Fill in this information to identify your case: 

United States Bankruptcy Court for the: 

Northern District of Illinois 

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

Official Form 101 

D Chapter? 

D Chapter11 

Q. Chapter 12 

li!1 Chapter 13 D Check if this is an 

amended filing 

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. 

f if M Identify Yourself 

1. Your full name 

2. 

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. 

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) 

Official Form 101 

About Debtor 1: · Ab~ut Debtor 2 (Spouse Only in a Joint Case): 

AQUITA 

First name First name 

s. 

Middle name Middle name 

DAVIS 

Last name Last name 

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

First name First name 

Middle name Middle name 

Last name Last name 

First name First name 

Middle name Middle name 

Last name Last name 

XXX XX - _8 ___ 8_ _i_ _2_ XXX XX ---_____ _ 

OR OR 

9xx - xx 9xx - xx 

Voluntary Petition for Individuals Filing for Bankruptcy page 1 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 1 of 72
Debtor 1 AQUITA S. DAVIS Case number (if known), _____________ _ 

First Name Middle Name Last Name 

Abo~t Debt<>r·1: Ab~~t Debtor 2 (Spouse Only In a Joi11tCas,!}: 

4. Any business names ~ I have not used any business names or EINs. Cl I have not used any business names or EINs. and Employer 

Identification Numbers 

{EIN) you have used in 

the last 8 years Business name Business name 

Include trade names and 

doing business as names Business name Business name 

--EIN 

- ------- EIN- - -------

- - EIN- ------- EIN- -------

5. Where you live If Debtor 2 lives at a different address: 

604 N. LARAMIE 

Number Street Number Street 

APT.2 

CHICAGO IL 60644 

City State ZIP Code City State ZIP Code 

COOK 

County County 

If your mailing address is different from the one If Debtor 2's mailing address is different from 

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

any notices to you at this mailing address. any notices to this mailing address. 

Number Street Number Street 

P.O. Box P.O. Box 

City State ZIP Code City State ZIP Code 

6. Why you are choosing Check one: Check one: 

this district to file for ~ Over the last 180 days before filing this petition, Cl Over the last 180 days before filing this petition, bankruptcy I have lived in this district longer than in any I have lived in this district longer than in any 

other district. other district. 

D I have another reason. Explain. D I have another reason. Explain. 

(See 28 U.S.C. § 1408.) (See 28 U.S.C. § 1408.) 

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page2 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 2 of 72
Debtor 1 AQUITA S. DAVIS Case number(itknown). ____________ _ First Name Middle Name Last Name 

•Mil Tell the Court About Your Bankruptcy Case 

' 1. 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. 

CJ Chapter7 

CJ Chapter 11 

0 Chapter 12 

liZI Chapter 13 

s. How you will pay the fee O 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. 

9. Have you filed for 

bankruptcy within the 

last 8 years? 

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? 

11. Do you rent your 

residence? 

Official Form 101 

liZI 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). 

CJ 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 1038) and file it with your petition. 

CJ No 

liZI Yes. District ND IL EASTERN DIV When 06/26/2015 Case number 15-22116 

MM/ DD/YYYY 

District ND IL EASTERN DIV When 08/22/2013 Case number 13-33456 

MM/ DD/YYYY 

District When Case number 

MM/ DD/YYYY 

!;a No 

CJ 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 

0 No. Go to line 12. 

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

residence? 

~ No. Go to line 12. 

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

this bankruptcy petition. 

Voluntary Petition for Individuals Filing for Bankruptcy page 3 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 3 of 72
Debtor1 AQUITA S. DAVIS Case number (it known) _____________ _ 

First Name Middle Name Last Name 

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. 

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 (51 D). 

~ No. Go to Part 4. 

D Yes. Name and location of business 

Name of business, if any 

Number Street 

City 

Check the appropriate box to describe your business: 

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

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

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

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

D None of the above 

ZIP Code 

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. 

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

the Bankruptcy Code. 

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

Bankruptcy Code. 

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? 

Official Form 101 

~No 

D Yes. What is the hazard? 

If immediate attention is needed, why is it needed? _________________ _ 

Where is the property? ----------------------------

Number Street 

City State ZIP Code 

Voluntary Petition for Individuals Filing for Bankruptcy page4 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 4 of 72
Debtor 1 AQUITA S. DAVIS Case number(ifknownJ, _____________ _ 

First Name Middle Name Last Name 

Explain Your Efforts to Receive a Briefing About Credit Counseling 

1s. 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. 

Official Form 101 

.Ab put ~btor 1: 

You must check one: 

Ga" 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. 

1:1 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. 

D 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. 

1:1 I am not required to receive a briefing about 

credit counseling because of: 

D Incapacity. I have a mental illness or a mental 

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

1:1 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. 

1:1 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. 

About DEtbtpr 2 (~po use Only In a: Jc>,int Ca,!e): 

You must check one: 

D 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. 

D 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. 

1:11 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. 

D I am not required to receive a briefing about 

credit counseling because of: 

D Incapacity. I have a mental illness or a mental 

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

1:1 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. 

D 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. 

Voluntary Petition for Individuals Filing for Bankruptcy page 5 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 5 of 72
Debtor 1 Case number (ii known>'--------------

Answer These Questions for Reporting Purposes 

1&. What kind of debts do 

you have? 

· 11. 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? 

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." 

D 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 investme.nt. 

~ No. Go to line 16c. 

D Yes. Go to line 17. 

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

r.;a No. I am not filing under Chapter 7. Go to line 18. 

D 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? 

D No 

D Yes 

'-----------------------------·-------------------·--··,,--. 

: 1s. How many creditors do 

· you estimate that you 

owe? 

: 19. How much do you 

' estimate your assets to 

be worth? 

i 20. How much do you 

· estimate your liabilities 

to be? 

l@fi Sign Below 

l f.'or you 

Official Form 101 

!;ti 1-49 

D 50-99 

D 100-199 

D 200-999 

!;ti $0-$50, 000 

D $50,001-$100,000 

D $100,001-$500.000 

D $500,001-$1 million 

!;ti $0-$50, 000 

D $50,001-$100,000 

D $100,001-$500,000 

D $500,001-$1 million 

D 1,000-5,ooo 

D 5,001-10,000 

D 10,001-25,000 

D $1,000,001-$10 million 

D $10,000,001-$50 million 

D $50,000,001-$100 million 

D $100,000,001-$500 million 

D $1,000,001-$10 million 

D $10,000,001-$50 million 

D $50,000,001-$100 million 

D $100,000,001-$500 million 

D 25,001-50,000 

D 50,001-100.000 

D More than 100,000 

D $500,000,001-$1 billion 

D $1,000,000,001-$10 billion 

D $10,000,000,001-$50 billion 

D More than $50 billion 

D $500,000,001-$1 billion 

D $1,000,000,001-$10 billion 

D $10,000,000,001-$50 billion 

D More than $50 billion 

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. 

X Q~i...lk C....::b- X ____ _ Signature if Debtor 1 Signature of Debtor 2 

Executed on / / 5 &01 l{) 

MM / DD /YYYY 

Executed on ".":':'::-:-::-::-----

MM / DD /YYYY 

Voluntary Petition for Individuals Filing for Bankruptcy page6 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 6 of 72
Debtor 1 AQUITA S. DAVIS Case number (itknownJ, _____________ _ 

First Name Middle Name 

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. 

Official Form 101 

Last Name 

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.fC. § 342(b) and, in a case in which§ 707(b)(4)(D) applies, certify that I have no 

knowledge after an inquirylhat the .(nformation in the schedules filed with the petition is incorrect. 

~: .,/· 

X Date 

MM DD /YYYY 

JOHN HADERLEIN, ESQ. 

Firm name 

815-C COUNTRY CLUB DRIVE 

Number Street 

..;;;;L=IBc.c:E=R..:.,;TYV;__;;__;;..c.:IL=L=E:...._ __________ ...;.;;;IL'--__ ...::6.,;:.0.c:..04..:.,;8:...._ _____ _ City State ZIP Code 

Contact phone (312) 316-4614 Email address john@bklaw1 .com 

6197623 IL 

Bar number State 

Voluntary Petition for Individuals Filing for Bankruptcy page 7 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 7 of 72
Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2 

2IILFLDO)RUP 106Sum 

Summary of Your Assets and Liabilities and Certain Statistical Information 12/15

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

information. Fill out all of your schedules first; then complete the information on this form. If you are filing amended schedules after you file 

your original forms, you must fill out a new Summary and check the box at the top of this page. 

