Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 12/17

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

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

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

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

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

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

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

(if known). Answer every question.

Part 1: Identify Yourself

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

1. Your full name

Write the name that is on your

government-issued picture

identification (for example,

your driver’s license or

passport).

Bring your picture

identification to your meeting

with the trustee.

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

___________________________

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

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

___________________________

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

2. All other names you

have used in the last 8

years

Include your married or

maiden names.

3. Only the last 4 digits of

your Social Security

number or federal

Individual Taxpayer

Identification number

(ITIN)

xxx – xx – ____ ____ ____ ____

OR

9 xx – xx – ____ ____ ____ ____

xxx – xx – ____ ____ ____ ____

OR

9 xx – xx – ____ ____ ____ ____

United States Bankruptcy Court for the:

____________________ District of _________________

(State) 

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

 Chapter 7 

 Chapter 11

 Chapter 12

 Chapter 13

 Fill in this information to identify your case:

 Check if this is an

amended filing

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

Bates

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Tracey

Eastern District of Virginia

Donira

0 6 7 0

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Document Page 1 of 16
About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 

4. Any business names

and Employer

Identification Numbers

(EIN) you have used in

the last 8 years

Include trade names and

doing business as names

 I have not used any business names or EINs.

_________________________________________________ 

Business name

_________________________________________________ 

Business name

_________________________________________________

EIN

_________________________________________________

EIN 

 I have not used any business names or EINs.

5. Where you live

_________________________________________________

Number Street

_________________________________________________

_________________________________________________ 

City State ZIP Code 

_________________________________________________

County

If your mailing address is different from the one 

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

any notices to you at this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________ 

City State ZIP Code 

If Debtor 2 lives at a different address:

_________________________________________________

Number Street

_________________________________________________

_________________________________________________

City State ZIP Code 

_________________________________________________

County

If Debtor 2’s mailing address is different from 

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

any notices to this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________ 

City State ZIP Code

6. Why you are choosing

this district to file for

bankruptcy

Check one:

 Over the last 180 days before filing this petition, I

have lived in this district longer than in any other

district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

Check one:

 Over the last 180 days before filing this petition, I

have lived in this district longer than in any other

district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

_________________________________________________ 

Business name

_________________________________________________ 

Business name

_________________________________________________

EIN

_________________________________________________

EIN 

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

Aldie VA 20105

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Loudoun County

26013 Braided Mane Terrace

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Document Page 2 of 16
Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the

Bankruptcy Code you

are choosing to file

under

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

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

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

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

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

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

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

with a pre-printed address.

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

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

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

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

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

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

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

9. Have you filed for

bankruptcy within the

last 8 years?

 No

 Yes.

10. Are any bankruptcy

cases pending or being

filed by a spouse who is

not filing this case with

you, or by a business

partner, or by an

affiliate?

 No

 Yes.

Debtor _________________________________________________ Relationship to you ________________________ 

District _______________________________________________ When _______________ Case number, if known__________________

Debtor _________________________________________________ Relationship to you ___________________________ 

District _______________________________________________ When _______________ Case number, if known__________________ 

11. Do you rent your

residence?

 No. Go to line 12.

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

 No. Go to line 12.

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

this bankruptcy petition.

District ____________________________________________ When ______________ Case number __________________

District ____________________________________________ When ______________ Case number __________________

District ____________________________________________ When ______________ Case number __________________

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

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Document Page 3 of 16
Part 3: Report About Any Businesses You Ow n as a Sole Proprietor

12. Are you a sole proprietor

of any full- or part-time

business?

A sole proprietorship is a

business you operate as an

individual, and is not a

separate legal entity such as

a corporation, partnership, or

LLC.

If you have more than one

sole proprietorship, use a

separate sheet and attach it

to this petition.

 No. Go to Part 4.

 Yes. Name and location of business

_______________________________________________________________________________________

Name of business, if any

_______________________________________________________________________________________

Number Street

_______________________________________________________________________________________

_______________________________________________ _______ __________________________

City State ZIP Code

Check the appropriate box to describe your business: 

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

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

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

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

 None of the above

13. Are you filing under

Chapter 11 of the

Bankruptcy Code and

are you a small business

debtor?

For a definition of small

business debtor, see

11 U.S.C. § 101(51D).

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

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

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

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

 No. I am not filing under Chapter 11.

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

the Bankruptcy Code. 

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

Bankruptcy Code.

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

14. Do you own or have any

property that poses or is

alleged to pose a threat

of imminent and

identifiable hazard to

public health or safety?

Or do you own any

property that needs

immediate attention?

For example, do you own

perishable goods, or livestock

that must be fed, or a building

that needs urgent repairs?

 No

 Yes. What is the hazard?

If immediate attention is needed, why is it needed?

