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

Official Form 101 

Voluntary Petition for Individuals Filing for Bankruptcy 12/15

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

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

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

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

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

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

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

(if known). Answer every question. 

Part 1: Identify Yourself

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

1. Your full name

Write the name that is on your

government-issued picture

identification (for example,

your driver’s license or

passport).

Bring your picture

identification to your meeting

with the trustee.

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

___________________________ 

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

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

___________________________ 

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

2. All other names you

have used in the last 8

years

Include your married or

maiden names.

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

3. Only the last 4 digits of

your Social Security

number or federal

Individual Taxpayer

Identification number

(ITIN)

xxx – xx – ____ ____ ____ ____ 

OR 

9 xx – xx – ____ ____ ____ ____

xxx – xx – ____ ____ ____ ____ 

OR 

9 xx – xx – ____ ____ ____ ____

United States Bankruptcy Court for the: 

__________ District of __________ 

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

Northern District of Illinois ✔

Jeremy Benjamin Gillum 5 5 6 8

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

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

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

4. Any business names

and Employer

Identification Numbers

(EIN) you have used in

the last 8 years

Include trade names and

doing business as names

 I have not used any business names or EINs.

_________________________________________________ 

Business name

_________________________________________________ 

Business name 

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN 

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN 

 I have not used any business names or EINs.

_________________________________________________ 

Business name

_________________________________________________ 

Business name 

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN 

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN 

5. Where you live

_________________________________________________ 

Number Street 

_________________________________________________ 

_________________________________________________ 

City State ZIP Code 

_________________________________________________ 

County 

If your mailing address is different from the one 

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

any notices to you at this mailing address.

_________________________________________________ 

Number Street 

_________________________________________________ 

P.O. Box 

_________________________________________________ 

City State ZIP Code 

If Debtor 2 lives at a different address: 

_________________________________________________ 

Number Street 

_________________________________________________ 

_________________________________________________ 

City State ZIP Code

_________________________________________________ 

County 

If Debtor 2’s mailing address is different from 

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

any notices to this mailing address.

_________________________________________________ 

Number Street 

_________________________________________________ 

P.O. Box 

_________________________________________________ 

City State ZIP Code

6. Why you are choosing

this district to file for

bankruptcy

Check one: 

 Over the last 180 days before filing this petition,

I have lived in this district longer than in any

other district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

________________________________________

________________________________________

________________________________________

________________________________________

Check one: 

 Over the last 180 days before filing this petition,

I have lived in this district longer than in any

other district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

________________________________________

________________________________________

________________________________________

________________________________________

Jeremy Benjamin Gillum ✔

277 N. Ashland Ave Palatine IL 60074 ✔

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

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

Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the

Bankruptcy Code you

are choosing to file

under

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

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

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

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

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

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

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

with a pre-printed address. 

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

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

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

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

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

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

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

9. Have you filed for

bankruptcy within the

last 8 years?

 No

 Yes. District __________________________ When _______________ Case number ___________________________

MM / DD / YYYY

District __________________________ When _______________ Case number ___________________________

MM / DD / YYYY

District __________________________ When _______________ Case number ___________________________ 

MM / DD / YYYY

10. Are any bankruptcy

cases pending or being

filed by a spouse who is

not filing this case with

you, or by a business

partner, or by an

affiliate?

 No

 Yes. Debtor _________________________________________________ Relationship to you _____________________

District __________________________ When _______________ Case number, if known____________________ 

MM / DD / YYYY

 Debtor _________________________________________________ Relationship to you _____________________ 

District __________________________ When _______________ Case number, if known____________________

MM / DD / YYYY

11. Do you rent your

residence?

 No. Go to line 12.

 Yes. Has your landlord obtained an eviction judgment against you and do you want to stay in your

residence?

 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.

Jeremy Benjamin Gillum ✔

✔

✔

✔

✔

✔

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

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

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

12. Are you a sole proprietor

of any full- or part-time

business?

A sole proprietorship is a

business you operate as an

individual, and is not a

separate legal entity such as

a corporation, partnership, or

LLC.

If you have more than one

sole proprietorship, use a

separate sheet and attach it

to this petition.

 No. Go to Part 4.

 Yes. Name and location of business

_______________________________________________________________________________________ 

Name of business, if any 

_______________________________________________________________________________________ 

Number Street 

_______________________________________________________________________________________ 

_______________________________________________ _______ __________________________ 

City State ZIP Code

Check the appropriate box to describe your business: 

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

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

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

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

 None of the above

13. Are you filing under

Chapter 11 of the

Bankruptcy Code and

are you a small business

debtor?

