AMENDED

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

Official Form 107 

Statement of Financial Affairs for Individuals Filing for Bankruptcy 4/19

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

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

number (if known). Answer every question.

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

1. What is your current marital status?

 Married

 Not married

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

 No

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

Debtor 1: Dates Debtor 1 

lived there 

Debtor 2: Dates Debtor 2 

lived there 

__________________________________________

Number Street

__________________________________________

__________________________________________ 

City State ZIP Code

From ________

To __________

 Same as Debtor 1

___________________________________________

Number Street

___________________________________________

___________________________________________ 

City State ZIP Code

 Same as Debtor 1

From ________

To ________

__________________________________________

Number Street

__________________________________________

__________________________________________ 

City State ZIP Code

From ________

To ________

 Same as Debtor 1

___________________________________________

Number Street

___________________________________________

___________________________________________ 

City State ZIP Code

 Same as Debtor 1

From ________

To ________

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

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

 No

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of ______________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

19-13762

 

✔

Tracey Donira Bates

Eastern District of Virginia

✔

✔

✔

Case 19-13762-KHK Doc 19 Filed 01/10/20 Entered 01/10/20 16:14:44 Desc Main

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AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

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

 No

 Yes. Fill in the details.

Debtor 1 Debtor 2 

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy: 

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

For last calendar year:

(January 1 to December 31, _________)

YYYY

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

For the calendar year before that: 

(January 1 to December 31, _________)

YYYY

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

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

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

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

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

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

 No

 Yes. Fill in the details.

Debtor 2 

Sources of income

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

Sources of income 

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

From January 1 of current 

year until the date you 

filed for bankruptcy: 

_________________________

_________________________ 

_________________________

For last calendar year:

(January 1 to 

December 31, _________)

$________________

$________________

$_________________ 

Part 2: Explain the Sources of Your Income 

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________ 

_________________________

_________________________

_________________________ 

_________________________

$________________

$________________

$_________________ 

$________________

$________________

$_________________ 

$________________

$________________

$_________________ 

$________________

$________________

$_________________ 

$________________

$________________

$_________________ 

Debtor 1

For the calendar year 

before that: 

(January 1 to 

December 31, _________)

✔

Tracey Donira Bates

✔

81,966.27

68,995.00

2019

2018

19-13762

✔

✔

Case 19-13762-KHK Doc 19 Filed 01/10/20 Entered 01/10/20 16:14:44 Desc Main

Document Page 2 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

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

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

During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,825* or more? 

 No. Go to line 7.

 Yes. List below each creditor to whom you paid a total of $6,825* or more in one or more payments and

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

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

* Subject to adjustment on 4/01/22 and every 3 years after that for cases filed on or after the date of adjustment.

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

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

 No. Go to line 7.

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

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

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

____________________________________

Creditor’s Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Dates of 

payment

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

_________

_________

_________

$_________________ $__________________  Mortgage 

 Car 

 Credit card 

 Loan repayment 

 Suppliers or vendors 

 Other ______________ 

____________________________________

Creditor’s Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________  Mortgage 

 Car 

 Credit card 

 Loan repayment 

 Suppliers or vendors 

 Other ______________

____________________________________

Creditor’s Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________  Mortgage 

 Car 

 Credit card 

 Loan repayment 

 Suppliers or vendors 

 Other _______________

Tracey Donira Bates

✔

19-13762

✔

Case 19-13762-KHK Doc 19 Filed 01/10/20 Entered 01/10/20 16:14:44 Desc Main

Document Page 3 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

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

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

such as child support and alimony.

 No

 Yes. List all payments to an insider.

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

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

an insider?

Include payments on debts guaranteed or cosigned by an insider.

 No

 Yes. List all payments that benefited an insider.

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

Include creditor’s name

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

Tracey Donira Bates

✔

✔

19-13762

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Document Page 4 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

 Part 4: Identify Legal Actions, Repossessions, and Foreclosures

9. Within 1 year before you filed for bankruptcy, were you a party in any lawsuit, court action, or administrative proceeding?

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

and contract disputes.

 No

 Yes. Fill in the details.

Case title:

Case number ________________________ 

Nature of the case Court or agency Status of the case

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

 Pending 

 On appeal

 Concluded

Case title:

Case number ________________________

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

 Pending 

 On appeal

 Concluded

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

Check all that apply and fill in the details below.

 No. Go to line 11.