Where is the property? 

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

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Document Page 4 of 16
Part 5: Explain Your Efforts to Receive a Briefing About Credit Counseling

15. Tell the court whether

you have received a

briefing about credit

counseling.

The law requires that you

receive a briefing about credit

counseling before you file for

bankruptcy. You must

truthfully check one of the

following choices. If you

cannot do so, you are not

eligible to file.

If you file anyway, the court

can dismiss your case, you

will lose whatever filing fee

you paid, and your creditors

can begin collection activities

again.

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

You must check one:

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

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

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

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

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so.

 Active duty. I am currently on active military

duty in a military combat zone.

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

You must check one:

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

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

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

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

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so.

 Active duty. I am currently on active military

duty in a military combat zone.

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

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

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Document Page 5 of 16
Part 6: Answ er These Questions for Reporting Purposes

16. What kind of debts do

you have?

16a. Are your debts primarily consumer debts? Consumer debts are defined in 11 U.S.C. § 101(8) 

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

 No. Go to line 16b.

 Yes. Go to line 17.

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

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

 No. Go to line 16c.

 Yes. Go to line 17.

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

_______________________________________________________________

17. Are you filing under

Chapter 7?

Do you estimate that after

any exempt property is

excluded and

administrative expenses

are paid that funds will be

available for distribution

to unsecured creditors?

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

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

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

 No

 Yes

18. How many creditors do

you estimate that you

owe?

 1-49

 50-99

 100-199

 200-999

 1,000-5,000

 5,001-10,000

 10,001-25,000

 25,001-50,000

 50,001-100,000

 More than 100,000

19. How much do you

estimate your assets to

be worth?

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

20. How much do you

estimate your liabilities

to be?

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

Part 7: Sign Below

For you

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

correct. 

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

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

under Chapter 7.

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

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

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

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

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

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

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Executed on _________________ Executed on __________________

MM / DD / YYYY MM / DD / YYYY

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

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11/15/2019

/s/ Tracey Donira Bates

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Document Page 6 of 16
For your attorney, if you are 

represented by one

If you are not represented 

by an attorney, you do not 

need to file this page.

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

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

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

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

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

_________________________________ Date _________________ 

Signature of Attorney for Debtor MM / DD / YYYY

_________________________________________________________________________________________________ 

Printed name 

_________________________________________________________________________________________________ 

Firm name 

_________________________________________________________________________________________________ 

Number Street 

_________________________________________________________________________________________________ 

______________________________________________________ ____________ ______________________________ 

City State ZIP Code 

Contact phone ______________________________ Email address _________________________________________ 

______________________________________________________ ____________ 

Bar number State 

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

327 W Main Street

434-483-5700

22903

William Harville

Charlottesville VA

VA

#3

/s/ William Harville

19802

11/15/2019

The Law Office of William Harville

harvillelaw@gmail.com

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Document Page 7 of 16
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 1

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

Individuals Filing for Bankruptcy (Form 2010)

This notice is for you if:

 You are an individual filing for bankruptcy, 

and 

 Your debts are primarily consumer debts.

Consumer debts are defined in 11 U.S.C. 

§ 101(8) as “incurred by an individual 

primarily for a personal, family, or 

household purpose.” 

The types of bankruptcy that are 

available to individuals

Individuals who meet the qualifications may file 

under one of four different chapters of the 

Bankruptcy Code: 

 Chapter 7 — Liquidation 

 Chapter 11 — Reorganization 

 Chapter 12 — Voluntary repayment plan 

for family farmers or 

fishermen

 Chapter 13 — Voluntary repayment plan 

for individuals with regular 

income 

You should have an attorney review your 

decision to file for bankruptcy and the choice of 

chapter. 

Chapter 7: Liquidation 

$245 filing fee

 $75 administrative fee

+ $15 trustee surcharge

$335 total fee

Chapter 7 is for individuals who have financial 

difficulty preventing them from paying their 

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

creditors. The primary purpose of filing under 

chapter 7 is to have your debts discharged. The 

bankruptcy discharge relieves you after 

bankruptcy from having to pay many of your 

pre-bankruptcy debts. Exceptions exist for 

particular debts, and liens on property may still 

be enforced after discharge. For example, a 

creditor may have the right to foreclose a home 

mortgage or repossess an automobile. 

However, if the court finds that you have 

committed certain kinds of improper conduct 

described in the Bankruptcy Code, the court 

may deny your discharge. 

You should know that even if you file 

chapter 7 and you receive a discharge, some 

debts are not discharged under the law. 

Therefore, you may still be responsible to pay: 

 most taxes; 

 most student loans; 

 domestic support and property settlement 

obligations; 

 

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

 most fines, penalties, forfeitures, and 

criminal restitution obligations; and 

 certain debts that are not listed in your 

bankruptcy papers. 