For a definition of small

business debtor, see

11 U.S.C. § 101(51D).

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

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

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

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

 No. I am not filing under Chapter 11.

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

the Bankruptcy Code. 

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

Bankruptcy Code. 

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

14. Do you own or have any

property that poses or is

alleged to pose a threat

of imminent and

identifiable hazard to

public health or safety?

Or do you own any

property that needs

immediate attention?

For example, do you own

perishable goods, or livestock

that must be fed, or a building

that needs urgent repairs?

 No

 Yes. What is the hazard? ________________________________________________________________________

________________________________________________________________________

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

________________________________________________________________________ 

Where is the property? ________________________________________________________________________ 

Number Street

________________________________________________________________________

________________________________________ _______ ____________________ 

City State ZIP Code 

Jeremy Benjamin Gillum ✔

✔

✔

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

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

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

15. Tell the court whether

you have received a

briefing about credit

counseling.

The law requires that you 

receive a briefing about credit 

counseling before you file for 

bankruptcy. You must 

truthfully check one of the 

following choices. If you 

cannot do so, you are not 

eligible to file. 

If you file anyway, the court 

can dismiss your case, you 

will lose whatever filing fee 

you paid, and your creditors 

can begin collection activities 

again. 

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

You must check one: 

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

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

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

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

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so. 

 Active duty. I am currently on active military

duty in a military combat zone. 

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court. 

You must check one: 

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

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

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

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

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so. 

 Active duty. I am currently on active military

duty in a military combat zone. 

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

Jeremy Benjamin Gillum ✔

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

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

For your attorney, if you are 

represented by one 

If you are not represented 

by an attorney, you do not 

need to file this page. 

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

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

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

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

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

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

_________________________________________________________________________________________________ 

Printed name 

_________________________________________________________________________________________________ 

Firm name 

_________________________________________________________________________________________________ 

Number Street 

_________________________________________________________________________________________________ 

______________________________________________________ ____________ ______________________________ 

City State ZIP Code

Contact phone _____________________________________ Email address ______________________________ 

______________________________________________________ ____________ 

Bar number State 

Jeremy Benjamin Gillum Arthur P. Sanderman 2118 Plum Grove Rd., #120 Rolling Meadows IL 60008 (847) 991-6092 apslaw@aim.com 6183897 IL

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Certificate Number: 17572-ILN-CC-027852911

17572-ILN-CC-027852911

CERTIFICATE OF COUNSELING

I CERTIFY that on August 3, 2016, at 11:13 o'clock AM PDT, Jeremy B Gillum

received from Dollar Learning Foundation, Inc., an agency approved pursuant to

11 U.S.C. § 111 to provide credit counseling in the Northern District of Illinois,

an individual [or group] briefing that complied with the provisions of 11 U.S.C.

§§ 109(h) and 111.

A debt repayment plan was not prepared. If a debt repayment plan was prepared, a

copy of the debt repayment plan is attached to this certificate.

This counseling session was conducted by internet.

Date: August 3, 2016 By: /s/Leigh-Anna M Thompson

Name: Leigh-Anna M Thompson

Title: Counselor

* Individuals who wish to file a bankruptcy case under title 11 of the United States Bankruptcy

Code are required to file with the United States Bankruptcy Court a completed certificate of

counseling from the nonprofit budget and credit counseling agency that provided the individual

the counseling services and a copy of the debt repayment plan, if any, developed through the

credit counseling agency. See 11 U.S.C. §§ 109(h) and 521(b).

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Personalized Action Plan

Prepared for: Gillum, Jeremy B

Root Cause Analysis

Divorce 

Poor Financial Management 

Death in the Family 

Unemployment 

Overspending 

Additional Notes:

A lot of the trouble that I'm in is due to the death of my wife in 03/15. She was the principle breadwinner in our family and I've been struggling ever since.

There were other factors, too, like poor financial planning and overspending, but the most significant problem I've had has been her death.

