1

UNITED STATES BANKRUPTCY COURT 

EASTERN DISTRICT OF VIRGINIA

______________ Division

CHAPTER 13 PLAN 

AND RELATED MOTIONS

Name of Debtor(s): Case No: 

This Plan, dated ______________________, is: 

L· the first Chapter 13 Plan filed in this case. 

L· a modified Plan that replaces the 

L· confirmed or L· unconfirmed Plan dated ___________________ 

Date and Time of Modified Plan Confirmation Hearing: 

_____________________________________________________ 

Place of Modified Plan Confirmation Hearing: 

_____________________________________________________ 

The Plan provisions modified by this filing are: 

Creditors affected by this modification are: 

1. Notices

To Creditors: 

Your rights may be affected by this plan. Your claim may be reduced, 

modified, or eliminated. You should read this plan carefully and 

discuss it with your attorney if you have one in this bankruptcy case. 

If you do not have an attorney, you may wish to consult one. 

If you oppose the plan’s treatment of your claim or any provision of 

this plan, you or your attorney must file an objection to confirmation 

at least 7 days before the date set for the hearing on confirmation, 

unless otherwise ordered by the Bankruptcy Court. 

Alexandria

Tracey D. Bates 19-13762-KHK

December 10, 2019

✔

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(1) Richmond and Alexandria Divisions: 

The Bankruptcy Court may confirm this plan without further notice if 

no objection to confirmation is filed. See Bankruptcy Rule 3015. 

(2) Norfolk and Newport News Divisions: a confirmation hearing will 

 be held even if no objections have been filed. 

 (a) A scheduled confirmation hearing will not be convened when: 

 (1) an amended plan is filed prior to the scheduled 

 confirmation hearing; or 

 (2) a consent resolution to an objection to confirmation 

 anticipates the filing of an amended plan and the objecting 

 party removes the scheduled confirmation hearing prior to 

 3:00 pm on the last business day before the confirmation 

 hearing. 

In addition, you may need to timely file a proof of claim in order to be 

paid under any plan. 

The following matters may be of particular importance. 

Debtors must check one box on each line to state whether or not the 

plan includes each of the following items. If an item is checked as 

“Not Included” or if both boxes are checked, the provision will be 

ineffective if set out later in the plan. 

A. A limit on the amount of a secured claim, set out in Section 4.A 

which may result in a partial payment or no payment at all to 

the secured creditor 

 Included  Not included

B. Avoidance of a judicial lien or nonpossessory, nonpurchasemoney security interest, set out in Section 8.A  Included  Not included

C. Nonstandard provisions, set out in Part 12  Included  Not included

2. Funding of Plan. The debtor(s) propose to pay the Trustee the sum of $__________________ 

per _________ for ____ months. Other payments to the Trustee are as follows: 

_____________________. The total amount to be paid into the Plan is $_____________. 

3. Priority Creditors. The Trustee shall pay allowed priority claims in full unless the creditor 

agrees otherwise. 

A. Administrative Claims under 11 U.S.C. § 1326.

1. The Trustee will be paid the percentage fee fixed under 28 U.S.C. § 586(e), not 

to exceed 10% of all sums received under the plan. 

2. Check one box: 

L· Debtor(s)’ attorney has chosen to be compensated pursuant to the “no-look” fee 

✔

✔

✔

450.00

month 60

27,000.00

✔

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under Local Bankruptcy Rule 2016-1(C)(1)(a) and (C)(3)(a) and will be paid 

$_________________, balance due of the total fee of $_________________

concurrently with or prior to the payments to remaining creditors. 

L· Debtor(s)’ attorney has chosen to be compensated pursuant to Local Bankruptcy 

Rule 2016-1(C)(1)(c)(ii) and must submit applications for compensation as set 

forth in the Local Rules. 

B. Claims under 11 U.S.C. § 507.

The following priority creditors will be paid by deferred cash payments pro rata with 

other priority creditors or in monthly installments as below, except that allowed claims 

pursuant to 11 U.S.C. § 507(a)(1) will be paid pursuant to 3.C below: 

Creditor Type of Priority Estimated Claim Payment and Term 

C. Claims under 11 U.S.C. § 507(a)(1) 

The following priority creditors will be paid prior to other priority creditors but concurrently with 

administrative claims above. 