Part 1: Summarize Your Assets 

Your assets

Value of what you own 

1. Schedule A/B: Property (Official Form 106A/B)

1a. Copy line 55, Total real estate, from Schedule A/B .......................................................................................................... $ ________________

 1b. Copy line 62, Total personal property, from Schedule A/B ............................................................................................... $ ________________

 1c. Copy line 63, Total of all property on Schedule A/B ......................................................................................................... $ ________________

Part 2: Summarize Your Liabilities 

Your liabilities 

Amount you owe

2. Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D)

2a. Copy the total you listed in Column A, Amount of claim, at the bottom of the last page of Part 1 of Schedule D ............ $ ________________

3. Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F)

3a. Copy the total claims from Part 1 (priority unsecured claims) from line 6e of Schedule E/F ............................................ $ ________________

 3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F ....................................... + $ ________________

Your total liabilities $ ________________

Part 3: Summarize Your Income and Expenses 

4. Schedule I: Your Income (Official Form 106I)

Copy your combined monthly income from line 12 of Schedule I .......................................................................................... $ ________________

5. Schedule J: Your Expenses (Official Form 106J)

Copy your monthly expenses from line 22c of Schedule J .................................................................................................... $ ________________

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 __________

Case number ___________________________________________ 

(If known)

Fill in this information to identify your case: 

 Check if this is an

amended filing

AQUITA S. DAVIS

Northern District of Illinois

0.00

23,600.00

23,600.00

15,200.00

0.00

118,735.00

133,935.00

3,199.92

2,964.00

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 8 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

 Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 2 of 2 

Part 4: Answer These Questions for Administrative and Statistical Records

6. Are you filing for bankruptcy under Chapters 7, 11, or 13?

 No. You have nothing to report on this part of the form. Check this box and submit this form to the court with your other schedules.

 Yes

7. What kind of debt do you have?

 Your debts are primarily consumer debts. Consumer debts are those “incurred by an individual primarily for a personal,

family, or household purpose.” 11 U.S.C. § 101(8). Fill out lines 8-9g for statistical purposes. 28 U.S.C. § 159.

 Your debts are not primarily consumer debts. You have nothing to report on this part of the form. Check this box and submit

this form to the court with your other schedules.

8. From the Statement of Your Current Monthly Income: Copy your total current monthly income from Official

Form 122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14. $ _________________ 

9. Copy the following special categories of claims from Part 4, line 6 of Schedule E/F:

Total claim

From Part 4 on Schedule E/F, copy the following: 

9a. Domestic support obligations (Copy line 6a.) $_____________________

9b. Taxes and certain other debts you owe the government. (Copy line 6b.) $_____________________

9c. Claims for death or personal injury while you were intoxicated. (Copy line 6c.) $_____________________

9d. Student loans. (Copy line 6f.) $_____________________ 

9e. Obligations arising out of a separation agreement or divorce that you did not report as 

priority claims. (Copy line 6g.) $_____________________ 

9f. Debts to pension or profit-sharing plans, and other similar debts. (Copy line 6h.) + $_____________________

9g. Total. Add lines 9a through 9f. $_____________________ 

AQUITA S. DAVIS

✔

✔

3,840.97

0.00

0.00

0.00

75,000.00

0.00

0.00

75,000.00

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 9 of 72
Official Form 106A/B Schedule A/B: Property page 1

2IILFLDO)RUP 106A/B 

Schedule A/B: Property 12/15

In each category, separately list and describe items. List an asset only once. If an asset fits in more than one category, list the asset in the 

category where you think it fits best. 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: Describe Each Residence, Building, Land, or Other Real Estate You Own or Have an Interest In

1. Do you own or have any legal or equitable interest in any residence, building, land, or similar property?

 No. Go to Part 2.

 Yes. Where is the property?

1.1. _________________________________________ 

Street address, if available, or other description 

_________________________________________ 

_________________________________________ 

City State ZIP Code 

_________________________________________ 

County

What is the property? Check all that apply.

 Single-family home

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$_______________ 

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

the entireties, or a life estate), if known. 

Who has an interest in the property? Check one.

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

__________________________________________

 Check if this is community property

(see instructions)

Other information you wish to add about this item, such as local 

property identification number: _______________________________

If you own or have more than one, list here: 

1.2. ________________________________________ 

Street address, if available, or other description 

________________________________________ 

________________________________________ 

City State ZIP Code 

________________________________________ 

County

What is the property? Check all that apply.

 Single-family home

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$_________________

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

the entireties, or a life estate), if known. 

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

__________________________________________

 Check if this is community property

(see instructions)

Other information you wish to add about this item, such as local 

property identification number: _______________________________

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 ___________

Case number ___________________________________________ 

Fill in this information to identify your case and this filing: 

 Check if this is an

amended filing

AQUITA S. DAVIS

Northern District of Illinois

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 10 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 2

1.3. ________________________________________ 

Street address, if available, or other description 

________________________________________ 

________________________________________ 

City State ZIP Code 

________________________________________ 

County

What is the property? Check all that apply.

 Single-family home

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$_________________

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

the entireties, or a life estate), if known. 

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

__________________________________________

 Check if this is community property

(see instructions)

Other information you wish to add about this item, such as local 

property identification number: _______________________________

2. Add the dollar value of the portion you own for all of your entries from Part 1, including any entries for pages

you have attached for Part 1. Write that number here. ...................................................................................... Î $_________________

Part 2: Describe Your Vehicles 

Do you own, lease, or have legal or equitable interest in any vehicles, whether they are registered or not? Include any vehicles 

you own that someone else drives. If you lease a vehicle, also report it on Schedule G: Executory Contracts and Unexpired Leases.

3. Cars, vans, trucks, tractors, sport utility vehicles, motorcycles

 No

 Yes

3.1. Make: ______________ 

Model: ______________ 

Year: ____________

Approximate mileage: ____________ 

Other information: 

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________

If you own or have more than one, describe here: 

3.2. Make: ______________ 

Model: ______________

Year: ____________

Approximate mileage: ____________ 

Other information: 

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________

AQUITA S. DAVIS

✔

Chevrolet

Malibu ✔

15200

60000

Being surrendered in plan

15,200.00 0.00

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 11 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 3

3.3. Make: ______________ 

Model: ______________

Year: ____________

Approximate mileage: ____________ 

Other information: 

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________

3.4. Make: ______________ 

Model: ______________

Year: ____________

Approximate mileage: ____________ 

Other information: 

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________

4. Watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories

Examples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle accessories

 No

 Yes

4.1. Make: ____________________ 

Model: ____________________ 

Year: ____________ 

Other information: 

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________

If you own or have more than one, list here: 

4.2. Make: ____________________ 

Model: ____________________ 

Year: ____________ 

Other information:

Who has an interest in the property? Check one. 

Debtor 1 only 

Debtor 2 only 

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property? 

$________________

Current value of the 

portion you own?

$________________

5. Add the dollar value of the portion you own for all of your entries from Part 2, including any entries for pages

you have attached for Part 2. Write that number here ........................................................................................................................ Î $_________________

AQUITA S. DAVIS

✔

0.00

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 12 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 4

Part 3: Describe Your Personal and Household Items 

Do you own or have any legal or equitable interest in any of the following items? Current value of the 

portion you own? 

Do not deduct secured claims 

or exemptions. 

6. Household goods and furnishings

Examples: Major appliances, furniture, linens, china, kitchenware

 No

 Yes. Describe. ........ $___________________

7. Electronics

Examples: Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music

collections; electronic devices including cell phones, cameras, media players, games 

 No

 Yes. Describe. ......... $___________________

8. Collectibles of value

Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects;

stamp, coin, or baseball card collections; other collections, memorabilia, collectibles 

 No

 Yes. Describe. ......... $___________________

9. Equipment for sports and hobbies

Examples: Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes

and kayaks; carpentry tools; musical instruments 

 No

 Yes. Describe. ......... $___________________

10.Firearms

Examples: Pistols, rifles, shotguns, ammunition, and related equipment

 No

 Yes. Describe. .......... $___________________

11.Clothes

Examples: Everyday clothes, furs, leather coats, designer wear, shoes, accessories

 No

 Yes. Describe. .......... $___________________

12.Jewelry

Examples: Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems,

gold, silver

 No

 Yes. Describe. .......... $___________________

13.Non-farm animals

Examples: Dogs, cats, birds, horses

 No

 Yes. Describe. .......... $___________________

14.Any other personal and household items you did not already list, including any health aids you did not list

 No

 Yes. Give specific

information. .............. $___________________

15. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached

for Part 3. Write that number here .................................................................................................................................................... Î $______________________ 

AQUITA S. DAVIS

✔ FURNITURE 1,000.00

✔ TV 500.00

✔

✔

✔

✔ CLOTHES 1,000.00

✔

✔

✔

2,500.00

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 13 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 5

Part 4: Describe Your Financial Assets

Do you own or have any legal or equitable interest in any of the following? Current value of the 

portion you own? 

Do not deduct secured claims 

or exemptions.

16.Cash

Examples: Money you have in your wallet, in your home, in a safe deposit box, and on hand when you file your petition

 No

 Yes ................................................................................................................................................................ Cash: ....................... $__________________

17.Deposits of money

Examples: Checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerage houses,

and other similar institutions. If you have multiple accounts with the same institution, list each. 

 No

 Yes ..................... Institution name:

17.1. Checking account: _________________________________________________________ 

17.2. Checking account: _________________________________________________________ 

17.3. Savings account: _________________________________________________________ 

17.4. Savings account: _________________________________________________________ 

17.5. Certificates of deposit: _________________________________________________________ 

17.6. Other financial account: _________________________________________________________ 

17.7. Other financial account: _________________________________________________________ 

17.8. Other financial account: _________________________________________________________ 

17.9. Other financial account: _________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

18.Bonds, mutual funds, or publicly traded stocks

Examples: Bond funds, investment accounts with brokerage firms, money market accounts

 No

 Yes ................. Institution or issuer name: 

_________________________________________________________________________________________ 

_________________________________________________________________________________________ 

_________________________________________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

19. Non-publicly traded stock and interests in incorporated and unincorporated businesses, including an interest in

an LLC, partnership, and joint venture

 No

Yes. Give specific

information about

them.........................