You may also be required to pay debts arising 

from:

 fraud or theft;

 fraud or defalcation while acting in breach 

of fiduciary capacity; 

 intentional injuries that you inflicted; and 

 death or personal injury caused by 

operating a motor vehicle, vessel, or 

aircraft while intoxicated from alcohol or 

drugs. 

If your debts are primarily consumer debts, the 

court can dismiss your chapter 7 case if it finds 

that you have enough income to repay 

creditors a certain amount. You must file 

Chapter 7 Statement of Your Current Monthly 

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

individual filing for bankruptcy under 

chapter 7. This form will determine your 

current monthly income and compare whether 

your income is more than the median income 

that applies in your state. 

If your income is not above the median for 

your state, you will not have to complete the 

other chapter 7 form, the Chapter 7 Means 

Test Calculation (Official Form 122A–2). 

If your income is above the median for your 

state, you must file a second form —the 

Chapter 7 Means Test Calculation (Official 

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

sometimes called the Means Test—deduct 

from your income living expenses and 

payments on certain debts to determine any 

amount available to pay unsecured creditors. If

your income is more than the median income 

for your state of residence and family size, 

depending on the results of the Means Test, the 

U.S. trustee, bankruptcy administrator, or 

creditors can file a motion to dismiss your case 

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

motion is filed, the court will decide if your 

case should be dismissed. To avoid dismissal, 

you may choose to proceed under another 

chapter of the Bankruptcy Code.

If you are an individual filing for chapter 7 

bankruptcy, the trustee may sell your property 

to pay your debts, subject to your right to 

exempt the property or a portion of the 

proceeds from the sale of the property. The 

property, and the proceeds from property that 

your bankruptcy trustee sells or liquidates that 

you are entitled to, is called exempt property. 

Exemptions may enable you to keep your 

home, a car, clothing, and household items or 

to receive some of the proceeds if the property 

is sold. 

Exemptions are not automatic. To exempt 

property, you must list it on Schedule C: The 

Property You Claim as Exempt (Official Form 

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

trustee may sell it and pay all of the proceeds 

to your creditors.

Chapter 11: Reorganization 

$1,167 filing fee

+ $550 administrative fee

$1,717 total fee

Chapter 11 is often used for reorganizing a 

business, but is also available to individuals. 

The provisions of chapter 11 are too 

complicated to summarize briefly. 

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

Chapter 12: Repayment plan for family 

farmers or fishermen

$200 filing fee

+ $75 administrative fee

$275 total fee

Similar to chapter 13, chapter 12 permits 

family farmers and fishermen to repay their 

debts over a period of time using future 

earnings and to discharge some debts that are 

not paid. 

Chapter 13: Repayment plan for 

individuals with regular 

income

$235 filing fee

+ $75 administrative fee

$310 total fee

Chapter 13 is for individuals who have regular 

income and would like to pay all or part of 

their debts in installments over a period of time

and to discharge some debts that are not paid. 

You are eligible for chapter 13 only if your 

debts are not more than certain dollar amounts 

set forth in 11 U.S.C. § 109. 

Under chapter 13, you must file with the court 

a plan to repay your creditors all or part of the 

money that you owe them, usually using your 

future earnings. If the court approves your 

plan, the court will allow you to repay your 

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

5 years, depending on your income and other 

factors.

After you make all the payments under your 

plan, many of your debts are discharged. The

debts that are not discharged and that you may 

still be responsible to pay include: 

 domestic support obligations, 

 most student loans, 

 certain taxes, 

 debts for fraud or theft,

 debts for fraud or defalcation while acting 

in a fiduciary capacity,

 most criminal fines and restitution 

obligations, 

 certain debts that are not listed in your 

bankruptcy papers, 

 certain debts for acts that caused death or 

personal injury, and 

 certain long-term secured debts. 

Read These Important Warnings 

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

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

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

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

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

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

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

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

and following all of the legal requirements. 

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

necessary documents.

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

bankruptcy case. Making a false statement, concealing property, or obtaining money or property by 

fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 

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

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

Bankruptcy crimes have serious 

consequences

 If you knowingly and fraudulently conceal 

assets or make a false oath or statement 

under penalty of perjury—either orally or 

in writing—in connection with a 

bankruptcy case, you may be fined, 

imprisoned, or both. 

 All information you supply in connection 

with a bankruptcy case is subject to 

examination by the Attorney General acting 

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

Office of the U.S. Attorney, and other 

offices and employees of the U.S. 

Department of Justice.

Make sure the court has your 

mailing address

The bankruptcy court sends notices to the 

mailing address you list on Voluntary Petition 

for Individuals Filing for Bankruptcy (Official 

Form 101). To ensure that you receive 

information about your case, Bankruptcy 

Rule 4002 requires that you notify the court of 

any changes in your address. 