Creditor Type of Priority Estimated Claim Payment and Term 

4. Secured Creditors: Motions to Value Collateral (“Cramdown”), Collateral being 

Surrendered, Adequate Protection Payments, and Payment of certain Secured Claims.

A. Motions to Value Collateral (other than claims protected from “cramdown” by 

11 U.S.C. § 1322(b)(2) or by the final paragraph of 11 U.S.C. § 1325(a)). Unless 

a written objection is timely filed with the Court, the Court may grant the 

debtor(s)’ motion to value collateral as set forth herein.

This section deals with valuation of certain claims secured by real and/or personal property, 

other than claims protected from “cramdown” by 11 U.S.C. § 1322(b)(2) [real estate which is 

debtor(s)’ principal residence] or by the final paragraph of 11 U.S.C. § 1325(a) [motor vehicles 

purchased within 910 days or any other thing of value purchased within 1 year before filing 

bankruptcy], in which the replacement value is asserted to be less than the amount owing on 

the debt. Such debts will be treated as secured claims only to the extent of the 

replacement value of the collateral. That value will be paid with interest as provided in 

sub-section D of this section. You must refer to section 4(D) below to determine the 

interest rate, monthly payment and estimated term of repayment of any “crammed 

down” loan. The deficiency balance owed on such a loan will be treated as an 

unsecured claim to be paid only to the extent provided in section 5 of the Plan. The 

following secured claims are to be “crammed down” to the following values: 

Creditor Collateral Purchase Date Est. Debt Bal. Replacement Value

3,723.00 5,223.00

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B. Real or Personal Property to be Surrendered.

Upon confirmation of the Plan, or before, the debtor(s) will surrender his/her/their interest in 

the collateral securing the claims of the following creditors in satisfaction of the secured portion 

of such creditors’ allowed claims. To the extent that the collateral does not satisfy the claim, 

any timely filed deficiency claim to which the creditor is entitled may be paid as a non-priority 

unsecured claim. Confirmation of the Plan shall terminate the automatic stay under §§ 362(a) 

and 1301(a) as to the interest of the debtor(s), any co-debtor(s) and the estate in the 

collateral. 

Creditor Collateral Description Estimated Value Estimated Total Claim 

C. Adequate Protection Payments.

The debtor(s) propose to make adequate protection payments required by 11 U.S.C. § 

1326(a) or otherwise upon claims secured by personal property, until the commencement of 

payments provided for in sections 4(D) and/or 7(B) of the Plan, as follows: 

Creditor Collateral Adeq. Protection Monthly Payment To Be Paid By 

Any adequate protection payment upon an unexpired lease of personal property assumed by the 

debtor(s) pursuant to section 7(B) of the Plan shall be made by the debtor(s) as required by 11 

U.S.C. § 1326(a)(1)(B) (payments coming due after the order for relief). 

D. Payment of Secured Claims on Property Being Retained (except those 

loans provided for in section 6 of the Plan): 

This section deals with payment of debts secured by real and/or personal property [including 

short term obligations, judgments, tax liens and other secured debts]. After confirmation of the 

Plan, the Trustee will pay to the holder of each allowed secured claim, which will be either the 

balance owed on the indebtedness or, where applicable, the collateral’s replacement value as 

specified in sub-section A of this section, whichever is less, with interest at the rate provided 

below, the monthly payment specified below until the amount of the secured claim has been 

paid in full. Upon confirmation of the Plan, the valuation specified in sub-section A and 

interest rate shown below will be binding unless a timely written objection to 

confirmation is filed with and sustained by the Court.

Approx. Bal. of Debt or Interest Monthly Payment

Creditor Collateral “Crammed Down” Value Rate & Est. Term

E. Other Debts.

Debts which are (i) mortgage loans secured by real estate which is the debtor(s)’ principal 

residence, or (ii) other long term obligations, whether secured or unsecured, to be continued 

upon the existing contract terms with any existing default in payments to be cured pursuant to 

11 U.S.C. § 1322(b)(5), are provided for in section 6 of the Plan. 

 

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5. Unsecured Claims.

