenue

Suite 400

Reston, VA 20190

May 3, 2017 $5,000.00  Secured debt

 Unsecured loan repayments

 Suppliers or vendors

 Services

 Other Legal Services 

3.4. Odin, Feldman & Pittleman P.C.

1775 Wiehle Avenue

Suite 400

Reston, VA 20190

May 4, 2017 $5,000.00  Secured debt

 Unsecured loan repayments

 Suppliers or vendors

 Services

 Other Legal Services 

4. Payments or other transfers of property made within 1 year before filing this case that benefited any insider

List payments or transfers, including expense reimbursements, made within 1 year before filing this case on debts owed to an insider or guaranteed

or cosigned by an insider unless the aggregate value of all property transferred to or for the benefit of the insider is less than $6,425. (This amount

may be adjusted on 4/01/19 and every 3 years after that with respect to cases filed on or after the date of adjustment.) Do not include any payments

listed in line 3. Insiders include officers, directors, and anyone in control of a corporate debtor and their relatives; general partners of a partnership

debtor and their relatives; affiliates of the debtor and insiders of such affiliates; and any managing agent of the debtor. 11 U.S.C. § 101(31).

 None.

Insider's name and address

Relationship to debtor

Dates Total amount of value Reasons for payment or transfer

4.1. Dr. Jennell Nelson

Managing Member

May 5, 2016 -

May 5, 2017

$79,001.48 Distributions (Contributions

were $103,661.59)

4.2. Dr. Jennell Nelson

Managing Member

May 5, 2016 -

May 5, 2017

$45,300.00 Gross Payroll

4.3. Dr. Jennell Nelson

Managing Member

June 29,

2016

$20,000.00 Purchase of medical equipment

at Sheriff's Sale for $2260.00

5. Repossessions, foreclosures, and returns

List all property of the debtor that was obtained by a creditor within 1 year before filing this case, including property repossessed by a creditor, sold at

a foreclosure sale, transferred by a deed in lieu of foreclosure, or returned to the seller. Do not include property listed in line 6.

 None

Creditor's name and address Describe of the Property Date Value of property

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 2

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

Creditor's name and address Describe of the Property Date Value of property

Piedmont Medical Real Estate, LLC Bank Account Garnishment 6/3/2016 $662.66

6. Setoffs

List any creditor, including a bank or financial institution, that within 90 days before filing this case set off or otherwise took anything from an account

of the debtor without permission or refused to make a payment at the debtor’s direction from an account of the debtor because the debtor owed a

debt.

 None

Creditor's name and address Description of the action creditor took Date action was

taken

Amount

Part 3: Legal Actions or Assignments

7. Legal actions, administrative proceedings, court actions, executions, attachments, or governmental audits

List the legal actions, proceedings, investigations, arbitrations, mediations, and audits by federal or state agencies in which the debtor was involved

in any capacity—within 1 year before filing this case.

 None.

