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Check if this is an

amended filing

12/15

1.

2.

3. xxx - xx- 0244

9 xx - xxxxx - xx9 xx - xxOfficial Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 1

Case number (if known) Chapter you are filing under:

Chapter 7

Chapter 11

Chapter 12

Chapter 13

Fill in this information to identify your case:

United States Bankruptcy Court for the:

Northern District of: Illinois

(State)

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy

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

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

would be yes if either debtor owns a car. When information is needed about the spouses separately, the form uses Debtor 1 and Debtor 2 to distinguish

between them. In joint cases, one of the spouses must report information as Debtor 1 and the other as Debtor 2. The same person must be Debtor 1 in all of

the forms.

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

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

Part 1: Identify Yourself

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

Your full name

Write the name that is on

your government-issued

picture identification (for

example, your driver's

license or passport

Bring your picture

identification to your meeting

with the trustee.

Evan

First name

L

Middle name

Grossman

Last name

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

First name

Middle name

Last name

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

All other names you

have used in the last

8 years

Include your married or

maiden names.

First name

Middle name

Last name

First name

Middle name

Last name

First name

Middle name

Last name

First name

Middle name

Last name

Only the last 4 digits

of your Social

Security number or

federal Individual

Taxpayer

Identification

number (ITIN)

OR OR

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

4.

5.

8484 Walredon Ave 

Number Street

Burr Ridge Illinois 60527 

City State Zip Code

Du Page 

County

Number Street

City State Zip Code

Number Street

City State Zip Code

County

Number Street

City State Zip Code

6.

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

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

Any business names

and Employer

Identification

Numbers (EIN) you

have used in the last

8 years

Include trade names and

doing business as names

I have not used any business names or EINs.

Business name

Business name

EIN

EIN

I have not used any business names or EINs.

Business name

Business name

EIN

EIN

Where you live

If your mailing address is different from the one above, fill

it in here. Note that the court will send any notices to you at this

mailing address.

If Debtor 2 lives at a different address:

If Debtor 2’s mailing address is different from yours, fill it in

here. Note that the court will send any notices to this mailing

address.

Why you are

choosing this

district to file for

bankruptcy

Check one:

Over the last 180 days before filing this petition, I have lived

in this district longer than in any other district.

I have another reason. Explain. (See 28 U.S.C. §§ 1408.)

Check one:

Over the last 180 days before filing this petition, I have lived

in this district longer than in any other district.

I have another reason. Explain. (See 28 U.S.C. §§ 1408.)

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

7.

8.

9.

Yes. District When

MM / DD / YYYY

Case number

District When

MM / DD / YYYY

Case number

District When

MM / DD / YYYY

Case number

10.

Yes. Debtor Relationship to you

District When

MM / DD / YYYY

Case number, if known

Debtor Relationship to you

District When

MM / DD / YYYY

Case number, if known

11. No. Go to line 12.

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

No. Go to line 12.

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

this bankruptcy petition.

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

Part 2: Tell the Court About Your Bankruptcy Case

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

B2010)). Also, go to the top of page 1 and check the appropriate box.

Chapter 7

Chapter 11

Chapter 12

Chapter 13

How you will pay the

fee

I will pay the entire fee when I file my petition. Please check with the clerk's office in your local

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

pay with cash, cashier's check, or money order... If your attorney is submitting your payment on your

behalf, your attorney may pay with a credit card or check with a pre-printed address.

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

Individuals to Pay Your Filing Fee in Installments (Official Form 103A).

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

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

150% of the official poverty line that applies to your family size and you are unable to pay the fee in

installments). If you choose this option, you must fill out the Application to Have the Chapter 7 Filing

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

Have you filed for

bankruptcy within

the last 8 years?

No.

Are any bankruptcy

cases pending or

being filed by a

spouse who is not

filing this case with

you, or by a

business partner, or

by an affiliate?

No.

Do you rent your

residence?

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 Document Page 11 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

12. No. Go to Part 4.

Yes. Name and location of business

Number Street

City State Zip Code

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

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

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

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

None of the above

13.

No. I am not filing under Chapter 11.

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

Bankruptcy Code.

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

14.

Yes.

Number Street

City State Zip Code

What is the hazard?

If immediate attention is needed, why is it needed?

Where is the property?

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

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

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.

Name of business, if any

Check the appropriate box to describe your business:

Are you filing under

Chapter 11 of the

Bankruptcy Code

and are you a small

business debtor?

For a definition of

small business debtor,

see 11 U.S.C. §

101(51D).

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

If you indicate that you are a small business debtor, you must attach your most recent balance sheet, statement of operations, cash-flow

statement, and federal income tax return or if any of these documents do not exist, follow the procedure in 11 U.S.C. § 11 16(1)(B).

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

Do you own or have

any property that

poses or is alleged

to pose a threat of

imminent and

identifiable hazard

to public health or

safety? Or do you

own any property

that needs

immediate attention?