A. Not separately classified. Allowed non-priority unsecured claims shall be paid pro 

rata from any distribution remaining after disbursement to allowed secured and priority 

claims. Estimated distribution is approximately _____%. The dividend percentage may 

vary depending on actual claims filed. If this case were liquidated under Chapter 7, the 

debtor(s) estimate that unsecured creditors would receive a dividend of approximately 

_____%. 

B. Separately classified unsecured claims. 

Creditor Basis for Classification Treatment 

6. Mortgage Loans Secured by Real Property Constituting the Debtor(s)’ Principal 

Residence; Other Long Term Payment Obligations, whether secured or unsecured, to 

be continued upon existing contract terms; Curing of any existing default under 11 

U.S.C. § 1322(b)(5).

A. Debtor(s) to make regular contract payments; arrears, if any, to be paid by 

Trustee. The creditors listed below will be paid by the debtor(s) pursuant to the 

contract without modification, except that arrearages, if any, will be paid by the Trustee 

either pro rata with other secured claims or on a fixed monthly basis as indicated below, 

without interest unless an interest rate is designated below for interest to be paid on the 

arrearage claim and such interest is provided for in the loan agreement. A default on the 

regular contract payments on the debtor(s) principal residence is a default under the 

terms of the plan. 

Regular Arrearage Monthly

Contract Estimated Interest Estimated Arrearage

Creditor Collateral Payment Arrearage Rate Cure Period Payment

B. Trustee to make contract payments and cure arrears, if any. The Trustee shall 

pay the creditors listed below the regular contract monthly payments that come due 

during the period of this Plan, and pre-petition arrearages on such debts shall be cured 

by the Trustee either pro rata with other secured claims or with monthly payments as 

set forth below. 

Regular

Contract Estimated Interest Rate Monthly Payment on

Creditor Collateral Payment Arrearage on Arrearage Arrearage & Est. Term

C. Restructured Mortgage Loans to be paid fully during term of Plan. Any 

mortgage loan against real estate constituting the debtor(s)’ principal residence upon 

which the last scheduled contract payment is due before the final payment under the 

Plan is due shall be paid by the Trustee during the term of the Plan as permitted by 11 

U.S.C. § 1322(c)(2) with interest at the rate specified below as follows: 

5.6

0.00

PennyMac 26013 Braided Mane $2,341.44 $0.00 0.00% N/A $0.00

 Terrace, Aldie, VA

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Interest Estimated Monthly

Creditor Collateral Rate Claim Payment & Term

7. Unexpired Leases and Executory Contracts. The debtor(s) move for assumption or

rejection of the executory contracts, leases and/or timeshare agreements listed below.

A. Executory contracts and unexpired leases to be rejected. The debtor(s)

reject the following executory contracts:

Creditor Type of Contract 

B. Executory contracts and unexpired leases to be assumed. The debtor(s)

assume the following executory contracts. The debtor(s) agree to abide by all terms

of the agreement. The Trustee will pay the pre-petition arrearages, if any, through

payments made pro rata with other priority claims or on a fixed monthly basis as

indicated below.

Monthly 

Payment Estimated 

Creditor Type of Contract Arrearage for Arrears Cure Period 

8. Liens Which Debtor(s) Seek to Avoid.

A. The debtor(s) move to avoid liens pursuant to 11 U.S.C. § 522(f). The debtor(s)

move to avoid the following judicial liens and non-possessory, non-purchase money liens

that impair the debtor(s)’ exemptions. Unless a written objection is timely filed

with the Court, the Court may grant the debtor(s)’ motion and cancel the

creditor’s lien. If an objection is filed, the Court will hear evidence and rule on the

motion at the confirmation hearing.

Creditor Collateral Exemption Basis Exemption Amount Value of Collateral 

B. Avoidance of security interests or liens on grounds other than 11 U.S.C. §

522(f). The debtor(s) have filed or will file and serve separate adversary proceedings to

avoid the following liens or security interests. The creditor should review the notice or

summons accompanying such pleadings as to the requirements for opposing such relief.

The listing here is for information purposes only.

Creditor Type of Lien Description of Collateral Basis for Avoidance 

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9. Treatment and Payment of Claims.

• All creditors must timely file a proof of claim to receive any payment from the Trustee.