Case title

Case number

Nature of case Court or agency's name and

address

Status of case

7.1. Delta Locum Tenens, LLC v.

Nelson Dermatology

CC-15-05538-E

Breach of

Contract

DALLAS COUNTY, TEXAS

1201 Elm Street

21st and 22nd Floors

Dallas, TX 75270

 Pending

 On appeal

 Concluded

7.2. Professional Media

Corporation v. Nelson

Dermatology

Breach of

Contract

District Court of MD Prince

George's Cty

14735 Main Street

Suite 173B

Upper Marlboro, MD 20772

 Pending

 On appeal

 Concluded

7.3. Piedmont Medical Real

Estate, LLC v. Nelson

Dermatology

CL 17003141, 17003142,

17003143

CL 15007930,

15003887,

16000686,

16002028,

16006490,

17000384,

17000385,

COLLECTION

ACTIONS

Prince William Circuit Court  Pending

 On appeal

 Concluded

7.4. Delta Locum Tenens, LLC v.

Nelson Dermatology

CL 16004072

Collection Action Prince William Circuit Court  Pending

 On appeal

 Concluded

7.5. Henry Shein, Inc. v. Nelson

Dermatology

GV 16007127

Collection Action Prince William General

District Court

 Pending

 On appeal

 Concluded

7.6. Caldwell Consultants v.

Nelson Dermatology

GV 160181126

Collection Action Prince William General

District Court

 Pending

 On appeal

 Concluded

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 3

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

Case title

Case number

Nature of case Court or agency's name and

address

Status of case

7.7. Thomas Breeden PC v.

Nelson Dermatology

GV 15016852

Collection Action Prince William County GDC  Pending

 On appeal

 Concluded

7.8. McKesson Medical Surgical

Top Holdings, Inc v. Nelson

Dermatology

GV 16018126

Collection Action Prince William GDC  Pending

 On appeal

 Concluded

8. Assignments and receivership

List any property in the hands of an assignee for the benefit of creditors during the 120 days before filing this case and any property in the hands of a

receiver, custodian, or other court-appointed officer within 1 year before filing this case.

 None

Part 4: Certain Gifts and Charitable Contributions

9. List all gifts or charitable contributions the debtor gave to a recipient within 2 years before filing this case unless the aggregate value of

the gifts to that recipient is less than $1,000

 None

Recipient's name and address Description of the gifts or contributions Dates given Value

Part 5: Certain Losses

10. All losses from fire, theft, or other casualty within 1 year before filing this case.

 None

Description of the property lost and

how the loss occurred

Amount of payments received for the loss

If you have received payments to cover the loss, for

example, from insurance, government compensation, or

tort liability, list the total received.

List unpaid claims on Official Form 106A/B (Schedule

A/B: Assets – Real and Personal Property).

Dates of loss Value of property

lost

Part 6: Certain Payments or Transfers

11. Payments related to bankruptcy

List any payments of money or other transfers of property made by the debtor or person acting on behalf of the debtor within 1 year before the filing

of this case to another person or entity, including attorneys, that the debtor consulted about debt consolidation or restructuring, seeking bankruptcy

relief, or filing a bankruptcy case.

 None.

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 4

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

Who was paid or who received

the transfer?

Address

If not money, describe any property transferred Dates Total amount or

value

11.1. Odin, Feldman & Pittleman

P.C.

1775 Wiehle Avenue

Suite 400

Reston, VA 20190 May 5, 2017 $4,450.90

Email or website address

lauren.mckelvey@ofplaw.com

Who made the payment, if not debtor?

Dr. Jennell Nelson

12. Self-settled trusts of which the debtor is a beneficiary

List any payments or transfers of property made by the debtor or a person acting on behalf of the debtor within 10 years before the filing of this case

to a self-settled trust or similar device.

Do not include transfers already listed on this statement.

 None.

Name of trust or device Describe any property transferred Dates transfers

were made

Total amount or

value

13. Transfers not already listed on this statement

List any transfers of money or other property by sale, trade, or any other means made by the debtor or a person acting on behalf of the debtor within

2 years before the filing of this case to another person, other than property transferred in the ordinary course of business or financial affairs. Include

both outright transfers and transfers made as security. Do not include gifts or transfers previously listed on this statement.

 None.

Who received transfer?

Address

Description of property transferred or

payments received or debts paid in exchange

Date transfer

was made

Total amount or

value

13.1

.

Piedmont Medical Real

Estate, LLC Garnishment 2015 - 2017 $16,861.89

Relationship to debtor

13.2

.

Delta Locum Tenems, LLC Garnishment 2015-2016 $2,208.16

Relationship to debtor

Part 7: Previous Locations

14. Previous addresses

List all previous addresses used by the debtor within 3 years before filing this case and the dates the addresses were used.

 Does not apply

Address Dates of occupancy

From-To

14.1. 8100 Ashton Avenue

Suite 207

Manassas, VA 20108

4/2015 - 12/2015

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 5

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

Address Dates of occupancy

From-To

14.2. 8140 Ashton Avenue

Suite 115

Manassas, VA 20109

4/2010 - 4/2015

Part 8: Health Care Bankruptcies

15. Health Care bankruptcies

Is the debtor primarily engaged in offering services and facilities for:

- diagnosing or treating injury, deformity, or disease, or

- providing any surgical, psychiatric, drug treatment, or obstetric care?

 No. Go to Part 9.

 Yes. Fill in the information below.