 Yes. Fill in the information below.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized, or levied.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized, or levied.

warrant in debt; Date filed:

02/22/2019

warrant in debt; Date filed:

02/08/2019

Leesburg

Leesburg

✔

Tracey Donira Bates

18 E Market St, 2nd Floor

18 E Market St, 2nd Floor

✔

20176

VA 20176

VA

Loudoun County General District Court

Loudoun County General District Court

Bank of America v Tracey Bates

Synchrony Bank (ProSource) v

Tracey Bates

19-13762

✔

✔

GV-19001397-00

GV-19001011-00

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Document Page 5 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

11. Within 90 days before you filed for bankruptcy, did any creditor, including a bank or financial institution, set off any amounts from your

accounts or refuse to make a payment because you owed a debt?

 No

 Yes. Fill in the details.

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the action the creditor took Date action 

was taken

Amount

____________ $________________

Last 4 digits of account number: XXXX– 

12. Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of

creditors, a court-appointed receiver, a custodian, or another official?

 No

 Yes

Part 5: List Certain Gifts and Contributions 

13.Within 2 years before you filed for bankruptcy, did you give any gifts with a total value of more than $600 per person?

 No

 Yes. Fill in the details for each gift.

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

Number Street

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

Number Street

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

✔

Tracey Donira Bates

✔

19-13762

✔

Case 19-13762-KHK Doc 19 Filed 01/10/20 Entered 01/10/20 16:14:44 Desc Main

Document Page 6 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

14.Within 2 years before you filed for bankruptcy, did you give any gifts or contributions with a total value of more than $600 to any charity?

 No

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

Gifts or contributions to charities 

that total more than $600

Describe what you contributed Date you 

contributed

Value 

_____________________________________

Charity’s Name

_____________________________________

_____________________________________

Number Street

_____________________________________

City State ZIP Code

_________

_________

$_____________

$_____________

Part 6: List Certain Losses 

15. Within 1 year before you filed for bankruptcy or since you filed for bankruptcy, did you lose anything because of theft, fire, other disaster,

or gambling?

 No

 Yes. Fill in the details.

Describe the property you lost and how 

the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending insurance 

claims on line 33 of Schedule A/B: Property. 

Date of your loss Value of property 

lost

_________ $_____________

Part 7: List Certain Payments or Transfers 

16. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone you

consulted about seeking bankruptcy or preparing a bankruptcy petition?

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

 No

 Yes. Fill in the details.

___________________________________

Person Who Was Paid 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

____________________________________________ 

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

Tracey Donira Bates

✔

327 W. Main Street, #3 1,500.00

William Harville

Charlottesville

✔

19-13762

✔

VA 22903

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Document Page 7 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 8

____________________________________

Person Who Was Paid 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

________________________________________________ 

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of 

payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

17. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone who

promised to help you deal with your creditors or to make payments to your creditors?

Do not include any payment or transfer that you listed on line 16.

 No

 Yes. Fill in the details.

____________________________________

Person Who Was Paid 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code 

Description and value of any property transferred Date payment or 

transfer was made

Amount of payment

_________

_________

$____________

$____________

18. Within 2 years before you filed for bankruptcy, did you sell, trade, or otherwise transfer any property to anyone, other than property 

transferred in the ordinary course of your business or financial affairs?

Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property).

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

 No

 Yes. Fill in the details.

___________________________________

Person Who Received Transfer 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Description and value of property 

transferred

Describe any property or payments received 

or debts paid in exchange

Date transfer 

was made

_________

Person’s relationship to you _____________

___________________________________

Person Who Received Transfer 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

_________

Person’s relationship to you _____________

✔

Tracey Donira Bates 19-13762

✔

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Document Page 8 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 9

19.Within 10 years before you filed for bankruptcy, did you transfer any property to a self-settled trust or similar device of which you

are a beneficiary? (These are often called asset-protection devices.)

 No

 Yes. Fill in the details.

Name of trust 

Description and value of the property transferred Date transfer 

was made

_________

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

20. Within 1 year before you filed for bankruptcy, were any financial accounts or instruments held in your name, or for your benefit,

closed, sold, moved, or transferred?

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

brokerage houses, pension funds, cooperatives, associations, and other financial institutions.

 No

 Yes. Fill in the details.

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code 

Last 4 digits of account number Type of account or 

instrument

Date account was 

closed, sold, moved, 

or transferred

Last balance before 

closing or transfer

XXXX–___ ___ ___ ___  Checking

 Savings

 Money market

 Brokerage 

 Other__________

_________ $___________

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

XXXX–___ ___ ___ ___  Checking

 Savings

 Money market

 Brokerage 

 Other__________

_________ $___________

21. Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for

securities, cash, or other valuables?