• If a claim is scheduled as unsecured and the creditor files a claim alleging the claim is

secured but does not timely object to confirmation of the Plan, the creditor may be treated as

unsecured for purposes of distribution under the Plan. This paragraph does not limit the right

of the creditor to enforce its lien, to the extent not avoided or provided for in this case, after

the debtor(s) receive a discharge.

• If a claim is listed in the Plan as secured and the creditor files a proof of claim alleging the

claim is unsecured, the creditor will be treated as unsecured for purposes of distribution

under the Plan.

• The Trustee may adjust the monthly disbursement amount as needed to pay an allowed

secured claim in full.

• If relief from the automatic stay is ordered as to any item of collateral listed in the plan, then,

unless otherwise ordered by the court, all payments as to that collateral will cease, and all

secured claims based on that collateral will no longer be treated by the plan.

• Unless otherwise ordered by the Court, the amount of the creditor’s total claim listed on the

proof of claim controls over any contrary amounts listed in the plan.

10. Vesting of Property of the Estate. Property of the estate shall revest in the debtor(s)

upon confirmation of the Plan. Notwithstanding such vesting, the debtor(s) may not

transfer, sell, refinance, encumber real property or enter into a mortgage loan

modification without approval of the Court after notice to the Trustee, any creditor who

has filed a request for notice and other creditors to the extent required by the Local Rules

of this Court.

11. Incurrence of indebtedness. The debtor(s) shall not voluntarily incur additional indebtedness

exceeding the cumulative total of $5,000 principal amount during the term of this Plan, whether

unsecured or secured, except upon approval of the Court after notice to the Trustee, any

creditor who has filed a request for notice, and other creditors to the extent required by the

Local Rules of this Court.

12. Nonstandard Plan Provisions

 None. If “None” is checked, the rest of Part 12 need not be completed or reproduced.

Under Bankruptcy Rule 3015(c), nonstandard provisions must be set forth below. A 

nonstandard provision is a provision not otherwise included in the Official Form or 

deviating from it. Nonstandard provisions set out elsewhere in this plan are ineffective. 

The following plan provisions will be effective only if there is a check in the box “Included” in § 1.C.

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Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 7 of 16
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By filing this document, the Attorney for Debtor(s) or Debtor(s) themselves, if not represented by an 

attorney, also certify(ies) that the wording and order of the provisions in this Chapter 13 plan are 

identical to those contained in the Local Form Plan, other than any nonstandard provisions included in 

Part 12. 

Exhibits: Copy of Debtor(s)’ Budget (Schedules I and J); Matrix of Parties Served with 3ODQ

Dated: __________________________

________________________________________ ________________________________________

Debtor 1 (Required) Debtor(s)’ Attorney

________________________________________

Debtor 2 (Required)

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December 10, 2019

/s/ Tracey D. Bates /s/ William Harville

Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 8 of 16
Certificate of Service 

I certify that on _____________________, I mailed a copy of the foregoing to the 

creditors and parties in interest on the attached Service List. 

__________________________________ 

Signature 

__________________________________ 

__________________________________ 

Address 

__________________________________ 

Telephone No:

CERTIFICATE OF SERVICE PURSUANT TO RULE 7004 

I hereby certify that on __________________________ true copies of the forgoing Chapter 13 Plan and 

Related Motions were served upon the following creditor(s): 

( ) by first class mail in conformity with the requirements of Rule 7004(b), Fed.R.Bankr.P.; or 

( ) by certified mail in conformity with the requirements of Rule 7004(h), Fed.R.Bankr.P. 

_____________________________________ 

Signature of attorney for debtor(s) 

[ver. 10/18] 

ε

December 10, 2019

/s/ William Harville

327 W. Main Street, #3

Charlottesville, VA 22903

434-483-5700

December 10, 2019

✔

/s/ William Harville

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Document Page 9 of 16
Official Form 106I Schedule I: Your Income page 1

Official Form 106I 

Schedule I: Your Income 12/15

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

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

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

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

Part 1: Describe Employment

1. Fill in your employment

information.

If you have more than one job,

attach a separate page with

information about additional

employers.

Include part-time, seasonal, or

self-employed work.

Occupation may include student

or homemaker, if it applies.