Name of entity: % of ownership: 

_____________________________________________________________________ ___________% 

_____________________________________________________________________ ___________% 

_____________________________________________________________________ ___________% 

$__________________ 

$__________________ 

$__________________ 

AQUITA S. DAVIS

✔ 100.00

✔

Checking 1,000.00

✔

✔

0%

0%

0%

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 14 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 6

20. Government and corporate bonds and other negotiable and non-negotiable instruments

Negotiable instruments include personal checks, cashiers’ checks, promissory notes, and money orders.

Non-negotiable instruments are those you cannot transfer to someone by signing or delivering them.

 No

Yes. Give specific

information about 

them.......................

Issuer name: 

______________________________________________________________________________________ 

______________________________________________________________________________________ 

______________________________________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

21. Retirement or pension accounts

Examples: Interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sharing plans

 No

 Yes. List each

account separately. Type of account: Institution name: 

401(k) or similar plan: ___________________________________________________________________ 

Pension plan: ___________________________________________________________________ 

IRA: ___________________________________________________________________ 

Retirement account: ___________________________________________________________________ 

Keogh: ___________________________________________________________________ 

Additional account: ___________________________________________________________________ 

Additional account: ___________________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

22.Security deposits and prepayments

Your share of all unused deposits you have made so that you may continue service or use from a company

Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications

companies, or others

 No

 Yes .......................... Institution name or individual: 

Electric: ______________________________________________________________________ 

Gas: ______________________________________________________________________ 

Heating oil: ______________________________________________________________________ 

Security deposit on rental unit: _____________________________________________________________ 

Prepaid rent: ______________________________________________________________________ 

Telephone: ______________________________________________________________________ 

Water: ______________________________________________________________________ 

Rented furniture: ______________________________________________________________________ 

Other: ______________________________________________________________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________

23.Annuities (A contract for a periodic payment of money to you, either for life or for a number of years)

 No

 Yes .......................... Issuer name and description: 

 _______________________________________________________________________________________ 

_______________________________________________________________________________________ 

_______________________________________________________________________________________ 

$__________________ 

$__________________ 

$__________________ 

AQUITA S. DAVIS

✔

✔

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 15 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 7

24. Interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program.

26 U.S.C. §§ 530(b)(1), 529A(b), and 529(b)(1).

 No

 Yes .................................... Institution name and description. Separately file the records of any interests.11 U.S.C. § 521(c):

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

 $_________________ 

$_________________ 

$_________________ 

25.Trusts, equitable or future interests in property (other than anything listed in line 1), and rights or powers

exercisable for your benefit

 No

 Yes. Give specific

information about them. ... $__________________ 

26. Patents, copyrights, trademarks, trade secrets, and other intellectual property

Examples: Internet domain names, websites, proceeds from royalties and licensing agreements

 No

 Yes. Give specific

information about them. ... $__________________ 

27. Licenses, franchises, and other general intangibles

Examples: Building permits, exclusive licenses, cooperative association holdings, liquor licenses, professional licenses

 No

 Yes. Give specific

information about them. ... $__________________

Money or property owed to you? Current value of the 

portion you own? 

Do not deduct secured 

claims or exemptions.

28.Tax refunds owed to you

 No

 Yes. Give specific information

about them, including whether 

you already filed the returns 

and the tax years. ....................... 

Federal: $_________________

State: $_________________

Local: $_________________

29. Family support

Examples: Past due or lump sum alimony, spousal support, child support, maintenance, divorce settlement, property settlement

 No

 Yes. Give specific information. ............. 

Alimony:

Maintenance: 

Support:

Divorce settlement: 

Property settlement: 

$________________ 

$________________ 

$________________ 

$________________ 

$________________

30. Other amounts someone owes you

Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compensation,

Social Security benefits; unpaid loans you made to someone else 

 No

 Yes. Give specific information. .............. 

$______________________

AQUITA S. DAVIS

✔

✔

✔

✔

✔

✔ Unpaid child support

20,000.00

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 16 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 8

31. Interests in insurance policies

Examples: Health, disability, or life insurance; health savings account (HSA); credit, homeowner’s, or renter’s insurance

 No

 Yes. Name the insurance company

of each policy and list its value. ... Company name: Beneficiary: 

___________________________________________ ____________________________ 

___________________________________________ ____________________________ 

___________________________________________ ____________________________ 

Surrender or refund value: 

$__________________ 

$__________________ 

$__________________

32. Any interest in property that is due you from someone who has died

If you are the beneficiary of a living trust, expect proceeds from a life insurance policy, or are currently entitled to receive

property because someone has died.

 No

 Yes. Give specific information. ............. 

$_____________________ 

33. Claims against third parties, whether or not you have filed a lawsuit or made a demand for payment

Examples: Accidents, employment disputes, insurance claims, or rights to sue

 No

 Yes. Describe each claim. .................... 

$______________________

34.Other contingent and unliquidated claims of every nature, including counterclaims of the debtor and rights

to set off claims

 No

 Yes. Describe each claim. .................... 

$_____________________ 

35.Any financial assets you did not already list

 No

 Yes. Give specific information............ $_____________________ 

36. Add the dollar value of all of your entries from Part 4, including any entries for pages you have attached

for Part 4. Write that number here .................................................................................................................................................... Î $_____________________ 

Part 5: Describe Any Business-Related Property You Own or Have an Interest In. List any real estate in Part 1. 

37.Do you own or have any legal or equitable interest in any business-related property?

 No. Go to Part 6.

 Yes. Go to line 38.

Current value of the 

portion you own? 

Do not deduct secured claims 

or exemptions.

38.Accounts receivable or commissions you already earned

 No

 Yes. Describe .......

$_____________________

39. Office equipment, furnishings, and supplies

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, electronic devices

 No

 Yes. Describe ....... $_____________________

AQUITA S. DAVIS

✔

✔

✔

✔

✔

21,100.00

✔

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 17 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 9

40.Machinery, fixtures, equipment, supplies you use in business, and tools of your trade

 No

 Yes. Describe ....... $_____________________

41. Inventory

 No

 Yes. Describe ....... $_____________________

42. Interests in partnerships or joint ventures

 No

 Yes. Describe ....... Name of entity: % of ownership: 

 ______________________________________________________________________ ________% 

 ______________________________________________________________________ ________% 

 ______________________________________________________________________ ________%

$_____________________

$_____________________

$_____________________

43.Customer lists, mailing lists, or other compilations

 No

 Yes. Do your lists include personally identifiable information (as defined in 11 U.S.C. § 101(41A))?

 No

 Yes. Describe. ....... 

$____________________

44.Any business-related property you did not already list

 No

 Yes. Give specific

information ......... ______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

45. Add the dollar value of all of your entries from Part 5, including any entries for pages you have attached

for Part 5. Write that number here .................................................................................................................................................... Î $____________________

Part 6: Describe Any Farm- and Commercial Fishing-Related Property You Own or Have an Interest In.

If you own or have an interest in farmland, list it in Part 1.

46.Do you own or have any legal or equitable interest in any farm- or commercial fishing-related property?

 No. Go to Part 7.

 Yes. Go to line 47.

  Current value of the 

portion you own? 

Do not deduct secured claims 

or exemptions.

47. Farm animals

Examples: Livestock, poultry, farm-raised fish

 No

 Yes ..........................

$___________________

AQUITA S. DAVIS

✔

✔

✔

✔

✔

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 18 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP$% Schedule A/B: Property page 10

48.Crops—either growing or harvested

 No

 Yes. Give specific

information. ............ $___________________

49.Farm and fishing equipment, implements, machinery, fixtures, and tools of trade

 No

 Yes .......................... 

$___________________

50.Farm and fishing supplies, chemicals, and feed

 No

 Yes .......................... 

$___________________

51.Any farm- and commercial fishing-related property you did not already list

 No

 Yes. Give specific

information. ............ $___________________

52. Add the dollar value of all of your entries from Part 6, including any entries for pages you have attached

for Part 6. Write that number here .................................................................................................................................................... Î $___________________

Part 7: Describe All Property You Own or Have an Interest in That You Did Not List Above 

53. Do you have other property of any kind you did not already list?

Examples: Season tickets, country club membership

 No

 Yes. Give specific

information. ............ 

$________________ 

$________________ 

$________________ 

54.Add the dollar value of all of your entries from Part 7. Write that number here ................................................................. Î $________________

Part 8: List the Totals of Each Part of this Form 

55.Part 1: Total real estate, line 2 ..............................................................................................................................................................Î $________________ 

56.Part 2: Total vehicles, line 5 $________________

57.Part 3: Total personal and household items, line 15 $________________

58.Part 4: Total financial assets, line 36 $________________

59.Part 5: Total business-related property, line 45 $________________

60.Part 6: Total farm- and fishing-related property, line 52 $________________

61.Part 7: Total other property not listed, line 54 + $________________

62.Total personal property. Add lines 56 through 61. .................... $________________ Copy personal property total Î + $_________________

63.Total of all property on Schedule A/B. Add line 55 + line 62. ......................................................................................... $_________________ 

AQUITA S. DAVIS

✔

✔

✔

✔

0.00

✔

0.00

0.00

0.00

2,500.00

21,100.00

0.00

0.00

0.00

23,600.00 23,600.00

23,600.00

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 19 of 72
Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __ 

2IILFLDO)RUP 106C 

Schedule C: The Property You Claim as Exempt 12/15

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

Using the property you listed on Schedule A/B: Property (Official Form 106A/B) as your source, list the property that you claim as exempt. If more 

space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On the top of any additional pages, write 

your name and case number (if known). 