Facility name and address Nature of the business operation, including type of services

the debtor provides

If debtor provides meals

and housing, number of

patients in debtor’s care

Part 9: Personally Identifiable Information

16. Does the debtor collect and retain personally identifiable information of customers?

 No.

 Yes. State the nature of the information collected and retained.

Medical Records

Does the debtor have a privacy policy about that information?

 No

 Yes

17. Within 6 years before filing this case, have any employees of the debtor been participants in any ERISA, 401(k), 403(b), or other pension or

profit-sharing plan made available by the debtor as an employee benefit?

 No. Go to Part 10.

 Yes. Does the debtor serve as plan administrator?

Part 10: Certain Financial Accounts, Safe Deposit Boxes, and Storage Units

18. Closed financial accounts

Within 1 year before filing this case, were any financial accounts or instruments held in the debtor’s name, or for the debtor’s benefit, closed, sold,

moved, or transferred?

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

cooperatives, associations, and other financial institutions.

 None

Financial Institution name and

Address

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

18.1. Bank of America XXXX-9091  Checking

 Savings

 Money Market

 Brokerage

 Other 

$0.00

19. Safe deposit boxes

List any safe deposit box or other depository for securities, cash, or other valuables the debtor now has or did have within 1 year before filing this

case.

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 6

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

 None

Depository institution name and address Names of anyone with

access to it

Address

Description of the contents Do you still

have it?

20. Off-premises storage

List any property kept in storage units or warehouses within 1 year before filing this case. Do not include facilities that are in a part of a building in

which the debtor does business.

 None

Facility name and address Names of anyone with

access to it

Description of the contents Do you still

have it?

Part 11: Property the Debtor Holds or Controls That the Debtor Does Not Own

21. Property held for another

List any property that the debtor holds or controls that another entity owns. Include any property borrowed from, being stored for, or held in trust. Do

not list leased or rented property.

 None

Part 12: Details About Environment Information

For the purpose of Part 12, the following definitions apply:

Environmental law means any statute or governmental regulation that concerns pollution, contamination, or hazardous material, regardless of the

medium affected (air, land, water, or any other medium).

Site means any location, facility, or property, including disposal sites, that the debtor now owns, operates, or utilizes or that the debtor formerly

owned, operated, or utilized.

Hazardous material means anything that an environmental law defines as hazardous or toxic, or describes as a pollutant, contaminant, or a

similarly harmful substance.

Report all notices, releases, and proceedings known, regardless of when they occurred.

22. Has the debtor been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders.

 No.

 Yes. Provide details below.

Case title

Case number

Court or agency name and

address

Nature of the case Status of case

23. Has any governmental unit otherwise notified the debtor that the debtor may be liable or potentially liable under or in violation of an

environmental law?

 No.

 Yes. Provide details below.

Site name and address Governmental unit name and

address

Environmental law, if known Date of notice

24. Has the debtor notified any governmental unit of any release of hazardous material?

 No.

 Yes. Provide details below.

Site name and address Governmental unit name and

address

Environmental law, if known Date of notice

Part 13: Details About the Debtor's Business or Connections to Any Business

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 7

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

25. Other businesses in which the debtor has or has had an interest

List any business for which the debtor was an owner, partner, member, or otherwise a person in control within 6 years before filing this case.

Include this information even if already listed in the Schedules.

 None

Business name address Describe the nature of the business Employer Identification number

Do not include Social Security number or ITIN.

Dates business existed

26. Books, records, and financial statements

26a. List all accountants and bookkeepers who maintained the debtor’s books and records within 2 years before filing this case.

 None

Name and address Date of service

From-To

26a.1. Brown Mobley & Way P.C.

Attn: Jackie Way

9161 Liberia Ave

#100

Manassas, VA 20110

26b. List all firms or individuals who have audited, compiled, or reviewed debtor’s books of account and records or prepared a financial statement

within 2 years before filing this case.

 None

26c. List all firms or individuals who were in possession of the debtor’s books of account and records when this case is filed.

 None

Name and address If any books of account and records are

unavailable, explain why

26c.1. Brown Mobley & Way P.C.

Attn: Jackie Way

9161 Liberia Avenue

#100

Manassas, VA 20110

26d. List all financial institutions, creditors, and other parties, including mercantile and trade agencies, to whom the debtor issued a financial

statement within 2 years before filing this case.