Budget Analysis

Budget Categories in Need of Improvement

Category Counseled % Current Budget Monthly Budget Guideline Difference

Savings 5% 0.00 0.00 0.00

Healthy Budget Categories

Category Counseled % Current Budget Monthly Budget Guideline Difference

Housing 31% 1275.00 0.00 ‐1275.00

Utilities 7% 273.00 0.00 ‐273.00

Food 13% 200.00 0.00 ‐200.00

Transportation 10% 35.00 0.00 ‐35.00

Clothing 3% 0.00 0.00 0.00

MedicalHealth 7% 0.00 0.00 0.00

Personal 6% 40.00 0.00 ‐40.00

Recreation 5% 20.00 0.00 ‐20.00

Miscellaneous 3% 225.00 0.00 ‐225.00

UnsecuredDebt 10% 450.00 0.00 ‐450.00

Financial Analysis

Your Net Worth

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Assets Liabilities

$195 ‐$74,000 =

($73,805)

Networth

Compare your Options

Based upon our analysis of your income, assets and credit profile, we recommend you consider one of the following options to assist you in eliminating

your debt.

On Your Own Debt Management Debt Settlement Bankruptcy

How does

it work?

Work directly with each creditor to

create a modification plan for

repayment.  Creditors may choose to

lower interest rates, eliminate late

fees or settle the debt for less than

the balance.

One consolidated monthly payment

made to Debt Management Agency to

reduce interest rates and fees

You default on your debt,

while sending monthly

payments to a settlement

firm that negotiates

settlements of less than the

original balances

Legal procedure which

eliminates your unsecured

debt

Estimated

Monthly

Payment

May be reduced May be reduced May be reduced N/A

Years to

Pay Off

Up to 20 years, when making only the

minimum payments 3‐5 years 3‐5 years

Chapter 7:  May help

eliminate most unsecured

debts                                    

Chapter 13:  5 year

payment plan

Average

Fees N/A

Varies by state and agency typically 25‐

50 set up fee and $5 per creditor per

month

$1500 ‐ $2000 plus (15% of

total debt) $1,500

Pros

Since you are doing this on your own,

you won’t have to pay any fees to a

third party provider.  You may be able

to preserve your credit rating. You will

have to create a monthly budget and

religiously stick to it.

Creditors may offer a reduction in

interest rate and elimination of late or

over limit fees. Collection calls will

likely stop. Minimal impact to your

credit score and if you manage to make

on time payments, your credit may

improve overtime.

If a settlement is negotiated

and accepted, you will pay

much less than you initially

owed on the account.

Creditors may not contact

you after filing for

bankruptcy

Cons

Calling your creditors one by one can

be very time consuming.  Some

creditors may be very strict and

unwilling to negotiate.  Your interest

rates could go up if payments are not

on time; you may be tempted to use

the credit you’ve made available by

paying off debt

You may need to pay a fee and, most of

the times, the fees are paid up front.

Arrangement is informal and creditors

may change benefits at any time.

Although interests will be reduced, they

will still be charged and will continue to

add to your total debt.

You may owe taxes on the

forgiven amount; you can be

sued by your creditors during

the process.  Your credit

standing and your credit

score will be severely

damaged for quite a while.

You might have a hard time

getting new credit after

filing for bankruptcy.

Effect on

Credit

Credit may be positively affected by

consistent, on‐time payments and

reduction in debt

Credit may be positively affected by

consistent, on‐time payments and

reduction in debt

Will have a negative effect

on your credit

Not all of your debts will be

discharged.

Additional Recommendations, Resources and Options Provided by your Counselor

Your unsecured debt expenses are over the recommended percentage for your budget. You may want to consider to stop borrowing money and using your

credit cards so that this expense does not continue to grow. You should only spend the money you have after all of your bills are paid. Your unsecured debt

expenses are over the recommended percentage for your budget. You may want to consider to stop borrowing money and using your credit cards so that

this expense does not continue to grow. You should only spend the money you have after all of your bills are paid. A debt management plan may be of

benefit to you. This is a debt relief option where a credit counseling agency works with your creditors to come up with a more suitable monthly payment for

your situation. An agreement is come to with your creditors to pay them a set amount of money each month over a certain period of time, usually 3‐5 years.

A debt management plan is administered by third party providers and can only be used to pay off unsecured debt. The National Foundation for Credit

Counseling (NFCC.org) and The Financial Counseling Association of America (FCAA.org) are the two largest organizations representing non‐profit consumer

counseling services across the country. You may visit their websites to be referred to one of their approved agencies. One option is to work directly with

your creditors. A Consumer Workout is where you negotiate directly with your creditors to create a modification plan for repayment and retain a positive

relationship with them. Creditors may also choose to accept and settle a debt if a reasonable proposal has been offered by the consumer. While the last

thing you probably want to do is talk with them, you may find that they are willing to work with you. Creditors will often listen to their client’s situation and

allow them to postpone a payment or two until their temporary financial hardship has been resolved. Since you are doing this on your own, you won’t have

to pay any fees to a third party provider.

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