For each item of property you claim as exempt, you must specify the amount of the exemption you claim. One way of doing so is to state a 

specific dollar amount as exempt. Alternatively, you may claim the full fair market value of the property being exempted up to the amount 

of any applicable statutory limit. Some exemptions—such as those for health aids, rights to receive certain benefits, and tax-exempt 

retirement funds—may be unlimited in dollar amount. However, if you claim an exemption of 100% of fair market value under a law that 

limits the exemption to a particular dollar amount and the value of the property is determined to exceed that amount, your exemption 

would be limited to the applicable statutory amount. 

Part 1: Identify the Property You Claim as Exempt

1. Which set of exemptions are you claiming? Check one only, even if your spouse is filing with you.

 You are claiming state and federal nonbankruptcy exemptions. 11 U.S.C. § 522(b)(3)

 You are claiming federal exemptions. 11 U.S.C. § 522(b)(2)

2. For any property you list on Schedule A/B that you claim as exempt, fill in the information below.

Brief description of the property and line on 

Schedule A/B that lists this property 

Current value of the 

portion you own 

Copy the value from 

Schedule A/B

Amount of the exemption you claim 

Check only one box for each exemption. 

Specific laws that allow exemption

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description: _________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ Line from 

Schedule A/B: ______ 

3. Are you claiming a homestead exemption of more than $155,675?

(Subject to adjustment on 4/01/16 and every 3 years after that for cases filed on or after the date of adjustment.)

 No

 Yes. Did you acquire the property covered by the exemption within 1,215 days before you filed this case?

 No

 Yes

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 __________

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

 Check if this is an

amended filing

AQUITA S. DAVIS

Northern District of Illinois

✔

2013 Chevy Malibu 0.00 ✔ 2,400.00 735 ILCS 5/12-1001(c)

3.1

FURNITURE 1,000.00 ✔ 1,000.00 735 ILCS 5/12-1001(b)

6

TV 500.00 ✔ 500.00 735 ILCS 5/12-1001(b)

7

✔

2

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 20 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP& Schedule C: The Property You Claim as Exempt page ___ of __

Part 2: Additional Page

Brief description of the property and line 

on Schedule A/B that lists this property 

Current value of the 

portion you own 

Copy the value from 

Schedule A/B

Amount of the exemption you claim 

Check only one box for each exemption

Specific laws that allow exemption

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief

description:

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

AQUITA S. DAVIS

CLOTHES 1,000.00 ✔ 1,000.00 735 ILCS 5/12-1001(b)

11

CASH 100.00 735 ILCS 5/12-1001(b) ✔ 100.00

16

CHECKING 1,000.00 ✔ 1,000.00 735 ILCS 5/12-1001(b)

17.1

2 2

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 21 of 72
2fficial Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___ 

2IILFLDO)RUP 106D 

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

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

information. If more space is needed, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any 

additional pages, write your name and case number (if known). 

1. Do any creditors have claims secured by your property?

 No. Check this box and submit this form to the court with your other schedules. You have nothing else to report on this form.

 Yes. Fill in all of the information below.

Part 1: List All Secured Claims 

2. List all secured claims. If a creditor has more than one secured claim, list the creditor separately

for each claim. If more than one creditor has a particular claim, list the other creditors in Part 2.

As much as possible, list the claims in alphabetical order according to the creditor’s name.

Column A 

Amount of claim

Do not deduct the 

value of collateral.

Column B 

Value of collateral 

that supports this 

claim

Column C 

Unsecured 

portion 

If any

2.1

______________________________________ 

Creditor’s Name 

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply. 

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

 Statutory lien (such as tax lien, mechanic’s lien) 

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

2.2

______________________________________ 

Creditor’s Name 

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply. 

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

 Statutory lien (such as tax lien, mechanic’s lien) 

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here: $________________

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 __________

Case number ___________________________________________ 

(If known)

Fill in this information to identify your case: 

 Check if this is an

amended filing

AQUITA S. DAVIS

Northern District of Illinois

✔

PRESTIGE FINANCIAL 10,000.00 10,000.00 0.00

1420 500 W. SALT LAKE CITY

SALT LAKE CITY UT 84115 ✔

✔ ✔

8842

3

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 22 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP' Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___ 

Part 1: 

Additional Page 

After listing any entries on this page, number them beginning with 2.3, followed 

by 2.4, and so forth.

Column A 

Amount of claim

Do not deduct the 

value of collateral.

Column B 

Value of collateral 

that supports this 

claim

Column C 

Unsecured 

portion 

If any

______________________________________ 

Creditor’s Name 

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply. 

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

 Statutory lien (such as tax lien, mechanic’s lien) 

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________ 

Creditor’s Name 

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply. 

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

 Statutory lien (such as tax lien, mechanic’s lien) 

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________ 

Creditor’s Name 

______________________________________ 

Number Street 

______________________________________ 

______________________________________ 

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

As of the date you file, the claim is: Check all that apply. 

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured 

car loan) 

 Statutory lien (such as tax lien, mechanic’s lien) 

 Judgment lien from a lawsuit 

 Other (including a right to offset) ____________________

Who owes the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here: $_________________ 

If this is the last page of your form, add the dollar value totals from all pages. 

Write that number here: $_________________ 

AQUITA S. DAVIS

2 3

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 23 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP' Part 2 of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___ 

Part 2: List Others to Be Notified for a Debt That You Already Listed 

Use this page only if you have others to be notified about your bankruptcy for a debt that you already listed in Part 1. For example, if a collection 

agency is trying to collect from you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection agency here. Similarly, if 

you have more than one creditor for any of the debts that you listed in Part 1, list the additional creditors here. If you do not have additional persons to 

be notified for any debts in Part 1, do not fill out or submit this page. 

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___ 

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

_____________________________________________________________________ 

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____ 

Last 4 digits of account number ___ ___ ___ ___ 

AQUITA S. DAVIS

2.1 PRESTIGE FINANCIAL SERVICES 2.1

8842

P.O. BOX 26707

SALT LAKE CITY UT 84126

3 3

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 24 of 72
Fill in this information to identify your case: 

Debtor1 AQUITA S. DAVIS First Name Middle Name 

Debtor2 

(Spouse, if filing) Firat Name Middle Name 

United States Bankruptcy Court for the: Northern District of Illinois 

Case number 

(If known) 

Official Form 106E/F 

Last Name 

Last Name 

Schedule E/F: Creditors Who Have Unsecured Claims 

D Check if this is an 

amended filing 

12/15 

Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY claims and Part 2 for creditors with NONPRIORITY claims. 

List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule 

AIB: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any 

creditors with partially secured claims that are listed in Schedule D: Creditors Who Have Claims Secured by Property. If more space is 

needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of 

any additional pages, write your name and case number (if known). 

List All of Your PRIORITY Unsecured Claims 

Do any creditors have priority unsecured claims against you? 

l;a No. Go to Part 2. 

Dves. 

2. List all of your priority unsecured claims/If a creditor has. more than one priority. unsecured. claim, list the creditor separately for each claim. For 

each claim listed, identify what type of claim it is .. ]fa claim has bqth priority J:iild nonpriority amounts Ji st t~at claim here and show bqth priority and 

nonpriority amounts. As much as possible, list the claims ih aJphabetical order according to th!:! creditor's name. lfyou have more. than tv.(o priority 

unsecured claims, fill out the Con~nuation Page of Part 1. If more than 011e.credito(holds a particular claim, list the other creditors in Part 3: 

(For an explanation of each type of cilaim, seethJ lnstructicinsfor'thisfoi:i:n in the instructirin booklet) 

EJ 1 --,---,-,~...,..,...------ Priority Creditor's Name 

Last 4 digits of account number _ _ _ _ $. _____ $ ____ $. ____ _ 

I 

I 

I 

2.2 

Number Street 

City State 

Who incurred the debt? Check one. 

D Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

ZIP Code 

D At least one of the debtors and another 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

D No 

D Yes 

Priority Creditor's Name 

Number Street 

City State 

Who incurred the debt? Check one. 

D Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

ZIP Code 

D At least one of the debtors and another 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

D No 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

Type of PRIORITY unsecured claim: 

D Domestic support obligations 

D Taxes and certain other debts you owe the government 

D Claims for death or personal injury while you were 

intoxicated 

D Other. Specify ____________ _ 

Last 4 digits of account number _ _ _ _ $ _____ $. ____ $ _____ 1 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

Type of PRIORITY unsecured claim: 

D Domestic support obligations 

D Taxes and certain other debts you owe the government 

D Claims for death or personal injury while you were 

intoxicated 

D Other. Specify ____________ _ 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of~ 

I 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 25 of 72
Debtor 1 AQUITA S. DAVIS Case number !it known) _______________ _ 

First Name Middle Name Last Name 

Your PRIORITY Unsecured Claims - Continuation Page 

After listing any entries on this page, number them beginning with 2.3, followed by 2.4, and so forth. 