Debtor 1 Debtor 2 or non-filing spouse

Employment status  Employed

 Not employed

 Employed

 Not employed

Occupation __________________________________ __________________________________

Employer’s name __________________________________ __________________________________

Employer’s address _______________________________________

Number Street

_______________________________________ 

_______________________________________ 

_______________________________________ 

City State ZIP Code

________________________________________

Number Street

________________________________________ 

________________________________________ 

________________________________________ 

City State ZIP Code

Part 2: Give Details About Monthly Income

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

spouse unless you are separated. 

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

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

For Debtor 1 For Debtor 2 or 

non-filing spouse

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

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

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

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

Debtor 1 ____________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ____________________________________________________________________ 

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

United States Bankruptcy Court for the: ______________________ District 

tate) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is: 

 An amended filing

 A supplement showing postpetition chapter 13

income as of the following date:

________________

MM / DD / YYYY

How long employed there?________________________ ________________________

Eastern District of Virginia

19-13762

7,609.03

0.00

7,609.03

12/10/2019

Washington, DC 20037

900 23rd Street NW

occupational therapist

✔

✔

Tracey Donira Bates

2.5 years

George Washington Hospital

Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 10 of 16
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106I Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or 

non-filing spouse

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

5. List all payroll deductions:

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

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

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

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

5e. Insurance 5e. $____________ $_____________

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

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

+ $_____________

6.

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

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

8. List all other income regularly received:

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

profession, or farm

Attach a statement for each property and business showing gross 

receipts, ordinary and necessary business expenses, and the total 

monthly net income. 8a.

$____________ $_____________

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

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

regularly receive

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

settlement, and property settlement. 8c.

$____________ $_____________

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

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

8f. Other government assistance that you regularly receive

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

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

Nutrition Assistance Program) or housing subsidies.

Specify: ___________________________________________________ 8f. $____________ $_____________

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

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

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

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

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

$___________ + $_____________ = $_____________

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

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

friends or relatives.

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

Specify: _______________________________________________________________________________ 11. + $_____________

12. $_____________

Combined 

monthly income

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

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

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

 No.

 Yes. Explain: 

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

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

$____________

$____________

$____________

6. $____________

$____________

$____________

$____________

$____________

$____________

0.00

1,538.70

47.67

0.00

19-13762

1,965.28

5,643.76

0.00

0.00

119.97

5,643.76

0.00

0.00

258.94

0.00

0.00

0.00

5,643.76

0.00

0.00

0.00

Decrease -- Debtor changed employers for health reasons and to reduce uncompensated travel time and

expense.

0.00

5,643.76

7,609.03

✔

0.00

Tracey Donira Bates

STD-Post

Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 11 of 16
Official Form 106I Schedule I: Your Income

Debtor 1 _ Case number (if known) 

First Name Middle Name Last Name

Continuation Sheet for Official Form 106I 

Tracey Donira Bates

1. Describe Employment:

Debtor: Tracey Donira Bates

Occupation: occupational therapist

Name of Employer: Dominion Plastic Surgery

Employer's Address: 2755 Hartland Road, Falls Church, VA 22043

Length of Employment: 1 month

-------

19-13762

Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 12 of 16
Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J 

Schedule J: Your Expenses 12/15 

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

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

(if known). Answer every question. 

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

 Yes. Does Debtor 2 live in a separate household?

 No

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

2. Do you have dependents?

Do not list Debtor 1 and

Debtor 2.

Do not state the dependents’

names.

 No

 Yes. Fill out this information for

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

Dependent’s relationship to 

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent live 

with you?

_________________________ ________

 No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

3. Do your expenses include

expenses of people other than

yourself and your dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

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

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

applicable date.

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

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

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

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

If not included in line 4:

4a. Real estate taxes 4a. $_____________________

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

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

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is: 

 An amended filing

 A supplement showing postpetition chapter 13

expenses as of the following date:

________________

MM / DD / YYYY

Eastern District of Virginia

2,313.00

0.00

0.00

100.00

306.00

19-13762 12/10/2019

✔

✔

✔

Tracey Donira Bates

Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 13 of 16
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106J Schedule J: Your Expenses page 2

Your expenses

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

6. Utilities:

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

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

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

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

7. Food and housekeeping supplies 7. $_____________________

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

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

10. Personal care products and services 10. $_____________________

11. Medical and dental expenses 11. $_____________________

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

Do not include car payments. 12.