 No

 Yes. Fill in the details.

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Who else had access to it? Describe the contents Do you still 

have it?

_______________________________________

Name 

_______________________________________

Number Street

_______________________________________

City State ZIP Code

 No

 Yes

Tracey Donira Bates

✔

✔

19-13762

✔

Case 19-13762-KHK Doc 19 Filed 01/10/20 Entered 01/10/20 16:14:44 Desc Main

Document Page 9 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 10

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

 No

 Yes. Fill in the details.

___________________________________

Name of Storage Facility

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Who else has or had access to it? Describe the contents Do you still 

have it?

_______________________________________

Name 

_______________________________________

Number Street

_______________________________________

CityState ZIP Code

 No

 Yes

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

23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for,

or hold in trust for someone.

 No

 Yes. Fill in the details.

___________________________________

Owner’s Name

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Where is the property? Describe the property Value

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

$__________

Part 10: Give Details About Environmental Information

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

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

hazardous or toxic substances, wastes, or material into the air, land, soil, surface water, groundwater, or other medium,

including statutes or regulations controlling the cleanup of these substances, wastes, or material.

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

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

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

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

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

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

 No

 Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

✔

Tracey Donira Bates

✔

19-13762

✔

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Document Page 10 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 11

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

 No

 Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

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

 No

 Yes. Fill in the details.

Case title 

Case number 

Court or agency Nature of the case Status of the 

case

________________________________

Court Name

________________________________

Number Street

________________________________

City State ZIP Code

 Pending 

 On appeal 

 Concluded

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

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

 A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time

 A member of a limited liability company (LLC) or limited liability partnership (LLP)

 A partner in a partnership

 An officer, director, or managing executive of a corporation

 An owner of at least 5% of the voting or equity securities of a corporation

 No. None of the above applies. Go to Part 12.

 Yes. Check all that apply above and fill in the details below for each business.

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper 

Dates business existed

From _______ To _______ 

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper

Dates business existed

From _______ To _______ 

✔

Tracey Donira Bates

✔

✔

19-13762

Case 19-13762-KHK Doc 19 Filed 01/10/20 Entered 01/10/20 16:14:44 Desc Main

Document Page 11 of 13
AMENDED

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 12

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper

Dates business existed

From _______ To _______ 

28. Within 2 years before you filed for bankruptcy, did you give a financial statement to anyone about your business? Include all financial

institutions, creditors, or other parties.

 No

 Yes. Fill in the details below.

____________________________________

Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Date issued

____________ 

MM / DD / YYYY

Part 12: Sign Below

I have read the answers on this Statement of Financial Affairs and any attachments, and I declare under penalty of perjury that the 

answers are true and correct. I understand that making a false statement, concealing property, or obtaining money or property by fraud 

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

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

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Date ________________ Date _________________

Did you attach additional pages to Your Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107)?

 No

 Yes

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

 No

 Yes. Name of person_____________________________________________________________. Attach the Bankruptcy Petition Preparer’s Notice,

Declaration, and Signature (Official Form 119).

✔

✔

Tracey Donira Bates

01/10/2020

19-13762

/s/ Tracey Donira Bates

Case 19-13762-KHK Doc 19 Filed 01/10/20 Entered 01/10/20 16:14:44 Desc Main

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AMENDED

Official Form 107

 

Statement of Financial Affairs for Individuals

Debtor 1 _ Case number (if known)

First Name Middle Name Last Name

Continuation Sheet for Official Form 107

Tracey Donira Bates 19-13762

9) Lawsuits

Case Title: Synchrony Bank (Haverty) v Tracey Bates

Case Number: GV-19001337-00

Court Name: Loudoun County General District Court

Court Address: 18 E Market St, 2nd Floor, Leesburg, VA 20176

Case Status: Pending

Nature of the case: warrant in debt; Date filed: 02/21/2019

-------

Case Title: GEICO Subrogee to Gulsha Ozalp v. Tracy Donira

Case Number: GV06-31119

Court Name: Fairfax General District Court

Court Address: 4110 Chain Bridge Rd, Fairfax, VA 22030

Case Status: Concluded

Nature of the case: warrant in debt

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Case 19-13762-KHK Doc 19 Filed 01/10/20 Entered 01/10/20 16:14:44 Desc Main

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