I 

Priority Creditor's Name 

Number Street 

City State 

Who incurred the debt? Check one. 

D Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

ZIP Code 

D At least one of the debtors and another 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

D No 

D Yes 

Priority Creditor's Name 

Number Street 

City State 

Who incurred the debt? Check one. 

D Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

ZIP Code 

D At least one of the debtors and another 

D Check if this claim is for a community debt 

I

I Is the claim subject to offset? 

D No I D Yes 

p ______________ _ Priority Creditor's Name 

Number Street 

City State 

Who incurred the debt? Check one. 

D Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

ZIP Code 

D At least one of the debtors and another 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

D No 

D Yes 

Last 4 digits of account number ___ _ 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

Type of PRIORITY unsecured claim: 

D Domestic support obligations 

D Taxes and certain other debts you owe the government 

D Claims for death or personal injury while you were 

intoxicated 

D Other. Specify ____________ _ 

Last 4 digits of account number ___ _ 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

Type of PRIORITY unsecured claim: 

D Domestic support obligations 

D Taxes and certain other debts you owe the government 

D Claims for death or personal injury while you were 

intoxicated 

D Other. Specify ____________ _ 

Last 4 digits of account number ___ _ 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

Type of PRIORITY unsecured claim: 

D Domestic support obligations 

D Taxes and certain other debts you owe the government 

D Claims for death or personal injury while you were 

intoxicated 

D Other. Specify ____________ _ 

Official Form 106E/F Schedule Elf: Creditors Who Have Unsecured Claims 

$. _____ $ ___ _ $ _____ , 

$ _____ $ ___ _ $. _____ i 

$ _____ $ ___ _ $ ____ _ 

page2_of JJ 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 26 of 72
Debtor 1 AQUITAS. DAVIS Case number(itknowni _____________ _ 

First Name Middle Name Last Name 

List All of Your NONPRIORITY Unsecured Claims 

3. Do any creditors have nonpriority unsecured claims against you? 

D No. You have nothing to report in this part. Submit this form to the court with your other schedules. 

!;a Yes 

I

I 4. 

I 

List all of your nonpriority unsecured claims in the alphabetical order of the. creditor who holds each claim. If a creditor has more thar one 

nonpriority unsecured claim, list the creditor separately for each clai.m. For each claim listed, identify what type of claim it is. Do not list claims already 

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3Jf you have more than three nonpriority unsecured 

claims fill out the Continuation Page of Part 2. 

EJ CITY OF CHICAGO 

Nonpriority Creditor's Name 

121 N. LASALLE, ROOM 107A Number Street 

CHICAGO 

City 

Who incurred the debt? Check one. 

Ill Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

IL 

State 

1 D Check if this claim is for a community debt ! Is the claim subject to offset? 

I ~ ~:s ~ ILLINOIS TOLLWAY 

Nonpriority Creditor's Name 

2700 OGDEN AVE. Number Street 

DOWNERS GROVE IL 

City State 

Who incurred the debt? Check one. 

Ill Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

\ll No 

D Yes 

~ CreditOne 

Nonpriority Creditor's Name 

585 Pilot Road Number Street 

Las Vegas 

City 

Who incurred the debt? Check one. 

!;c1' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

NV 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

!;cJ' No 

D Yes 

60602 

ZIP Code 

60515 

ZIP Code 

89119 

ZIP Code 

Last 4 digits of account number J!.. J!.. _±_ ~ 

When was the debt incurred? 01/01/2014 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

!if' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

~ Other. specify PARKING TICKETS 

$ 16,000.00 -------

Last 4 digits of account number __.!!. __.!!. __! -1. $ ___ 1 ~·o_o_o_._o_o, 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

l:;:t Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

~ Other.Specify TOLLWAY FEES 

Last 4 digits of account number -8. _a _4 __2 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

~ Contingent 

D Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

~ Other. Specify CREDIT CARD 

$ ______ 685.00 _ 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page~of-lJ 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 27 of 72
Debtor1 AQUITA S. DAVIS Case number (ff known~-------------- First Name Middle Name Last Name 

Your NONPRIORITY Unsecured Claims - Continuation Page 

! After listing any entries on this page, number them beginning v,rith 4.4, fc>,llowed by,4.5, an.d.so.forth. 

I 

~ P First Premier Bank I ~N-on-p~rto_rt,_ty..,C-re-d-ito""'r-s-Na_m_e ________________ _ 

4.5 

I 

bi] 

I 

I 

601 S. Minnesota 

Number Street 

Sioux Falls 

City 

Who incurred the debt? Check one. 

i;il' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

SD 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

liZf No 

D Yes 

Com Ed/Exelon 

Nonprtortty Creditors Name 

10 S. Dearborn 

Number Street 

Chicago IL 

City State 

Who incurred the debt? Check one. 

D Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

liZf No 

D Yes 

Peoples Energy 

Nonprtortty Creditors Name 

130 East Randolph, Suite 2400 

Number Street 

Chicago 

City 

Who incurred the debt? Check one. 

~ Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

IL 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

iiZ( No 

D Yes 

57104 

ZIP Code 

60603 

ZIP Code 

60601 

ZIP Code 

Last 4 digits of account number JL JL --1__ _l_ 

When was the debt incurred? 07/01/2014 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

t;il' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

liZf Other. Specify_;c.Cc..cre'""'d"'"it.c...c..:;.a"'"rc..:dc_._ _____ _ 

Last 4 digits of account number JL JL --1__ _l_ 

When was the debt incurred? 08/01/2014 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

t;il' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

t;il' Other. Specify UTILITY BILL 

Last 4 digits of account number JL JL _±_ _l_ 

When was the debt incurred? 12/01/2013 

As of the date you file, the claim is: Check all that apply. 

~ Contingent 

D Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as ~riority claims 

D Debts to pension or prp!it-sharing plans, and other similar debts 

lia' Other. Specify UTILITY BILL 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims 

$ 700.00 

$ 900.00 

s_7_5_o_.o_o 

page!_ of .JL 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 28 of 72
Debtor 1 AQUITA S. DAVIS Case number (ifknown)1 _____________ _ 

First Name Middle Name Last Name 

Your NONPRIORITY Unsecured Claims - Continuation Page 

I After listing any entries on this page,,number them beginni11g W!th 4,4, followed by 4.5, ,111d so forth. 

1

4

·

7

1 T MOBILE I 

I 

~ 

Nonprtortty Creditor's Name 

12920 SE 38TH ST Number Street 

BELLEVUE 

City 

Who incurred the debt? Check one. 

i;il' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

WA 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

lilf No 

D Yes 

AT&T 

Nonprtortty Creditor's Name 

208 S. AKARD ST. Number Street 

DALLAS 

City 

Who incurred the debt? Check one. 

!;ii' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

TX 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

liZf No 

D Yes 

AT&T MOBILE 

Nonprtortty Creditor's Name 

208S. AKARD Number Street 

DALLAS 

City 

Who incurred the debt? Check one. 

!;a' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

TX 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

D No 

liZf Yes 

98006 

ZIP Code 

75202 

ZIP Code 

75202 

ZIP Code 

Last 4 digits of account number JL JL _!_ _l__ 

When was the debt incurred? 12/01/2012 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

!;ii' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

liZf Other. Specity-'-P-'-H'-'O'--'N-=E ______ _ 

Last 4 digits of account number _§_ _§_ _!_ _l_ 

When was the debt incurred? 07/01/2014 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

!;ii' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

liZf Other. Specity-'-P.:..H-'--'O:::...:...:Nc:=E=---------

Last 4 digits of account number _§_ _§_ _!_ _l_ 

When was the debt incurred? 03/01/2015 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

!;ii' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

~ Other. Specity-'-P.:..H.,_,O:ccN~E,___ _____ _ 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims 

s 2,500.00 

s 3,500.00 

s 2,000.00 

page;,;a_ 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 29 of 72
Debtor1 AQUITA S. DAVIS Case number (it known), _____________ _ 

First Name Middle Name Last Name 

Your NONPRIORITY Unsecured Claims - Continuation Page 

! After listing any entries on this pa~e, number them beginning with 4.4;.followed by:;4.5, and so t,orth. 

1

5

.ol PAYCHECK DIRECT I 

5.1 

5.2 

Nonpriority Creditor's Name 

6250 RIDGEWOOD RD Number Street 

ST. CLOUD 

City 

Who incurred the debt? Check one. 

i;il' Debtor 1 only 

0 Debtor 2 only 

0 Debtor 1 and Debtor 2 only 

0 At least one of the debtors and another 

MN 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

liZf No 

0 Yes 

AMERICAN FINANCIAL 

Nonpriority Creditor's Name 

301 EAST FOURTH ST. Number Street 

CINCINNATI 

City 

Who incurred the debt? Check one. 

~ Debtor 1 only 

0 Debtor 2 only 

0 Debtor 1 and Debtor 2 only 

0 At least one of the debtors and another 

OH 

State 

0 Check if this claim is for a community debt 

Is the claim subject to offset? 

litl' No 

0 Yes 

SPEEDY CASH 

Nonpriority Creditor's Name 

1100 LOWER AZUSA RD. Number Street 

EL MONTE 

City 

Who incurred the debt? Check one. 