$_____________________

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

14. Charitable contributions and religious donations 14. $_____________________

15. Insurance.

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

1

15a. Life insurance 15a. $_____________________

15b. Health insurance 15b. $_____________________

15c. Vehicle insurance 15c. $_____________________

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

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

Specify: ________________________________________________________ 16. $_____________________

17. Installment or lease payments:

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

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

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

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

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

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

$_____________________

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

Specify:_______________________________________________________ 19. $_____________________

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

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

20b. Real estate taxes 20b. $_____________________

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

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

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

100.00

433.00

33.50

370.00

84.81

0.00

344.13

personal property tax 20.00

19-13762

0.00

90.00

Alarm system

235.00

0.00

211.00

195.00

0.00

46.00

Tracey Donira Bates

100.00

0.00

0.00

malpractice

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 14 of 16
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106J Schedule J: Your Expenses page 3

21. +$_____________________

22a.

22b.

21. Other. Specify:______________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

22. Calculate your monthly expenses.

22a. Add lines 4 through 21.

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

and 22b. The result is your monthly expenses. 22c.

$_____________________

$_____________________

$_____________________

23. Calculate your monthly net income.

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

$_____________________

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

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

The result is your monthly net income. 23c.

$_____________________

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

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

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

 No.

 Yes. Explain here: 

 +$_____________________

 +$_____________________

60.00

52.00

✔

100.00

19-13762

5,193.44

5,193.44

travel for professional education

satellite radio and car net

emergencies & contingencies

Tracey Donira Bates

5,193.44

5,643.76

450.32

Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 15 of 16
GW University Hospital

PO Box 31001-0827

Pasadena, CA 91110-0827

GWU Medical Faculty Associates

PO Box 392187

Pittsburgh, PA 15251-9187

I.C. System

PO BO 64378

Saint Paul, MN 55164

INOVA Fairfax Hospital

2290 Telestar Court

Falls Church, VA 22042-1207

INOVA Medicredit

2990 Telestar Ct, 3rd Floor

Falls Church, VA 22042-8587

J Douglas Lewis

7500 Diplomat Dr, Suite 201

Manassas, VA 20109

Lowe's

PO Box 981064

El Paso, TX 79998

Medical Faculty Associates

PO Box 48458

Oak Park, MI 48237

New York University

Credit Dept

105 East 17th St, 3rd Floor

New York, NY 10003-2015

PennyMac

PO Box 514387

Los Angeles, CA 90051-4387

Synchrony Bank - Haverty's

Bankruptcy Dept

PO Box 965061

Orland, FL 32896-5061

Synchrony Bank - Pro Source

Bankruptcy Dept

PO Box 965061

Orlando, FL 32896-5061

Synchrony Bank / CCA Carpet Co-op

PO Box 965036

Orlando, FL 32896

Wells Fargo

PO Box 94435

Albuquerque, NM 87199

Wells Fargo

PO Box 14517

Des Moines, IA 50306

American Anesthesiology of Va

PO Box120153

Grand Rapids, MI 49528-0103

Avadian Credit Union

PO Box 360287

Birmingham, AL 35236-0287

Bank of America

PO Box 15019

Wilmington, DE 19886-5019

Capitol One

PO Box 30285

Salt Lake City, UT 84130-0285

Chase Business

270 Park Avenue

New York, NY 10017

Chase Card

270 Park Avenue

New York, NY 10017

Client Services Inc

3451 Harry S Truman Blvd

Saint Charles, MO 63301

Commenity - Williams Sonoma

Bankruptcy Dept

PO Box 182125

Columbus, OH 43218-2125

Credit Bureau Resolution

PO Box 14517

Des Moines, IA 50306

Credit Control

PO Box 31179

Tampa, FL 33631

Discover Student Loans

PO Box 6107

Carol Stream, IL 60197-6107

FED LOAN SERV

PO Box 60610

Harrisburg, PA 17106

Firstmark Services

PO Box 82522

Lincoln, NE 68501-2522

Frost Arnett Company

PO Box 198988

Nashville, TN 37219-8988

GEICO Subrogee to Gulsha Ozalp

Chaplin & Gonet

5211 West Broad St, #100

Richmond, VA 23230

Case 19-13762-KHK Doc 16 Filed 12/10/19 Entered 12/10/19 17:39:37 Desc Main

Document Page 16 of 16