 None

Name and address

26d.1. Piedmont Medical Real Estate, LLC

26d.2. Delta Locum Tenems, LLC

27. Inventories

Have any inventories of the debtor’s property been taken within 2 years before filing this case?

 No

 Yes. Give the details about the two most recent inventories.

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 8

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

Name of the person who supervised the taking of the

inventory

Date of inventory The dollar amount and basis (cost, market,

or other basis) of each inventory

27.1

.

Dr. Jennell Nelson

5/8/2017 $3,600.00 / Cost Basis

Name and address of the person who has possession of

inventory records

Elizabeth Niaz

28. List the debtor’s officers, directors, managing members, general partners, members in control, controlling shareholders, or other people

in control of the debtor at the time of the filing of this case.

Name Address Position and nature of any

interest

% of interest, if

any

Dr. Jennell Nelson 8974 Yellowleg Court

Gainesville, VA 20155

Shareholder 100

29. Within 1 year before the filing of this case, did the debtor have officers, directors, managing members, general partners, members in

control of the debtor, or shareholders in control of the debtor who no longer hold these positions?

 No

 Yes. Identify below.

30. Payments, distributions, or withdrawals credited or given to insiders

Within 1 year before filing this case, did the debtor provide an insider with value in any form, including salary, other compensation, draws, bonuses,

loans, credits on loans, stock redemptions, and options exercised?

 No

 Yes. Identify below.

Name and address of recipient Amount of money or description and value of

property

Dates Reason for

providing the value

30.1

.

Dr. Jennell Nelson

$79,001.48

May 5, 2016 -

May 5, 2017 Salary

Relationship to debtor

Managing Member

30.2

.

Employee Payroll 45,300.00

May 5, 2016 -

May 5, 2017 Payroll

Relationship to debtor

Employees of Debtor

30.3

.

Payroll Distributions &

Contributions

103,661.59

Payroll

Distributions &

Contributions

Relationship to debtor

31. Within 6 years before filing this case, has the debtor been a member of any consolidated group for tax purposes?

 No

 Yes. Identify below.

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 9

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Debtor Nelson Dermatology, PLLC Case number (if known) 17-11536-BFK

Name of the parent corporation Employer Identification number of the parent

corporation

32. Within 6 years before filing this case, has the debtor as an employer been responsible for contributing to a pension fund?

 No

 Yes. Identify below.

Name of the parent corporation Employer Identification number of the parent

corporation

Part 14: Signature and Declaration

WARNING -- Bankruptcy fraud is a serious crime. 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 $500,000 or imprisonment for up to 20 years, or both.

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

I have examined the information in this Statement of Financial Affairs and any attachments and have a reasonable belief that the information is true

and correct.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on June 1, 2017

/s/ Dr. Jennell E. Nelson Dr. Jennell E. Nelson

Signature of individual signing on behalf of the debtor Printed name

Position or relationship to debtor Managing Member

Are additional pages to Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy (Official Form 207) attached?

 No

 Yes

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 10

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United States Bankruptcy Court

Eastern District of Virginia

In re Nelson Dermatology, PLLC Case No. 17-11536-BFK

Debtor(s) Chapter 11

LIST OF EQUITY SECURITY HOLDERS

Following is the list of the Debtor's equity security holders which is prepared in accordance with rule 1007(a)(3) for filing in this Chapter 11 Case

Name and last known address or place of

business of holder

Security Class Number of Securities Kind of Interest

Dr. Jennell E. Nelson

8974 Yellowleg Court

Gainesville, VA 20155

Shareholder 100% Interest

DECLARATION UNDER PENALTY OF PERJURY ON BEHALF OF CORPORATION OR PARTNERSHIP

I, the Managing Member of the corporation named as the debtor in this case, declare under penalty of perjury that I

have read the foregoing List of Equity Security Holders and that it is true and correct to the best of my information and

belief.

Date June 1, 2017 Signature /s/ Dr. Jennell E. Nelson

Dr. Jennell E. Nelson

Penalty for making a false statement of concealing property: Fine of up to $500,000 or imprisonment for up to 5 years or both.

 18 U.S.C. §§ 152 and 3571.

Sheet 1 of 1 in List of Equity Security Holders

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