~ Debtor 1 only 

0 Debtor 2 only 

0 Debtor 1 and Debtor 2 only 

0 At least one of the debtors and another 

CA 

State 

0 Check if this claim is for a community debt 

Is the claim subject to offset? 

0 No 

liZf Yes 

56303 

ZIP Code 

45202 

ZIP Code 

91731 

ZIP Code 

Last 4 digits of account number ~ ~ __!_ _l_ 

When was the debt incurred? 04/01/2015 

As of the date you file, the claim is: Check all that apply. 

0 Contingent 

~ Unliquidated 

0 Disputed 

Type of NONPRIORITY unsecured claim: 

0 Student loans 

0 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

0 Debts to pension or profit-sharing plans, and other similar debts 

liZf Other. Specify PAY DAY LOAN 

Last 4 digits of account number ~ ~ __!_ £ 

When was the debt incurred? 04/01/2015 

As of the date you file, the claim is: Check all that apply. 

0 Contingent 

~ Unliquidated 

0 Disputed 

Type of NONPRIORITY unsecured claim: 

0 Student loans 

0 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

0 Debts to pension or profit-sharing plans, and other similar debts 

litl' Other. Specify CREDIT CARD 

Last 4 digits of account number JL JL _±_ _l_ 

When was the debt incurred? 05/01/2015 

As of the date you file, the claim is: Check all that apply. 

0 Contingent 

~ Unliquidated 

0 Disputed 

Type of NONPRIORITY unsecured claim: 

0 Student loans 

0 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

0 Debts to pension or profit-sharing plans, and other similar debts 

~ Other. Specify PAY DAY LOAN 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims 

$ 1,000.00 

i 

$ 2,000.001 

I 

$ 1,000.001 

I 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 30 of 72
Debtor 1 AQUITA S. DAVIS Case number (if known), _____________ _ 

First Name Middle Name Last Name 

Your NONPRIORITY Unsecured Claims - Continuation Page 

i I After listing any entries on this. page, number them begiimlng with 4.4, followed by 4;5, a11d so.forth. 

~ ~ DEPARTMENT OF EDUCATION I 

5.4 

~ 

I 

Nonpriority Creditor's Name 

400 MARYLAND AVE. Number Street 

WASHINGTON 

City 

Who incurred the debt? Check one. 

l;il' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

DC 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

lilf No 

D Yes 

20202 

ZIP Code 

IL DEPARTMENT OF HUMAN SERVICES 

Nonpriority Creditor's Name 

100 SOUTH GRAND AVENUE EAST Number Street 

SPRINGFIELD 

City 

Who incurred the debt? Check one. 

l;il' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

IL 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

lilf No 

D Yes 

62762 

ZIP Code 

IL DEPT OF EMPLOYMENT SECUIRTY 

Nonpriority Creditor's Name 

1300 S. 9TH ST. Number Street 

SPRINGFIELD 

City 

Who incurred the debt? Check one. 

l;il' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

IL 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

D No 

liZI' Yes 

62703 

ZIP Code 

Last 4 digits of account number JL JL ~ _l_ 

When was the debt incurred? 02/01/2010 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

!;ii' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

D Other. Specify ___________ _ 

Last 4 digits of account number JL JL ~ _l_ 

When was the debt incurred? 04/01/2015 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

!;ii' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

~Other.Specify OEVRPAYMENT 

Last 4 digits of account number JL JL _A__ ..£ 

When was the debt incurred? 04/01/2015 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

!;a' Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

~Other.Specify OVERPAYMENT 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims 

! 

$15,000.001 

I 

i $ 3,500.001 

I 

$ 2,000.001 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 31 of 72
Debtor1 AQUITA S. DAVIS Case number (ff known), _____________ _ 

First Name Middle Name Last Name 

Your NONPRIORITY Unsecured Claims - Continuation Page 

, After listing any entries on this page, number them beginning with 4.4; 'followed by 4.5, and so .fqrth. 

Q 

~ CREDIT UNION ONE 

5.7 

Nonpriority Creditor's Name 

200 EAST CHAMPAIGN AVE. Number Street 

RANTOUL 

City 

Who incurred the debt? Check one. 

i;il' Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

IL 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

liZf No 

D Yes 

61866 

ZIP Code 

COLORADO TECHNICAL ONLINE UNIVERSITY 

liiJ 

I 

Nonpriority Creditor's Name 

4435 N. CHESTNUT Number Street 

COLORADO SPRINGS 

City 

Who incurred the debt? Check one. 

~ Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

co 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

lit(" No 

D Yes 

NORTHWESTERN COLLEGE 

Nonpriority Creditor's Name 

4811 N. MILWAUKEE Number Street 

CHICAGO 

City 

Who incurred the debt? Check one. 

~ Debtor 1 only 

D Debtor 2 only 

D Debtor 1 and Debtor 2 only 

D At least one of the debtors and another 

IL 

State 

D Check if this claim is for a community debt 

Is the claim subject to offset? 

D No 

lid" Yes 

80907 

ZIP Code 

60630 

ZIP Code 

Last 4 digits of account number JL JL _!_ ..£. 

When was the debt incurred? 12/01/2014 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

~ Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

litf Other. Specify ___________ _ 

Last 4 digits of account number JL JL _±_ ..£_ 

When was the debt incurred? 06/01/2010 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

~ Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

litl" Other. Specify SCHOOL FEES 

Last 4 digits of account number _§__ _§__ _±_ ..1.... 

When was the debt incurred? 10/01/2015 

As of the date you file, the claim is: Check all that apply. 

D Contingent 

~ Unliquidated 

D Disputed 

Type of NONPRIORITY unsecured claim: 

D Student loans 

D Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

D Debts to pension or profit-sharing plans, and other similar debts 

litl" Other. specify SCHOOL FEES 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims 

$ 1,000.00 

$ 1,500.00 

$ 3,500.00 I ·---'-----, 

pageiof If 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 32 of 72
Debtor 1 AQUITA S. DAVIS Case number (if known). ______________ _ 

First Name Middle Name Last Name 

Your NONPRIORITY Unsecured Claims - Continuation Page 

', '" , 

After listing any entries on this page, number th~m beginning V.:11:h 4.4, followed by 4.5, arid so forth. 

I 

~ 

LJ 

_J 

ILLINOIS STATE POLICE 

Nonpriority Creditor's Name 

HENRY/LYNN COURT, 407 W. CENTER Number Street 

CAMBRIDGE 

City 

Who incurred the debt? Check one. 

i;a' Debtor 1 only 

0 Debtor 2 only 

0 Debtor 1 and Debtor 2 only 

0 At least one of the debtors and another 

IL 

State 

0 Check if this claim is for a community debt 

Is the claim subject to offset? 

~No 

0 Yes 

Nonpriority Creditor's Name 

Number Street 

City 

Who incurred the debt? Check one. 

~ Debtor 1 only 

0 Debtor 2 only 

0 Debtor 1 and Debtor 2 only 

0 At least one of the debtors and another 

State 

0 Check if this claim is for a community debt 

Is the claim subject to offset? 

~No 

0 Yes 

Nonpriority Creditor's Name 

Number Street 

City 

Who incurred the debt? Check one. 

!;ii' Debtor 1 only 

0 Debtor 2 only 

0 Debtor 1 and Debtor 2 only 

0 At least one of the debtors and another 

State 

0 Check if this claim is for a community debt 

Is the claim subject to offset? 

0 No 

~ Yes 

61238 

ZIP Code 

ZIP Code 

ZIP Code 

Last 4 digits of account number JL JL _!_ _l_ 

When was the debt incurred? 08/18/2016 

As of the date you file, the claim is: Check all that apply. 

0 Contingent 

~ Unliquidated 

0 Disputed 

Type of NONPRIORITY unsecured claim: 

0 Student loans 

0 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

0 Debts to pension or profit-sharing plans, and other similar debts 

~ Other. Specify TRAFFIC TICKET 

Last 4 digits of account number ___ _ 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

0 Contingent 

~ Unliquidated 

0 Disputed 

Type of NONPRIORITY unsecured claim: 

0 Student loans 

0 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

0 Debts to pension or profit-sharing plans, and other similar debts 

~ Other. Specify ___________ _ 

Last 4 digits of account number ___ _ 

When was the debt incurred? 

As of the date you file, the claim is: Check all that apply. 

0 Contingent 

i;a' Unliquidated 

0 Disputed 

Type of NONPRIORITY unsecured claim: 

0 Student loans 

0 Obligations arising out of a separation agreement or divorce that 

you did not report as priority claims 

0 Debts to pension or profit-sharing plans, and other similar debts 

~ Other. Specify ___________ _ 

Official Form 106E/F Schedule Elf: Creditors Who Have Unsecured :laims 

$ 200.00 

$ ____ _ 

$ ____ _ 

page2ofJL 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 33 of 72
Debtor 1 AQUITA S. DAVIS Case number (if known), _____________ _ 

First Name Middle Name Last Name 

List Others to Be Notified About a Debt That You Already Listed 

Use this page only if you have others to be notified about your bankruptcy, for a debt that you already listed in Parts 1 or 2. For 

example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or 

2, then list the collection agency here. Similarly, if you have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the 

additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill out or submit this page. 