A married couple may file a bankruptcy case 

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

case and each spouse lists the same mailing 

address on the bankruptcy petition, the 

bankruptcy court generally will mail you and 

your spouse one copy of each notice, unless 

you file a statement with the court asking that 

each spouse receive separate copies.

Understand w hich services you 

could receive from credit 

counseling agencies

The law generally requires that you receive a 

credit counseling briefing from an approved 

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

If you are filing a joint case, both spouses must 

receive the briefing. With limited exceptions, 

you must receive it within the 180 days before

you file your bankruptcy petition. This briefing 

is usually conducted by telephone or on the 

Internet. 

In addition, after filing a bankruptcy case, you 

generally must complete a financial 

management instructional course before you 

can receive a discharge. If you are filing a joint 

case, both spouses must complete the course. 

You can obtain the list of agencies approved to 

provide both the briefing and the instructional 

course from: 

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

In Alabama and North Carolina, go to: 

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

BankruptcyResources/ApprovedCredit 

AndDebtCounselors.aspx. 

If you do not have access to a computer, the 

clerk of the bankruptcy court may be able to 

help you obtain the list.

Warning: File Your Forms on Time

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

requires that you promptly file detailed information 

about your creditors, assets, liabilities, income, 

expenses and general financial condition. The 

court may dismiss your bankruptcy case if you do 

not file this information within the deadlines set by 

the Bankruptcy Code, the Bankruptcy Rules, and 

the local rules of the court. 

For more information about the documents and 

their deadlines, go to: 

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

s.html#procedure. 

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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

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United States Bankruptcy Court

In re: Case No.

Chapter

Debtor(s)

Verification of Creditor Matrix

The above-named Debtor(s) hereby verify that the attached list of creditors is

true and correct to the best of their knowledge.

Date:

Signature of Debtor

Signature of Joint Debtor

13

Eastern District of Virginia

11/15/2019 /s/ Tracey Donira Bates

Tracey Donira Bates

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B2030 (Form 2030) (12/15) 

United States Bankruptcy Court 

__________________________________

In re 

Case No. _______________ 

Debtor Chapter________________ 

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR 

1. Pursuant to 11 U .S.C. § 329(a) and Fed. Bankr. P. 2016(b), I certify that I am the attorney for the

above named debtor(s) and that compensation paid to me within one year before the filing of the

petition in bankruptcy, or agreed to be paid to me, for services rendered or to be rendered on behalf of

the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows:

For legal services, I have agreed to accept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________ 

Prior to the filing of this statement I have received. . . . . . . . . . . . . . . . . . . . . . . . $______________ 

Balance Due. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________ 

2. The source of the compensation paid to me was:

 Debtor Other (specify) 

3. The source of compensation to be paid to me is:

 Debtor Other (specify) 

4. I have not agreed to share the above-disclosed compensation with any other person unless they

are members and associates of my law firm.

 I have agreed to share the above-disclosed compensation with a other person or persons who 

are not members or associates of my law firm. A copy of the Agreement, together with a list of the names 

of the people sharing the compensation is attached. 

5. In return of the above-disclosed fee, I have agreed to render legal service for all aspects of the

bankruptcy case, including:

a. Analysis of the debtor’s financial situation, and rendering advice to the debtor in determining

whether to file a petition in bankruptcy;

b. Preparation and filing of any petition, schedules, statements of affairs and plan which may be

required;

c. Representation of the debtor at the meeting of creditors and confirmation hearing, and any

adjourned hearings thereof;

FLAT FEE

RETAINER 

For legal services, I have agreed to accept a retainer of . . . . . . . . . . . . . . . . . . . . $______________ 

The undersigned shall bill against the retainer at an hourly rate of . . . . . . . . . . . $______________ 

[Or attach firm hourly rate schedule.] Debtor(s) have agreed to pay all Court 

approved fees and expenses exceeding the amount of the retainer.

Eastern District of Virginia

✔

13

5,296.00

0.00

5,296.00

Tracey Donira Bates

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B2030 (Form 2030) (12/15) 

d. [Other provisions as needed]

6. By agreement with the debtor(s), the above-disclosed fee does not include the following services:

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CERTIFICATION

I certify that the foregoing is a complete statement of any agreement or arrangement for

payment to me for representation of the debtor(s) in this bankruptcy proceeding. 

_____________________ 

Date 

 _________________________________________ 

 Signature of Attorney 

 _________________________________________

Name of law firm 

327 W Main Street

#3

Charlottesville, VA 22903

434-483-5700

harvillelaw@gmail.com

The Law Office of William Harville

11/15/2019 /s/ William Harville, 19802

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