ARNOLD SCOTT HARRIS Name 

111 W. JACKSON, STE 600 

Number Street 

CHICAGO IL 60604 

LINEBARGER GOGGAN AND SAMPSON Name 

P.O. BOX 06152 Number Street 

CHICAGO IL 60606 

City State ZIP Code 

USDOE DEBT COLLECTION SERVICE Name 

SAN FRANCISCO SERVICE CENTER Number Street 

50 BEALE ST., #8629 

On which entry in Part 1 or Part 2 did you list the original creditor? 

Line .1,.1_ of (Check one): 0 Part 1: Creditors with Priority Unsecured Claims 

~ Part 2: Creditors with Nonpriority Unsecured Claims 

Last 4 digits of account number J!. J!. _! _1_ 

On which entry in Part 1 or Part 2 did you list the original creditor? 

Line ..1,1._ of (Check one): 0 Part 1: Creditors with Priority Unsecured Claims 

~ Part 2: Creditors with Nonpriority Unsecured 

Claims 

Last 4 digits of account number J!. J!. _±. _1_ 

On which entry in Part 1 or Part 2 did you list the original creditor? 

Line~ of (Check one): 0 Part 1: Creditors with Priority Unsecured Claims 

lil' Part 2: Creditors with Nonpriority Unsecured 

Claims 

SAN FRANCISCO CA 94705 Last 4 digits of account number~ ~ _± ~ ~l!Le,,---ffl-""··----,m--""S""ta-'te ___ z""1_P""Co._d_e ______________________________ _ 

Name 

Number Street 

50 BEALE ST., #8629 

City 

NAVIENT 

Name 

123 JUSTISON ST. 

Number Street 

WILMINGTON 

Ci!): 

Name 

Number Street 

Ci 

Name 

Number Street 

City 

Official Form 106E/F 

State 

DE 

State 

State 

State 

ZIP Code 

19801 

ZIP Code 

ZIP Code 

ZIP Code 

On which entry in Part 1 or Part 2 did you list the original creditor? 

Line 

Claims 

of (Check one): 0 Part 1: Creditors with Priority Unsecured Claims 

0 Part 2: Creditors with Nonpriority Unsecured 

Last 4 digits of account number _ __ _ 

On which entry in Part 1 or Part 2 did you list the original creditor? 

Line ..§d_ of (Check one): 0 Part 1: Creditors with Priority Unsecured Claims 

liZf' Part 2: Creditors with Nonpriority Unsecured 

Claims 

Last 4 digits of account number J!. J!. _! _1_ 

On which entry in Part 1 or Part 2 did you list the original creditor? 

Line 

Claims 

of (Check one): 0 Part 1: Creditors with Priority Unsecured Claims 

0 Part 2: Creditors with Nonpriority Unsecured 

Last 4 digits of account number _ __ _ 

On which entry in Part 1 or Part 2 did you list the original creditor? 

Line 

Claims 

of ( Check one): 0 Part 1: Creditors with Priority Unsecured Claims 

0 Part 2: Creditors with Nonpriority Unsecured 

Last 4 digits of account number _ __ _ 

Schedule E/F: Creditors Who Have Unsecured Claims 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 34 of 72
Debtor 1 AQUITAS. DAVIS Case number(itknown), _____________ _ 

First Name Middle Name Last Name 

Add the Amounts for Each Type of Unsecured Claim 

s. Total the amounts of certain types of unsecured claims. This information is for statistical reporting purposes only. 28 U.S.C. § 159. 

Add the amounts for each type of unsecured claim. 

Total claim 

Total claims 6a. Domestic support obligations 6a. $ 0.00 

from Part 1 6b. Taxes and certain other debts you owe the 

government 6b. $ 0.00 

6c. Claims for death or personal injury while you were 

intoxicated 6c. $ 0.00 

6d. Other. Add all other priority unsecured claims. 

Write that amount here. 6d. +$ 0.00 

6e. Total. Add lines 6a through 6d. 6e. 

$ 0.00 

Total claim 

Total claims 6f. Student loans 6f. 75,000.00 $ 

fromPart2 6g. Obligations arising out of a separation agreement 

or divorce that you did not report as priority 0.00 claims 6g. $ 

6h. Debts to pension or profit-sharing plans, and other 

similar debts 6h. $ 0.00 

6i. Other. Add all other nonpriority unsecured claims. 

Write that amount here. 6i. +$ 

6j. Total. Add lines 6f through 6i. 6j. 

$ 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 35 of 72
Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___ 

2IILFLDO)RUP 106G 

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

information. If more space is needed, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any 

additional pages, write your name and case number (if known). 

1. Do you have any executory contracts or unexpired leases?

 No. Check this box and file this form with the court with your other schedules. You have nothing else to report on this form.

 Yes. Fill in all of the information below even if the contracts or leases are listed on Schedule A/B: Property (Official Form 106A/B).

2. List separately each person or company with whom you have the contract or lease. Then state what each contract or lease is for (for

example, rent, vehicle lease, cell phone). See the instructions for this form in the instruction booklet for more examples of executory contracts and

unexpired leases.

Person or company with whom you have the contract or lease State what the contract or lease is for

2.1 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code

2.2 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code

2.3 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code

2.4 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code

2.5 _____________________________________________________________________ 

Name

_____________________________________________________________________ 

Number Street 

_____________________________________________________________________ 

City State ZIP Code

Debtor __________________________________________________________________ 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 ________

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

 Check if this is an

amended filing

AQUITA S. DAVIS

Northern District of Illinois

✔

1

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 36 of 72
Official Form 106H Schedule H: Your Codebtors page 1 of ___ 

2IILFLDO)RUP 106H 

Schedule H: Your Codebtors 12/15

Codebtors are people or entities who are also liable for any debts you may have. 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, copy the Additional Page, fill it out, 

and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and 

case number (if known). Answer every question. 

1. Do you have any codebtors? (If you are filing a joint case, do not list either spouse as a codebtor.)

 No

 Yes

2. Within the last 8 years, have you lived 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. Go to line 3.

 Yes. Did your spouse, former spouse, or legal equivalent live with you at the time?

 No

 Yes. In which community state or territory did you live? __________________. Fill in the name and current address of that person.

______________________________________________________________________

Name of your spouse, former spouse, or legal equivalent 

______________________________________________________________________

Number Street 

______________________________________________________________________

City State ZIP Code

3. In Column 1, list all of your codebtors. Do not include your spouse as a codebtor if your spouse is filing with you. List the person

shown in line 2 again as a codebtor only if that person is a guarantor or cosigner. Make sure you have listed the creditor on

Schedule D (Official Form 106D), Schedule E/F (Official Form 106E/F), or Schedule G (Official Form 106G). Use Schedule D,

Schedule E/F, or Schedule G to fill out Column 2.

Column 1: Your codebtor Column 2: The creditor to whom you owe the debt 

Check all schedules that apply: 

3.1 ________________________________________________________________________________

Name 

________________________________________________________________________________

Number Street 

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

3.2 ________________________________________________________________________________

Name 

________________________________________________________________________________

Number Street 

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

3.3 ________________________________________________________________________________

Name 

________________________________________________________________________________

Number Street 

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

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 ________

Case number ____________________________________________ 

(If known)

Fill in this information to identify your case: 

 Check if this is an

amended filing

AQUITA S. DAVIS

Northern District of Illinois

✔

1

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 37 of 72
Official Form 106I Schedule I: Your Income page 1

2IILFLDO)RUP 106I 

Schedule I: Your Income 12/15

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

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

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

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

Part 1: Describe Employment 

1. Fill in your employment

information.

If you have more than one job,

attach a separate page with

information about additional

employers.

Include part-time, seasonal, or

self-employed work.

Occupation may include student

or homemaker, if it applies.

Debtor 1 Debtor 2 or non-filing spouse 

Employment status  Employed

 Not employed

 Employed

 Not employed

Occupation __________________________________ __________________________________ 

Employer’s name __________________________________ __________________________________ 

Employer’s address _______________________________________ 

Number Street 

_______________________________________ 

_______________________________________ 

_______________________________________ 

City State ZIP Code

________________________________________ 

Number Street 

________________________________________ 

________________________________________ 

________________________________________ 

City State ZIP Code

How long employed there? _______ _______

Part 2: Give Details About Monthly Income 

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

spouse unless you are separated. 

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

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

For Debtor 1 For Debtor 2 or 

non-filing spouse 

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

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

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

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

Debtor 1 ____________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ____________________________________________________________________ 

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

United States Bankruptcy Court for the: __________ District of ___________

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

Check if this is: 

 An amended filing

 A supplement showing postpetition chapter 13

income as of the following date:

________________

MM / DD / YYYY 

AQUITA S. DAVIS

Northern District of Illinois

✔

ADMINISTRATIVE

Cook County Hospital and Health

15900 S. CICERO

OAK FOREST IL 60452

2 YEARS 2 YEARS

3,373.97

3,373.97

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 38 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP, Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or 

non-filing spouse

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

5. List all payroll deductions:

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

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

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

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

5e. Insurance 5e. $____________ $_____________

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

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

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

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h. 6. $____________ $_____________

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

8. List all other income regularly received:

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

profession, or farm 

Attach a statement for each property and business showing gross 

receipts, ordinary and necessary business expenses, and the total 

monthly net income. 8a. $____________ $_____________ 

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

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

regularly receive 

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

settlement, and property settlement. 8c. $____________ $_____________ 

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

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

8f. Other government assistance that you regularly receive 

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

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

Nutrition Assistance Program) or housing subsidies. 

Specify: ___________________________________________________ 8f. $____________ $_____________ 

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

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

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

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

Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse. 10. $___________ + $_____________ = $_____________

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

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

friends or relatives.

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

Specify: _______________________________________________________________________________ 11. + $_____________

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

Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies 12. $_____________

Combined 

monthly income 

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

 No.

 Yes. Explain:

AQUITA S. DAVIS

3,373.97

641.05

2,732.92

140.00

food stamps 327.00

467.00

3,199.92 3,199.92 3,199.92

food stamps

3,199.92

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 39 of 72
Official Form 106J Schedule J: Your Expenses page 1

2IILFLDO)RUP 106J 

Schedule J: Your Expenses 12/15 

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

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

(if known). Answer every question. 

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

 Yes. Does Debtor 2 live in a separate household?

 No

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

2. Do you have dependents?

Do not list Debtor 1 and

Debtor 2.

Do not state the dependents’

names.

 No

 Yes. Fill out this information for

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

Dependent’s relationship to 

Debtor 1 or Debtor 2

Dependent’s 

age

Does dependent live 

with you?

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

3. Do your expenses include

expenses of people other than

yourself and your dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

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

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

applicable date. 

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

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

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

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

If not included in line 4:

4a. Real estate taxes 4a. $_____________________ 

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

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

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

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: __________ District of __________

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

Check if this is: 

 An amended filing

 A supplement showing postpetition chapter 13

expenses as of the following date:

________________

MM / DD / YYYY 

AQUITA S. DAVIS

Northern District of Illinois

✔

✔

child 18 ✔

1,400.00

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 40 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP- Schedule J: Your Expenses page 2

Your expenses

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

6. Utilities:

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

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

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

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

7. Food and housekeeping supplies 7. $_____________________

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

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

10. Personal care products and services 10. $_____________________

11. Medical and dental expenses 11. $_____________________

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

Do not include car payments. 12. $_____________________

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

14. Charitable contributions and religious donations 14. $_____________________

15. Insurance.

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

1

15a. Life insurance 15a. $_____________________ 

15b. Health insurance 15b. $_____________________ 

15c. Vehicle insurance 15c. $_____________________ 

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

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

Specify: ________________________________________________________ 16. $_____________________

17. Installment or lease payments:

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

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

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

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

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

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

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

Specify:_______________________________________________________ 19. $_____________________

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

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

20b. Real estate taxes 20b. $_____________________ 

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

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

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

AQUITA S. DAVIS

209.00

120.00

358.00

50.00

50.00

140.00

28.00

21.00

175.00

tuition for child in college 413.00

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 41 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP- Schedule J: Your Expenses page 3

21. Other. Specify: _________________________________________________ 21. +$_____________________

22. Calculate your monthly expenses.

22a. Add lines 4 through 21. 22a.

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

22c. Add line 22a and 22b. The result is your monthly expenses. 22c.

$_____________________ 

$_____________________ 

$_____________________ 

23. Calculate your monthly net income.

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

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

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

The result is your monthly net income. 23c. $_____________________

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

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

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

 No.

 Yes. Explain here: 

AQUITA S. DAVIS

2,964.00

2,964.00

3,199.92

2,964.00

235.92

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 42 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 43 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 44 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 45 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 46 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 47 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 48 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 49 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 50 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 51 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 52 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 53 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 54 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 55 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 56 of 72
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

2IILFLDO)RUP 107 

Statement of Financial Affairs for Individuals Filing for Bankruptcy 12/15

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

information. If more space is needed, attach 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).

Part 2: Explain the Sources of Your Income 

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 ______________

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

 Check if this is an

amended filing

AQUITA S. DAVIS

Northern District of Illinois

✔

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 57 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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 1 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, ______) YYYY

__________________

__________________

__________________

$_________________

$_________________

$_________________

_____________________

_____________________

_____________________

$_________________

$_________________

$_________________

For the calendar year before that: 

(January 1 to December 31, ______) YYYY

__________________

__________________

__________________

$_________________

$_________________

$_________________

_____________________

_____________________

_____________________

$_________________

$_________________

$_________________

AQUITA S. DAVIS

✔

✔ 13,530.88

✔

20,951.00

2015

✔

2014 27,189.00

✔

2015

2015

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 58 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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 $6,225* or more? 

 No. Go to line 7.

 Yes. List below each creditor to whom you paid a total of $6,225* 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 4/01/16 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 ____________

AQUITA S. DAVIS

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 59 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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

_________

_________

_________

$____________ $____________

AQUITA S. DAVIS

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 60 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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.

AQUITA S. DAVIS

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 61 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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 ______________

_________

_________

$_____________

$_____________

AQUITA S. DAVIS

✔

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 62 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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

AQUITA S. DAVIS

✔

✔

✔

JOHN HADERLEIN, ESQ.

815- COUNTRY CLUB DR. CHECK - filing fees for chapter 13 bankruptcy

case 08/23/2016 310.00

LIBERTYVILLE IL 60048

john@bklaw1.com

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 63 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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 _____________ 

AQUITA S. DAVIS

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 64 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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



AQUITA S. DAVIS

✔

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 65 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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 

_______________________________________

City State 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

_________

AQUITA S. DAVIS

✔

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 66 of 72
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

2IILFLDO)RUP 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 _______ 

AQUITA S. DAVIS

✔

✔

✔

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 67 of 72
Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 68 of 72
INRE: 

UNITED STATES BANKRUPTCY COURT 

NORTHERN DISTRICT OF ILLINOIS 

A3 u ?te, Oc'-.J, ~' DEBTOR 

) 

) 

) 

) 

) 

No /•2 

Chapter f--0 

VERIFICATION OF CREDITOR MATRIX 

Number of Creditors: 

The above-named Debtor(s) hereby verifies that the list of creditors is true and correct 

to the best of my knowledge. 

Date: ·7 / I b /c9-(j lf 

I I 

Isl abflc utJ 

Debtor 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 69 of 72
Aquita S. Davis 

604 N. Laramie 

Apt. 2 

Chicago, IL 60644 

John Haderlein, Esq. 

815-C Country Club Dr. 

Libertyville, IL 60048 

Prestige Financial Services 

P.O. Box 26707 

Salt Lake City, UT 84126 

Prestige Financial 

1420 500 W. Salt Lake City 

Salt Lake City, UT 84115 

City of Chicago 

Revenue Department 

121 N. LaSalle St. 

Room 107A 

Chicago, IL 60602 

Arnold Scott Harris, PC 

111 W. Jackson 

Suite 600 

Chicago, IL 60604 

Linebarger Goggan Blair & Sampson 

P.O. Box 06152 

Chicago, IL 60606-0152 

Illinois Tollway 

2700 Ogden Ave. 

Downers Grove, IL 60515 

Credit One 

585 Pilot Rd. 

Las Vegas, NV 89119 

First Premier Bank 

601 S. Minnesota 

Sioux Falls, SD 57104 

Com Ed/Exelon 

10 S. Dearborn 

Chicago, IL 60603 

Peoples Energy 

130 E. RANDOLPH 

SUITE 2400 

CHICAGO, IL 60601 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 70 of 72
T-Mobile 

12920 SE 38TH ST 

BELLVUE, WA 98006 

AT&T 

208 S. AKARD ST. 

DALLAS, TX 75202 

ATT Mobile 

208 S. AKARD ST. 

DALLAS, TX 75202 

Paycheck Direct 

6250 RIDGEWOOD RD. 

ST. CLOUD, MN 56303 

American Financial 

301 EAST FOURTH ST. 

CINCINNATI, OH 45202 

Speedy Cash Pay Day Loan 

1100 LOWER ASUZA RD 

EL MONTE, CA 91731 

US Department of Ed 

400 Maryland Ave. 

Washington, DC 20202 

USDOE COLLECTION SERVICE 

SAN FRANCISCO SERVICE CENTER 

50 BEALE ST. 

#8629 

SAN FRANCISCO, CA 94705 

NAVIENT 

123 JUSTISON ST. 

WILMINGTON, DE 19801 

Illinois Department of Human Services 

100 SOUTH GRAND AVE. EAST 

SPRINGFIELD, IL 62762 

IDES 

1300 S. 9TH ST. 

SPRINGFIELD, IL 62703 

Credit Union 1 

200 EAST CHAMPAIGN AVE. 

RANTOUL, IL 61866 

Colorado Technical Online University 

4435 N. CHESTNUT 

COLORADO SPRINGS, CO 80907 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 71 of 72
Northwestern College 

4811 N. MILWAUKEE 

CHICAGO, IL 60630 

Illinois State Police 

HENRY/LYNN COURT 

407 W. Center 

Cambridge, IL 61238 

Case 16-27070 Doc 1 Filed 08/23/16 Entered 08/23/16 15:52:31 Desc Main

 Document Page 72 of 72