For example, do you

own perishable goods,

or livestock that must

be fed, or a building

that needs urgent

repairs?

No.

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

15.

Incapacity. I have a mental illness or a mental

deficiency that makes me incapable of

realizing or making rational decisions

about finances.

Disability. My physical disability causes me to be

unable to participate in a briefing in

person, by phone, or through the

internet, even after I reasonably tried to

do so.

Active duty. I am currently on active military duty in a

military combat zone.

Incapacity. I have a mental illness or a mental

deficiency that makes me incapable of

realizing or making rational decisions

about finances.

Disability. My physical disability causes me to be

unable to participate in a briefing in

person, by phone, or through the

internet, even after I reasonably tried to

do so.

Active duty. I am currently on active military duty in a

military combat zone.

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

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

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

Tell the court

whether you have

received 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.

You must check one:

I received a briefing from an approved credit

counseling agency within the 180 days before I filed this

bankruptcy petition, and I received a certificate of

completion.

Attach a copy of the certificate and the payment plan, if any,

that you developed with the agency.

I received a briefing from an approved credit

counseling agency within the 180 days before I filed this

bankruptcy petition, but I do not have a certificate of

completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

I certify that I asked for credit counseling services from

an approved agency, but was unable to obtain those

services during the 7 days after I made my request, and

exigent circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the requirement,

attach a separate sheet explaining what efforts you made to

obtain the briefing, why you were unable to obtain it before you

filed for bankruptcy, and what exigent circumstances required

you to file this case.

Your case may be dismissed if the court is dissatisfied with

your reasons for not receiving a briefing before you filed for

bankruptcy.

If the court is satisfied with your reasons, you must still

receive a briefing within 30 days after you file. You must file a

certificate from the approved agency, along with a copy of the

payment plan you developed, if any. If you do not do so, your

case may be dismissed.

Any extension of the 30-day deadline is granted only for cause

and is limited to a maximum of 15 days.

I am not required to receive a briefing about credit

counseling because of:

If you believe you are not required to receive a briefing about

credit counseling, you must file a motion for waiver of credit

counseling with the court.

You must check one:

I received a briefing from an approved credit

counseling agency within the 180 days before I filed this

bankruptcy petition, and I received a certificate of

completion.

Attach a copy of the certificate and the payment plan, if any,

that you developed with the agency.

I received a briefing from an approved credit

counseling agency within the 180 days before I filed this

bankruptcy petition, but I do not have a certificate of

completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

I certify that I asked for credit counseling services from

an approved agency, but was unable to obtain those

services during the 7 days after I made my request, and

exigent circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the requirement,

attach a separate sheet explaining what efforts you made to

obtain the briefing, why you were unable to obtain it before you

filed for bankruptcy, and what exigent circumstances required

you to file this case.

Your case may be dismissed if the court is dissatisfied with

your reasons for not receiving a briefing before you filed for

bankruptcy.

If the court is satisfied with your reasons, you must still

receive a briefing within 30 days after you file. You must file a

certificate from the approved agency, along with a copy of the

payment plan you developed, if any. If you do not do so, your

case may be dismissed.

Any extension of the 30-day deadline is granted only for cause

and is limited to a maximum of 15 days.

I am not required to receive a briefing about credit

counseling because of:

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.

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 13 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

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

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

No. Go to line 16b.

Yes. Go to line 17.

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

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

investment.

No. Go to line 16c.

Yes. Go to line 17.

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

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

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

paid that funds will be available to distribute to unsecured creditors?

No.

Yes.

18. 1-49

50-99

100-199

200-999

1,000-5,000

5,001-10,000

10,001-25,000

25,001-50,000

50,001-100,000

More than 100,000

19. $0-$50,000

$50,001-$100,000

$100,001-$500,000

$500,001-$1 million

$1,000,001-$10 million

$10,000,001-$50 million

$50,000,001-$100 million

$100,000,001-$500 million

$500,000,001-$1 billion

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

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

More than $50 billion

20. $0-$50,000

$50,001-$100,000

$100,001-$500,000

$500,001-$1 million

$1,000,001-$10 million

$10,000,001-$50 million

$50,000,001-$100 million

$100,000,001-$500 million

$500,000,001-$1 billion

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

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

More than $50 billion

For you

û /s/ Evan Grossman

Signature of Debtor 1

û

Signature of Debtor 2

Executed on 8/2/2016

MM / DD / YYYY

Executed on 

MM / DD / YYYY

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

Part 6: Answer These Questions for Reporting Purposes

What kind of debts

do you have?

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?

How many creditors

do you estimate that

you owe?

How much do you

estimate your assets

to be worth?

How much do you

estimate your

liabilities to be?

Part 7: Sign Below

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.

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 Document Page 14 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

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. û /s/ Ben Schneider

Signature of Attorney for Debtor

Date 8/2/2016

MM / DD / YYYY

8424 Skokie Blvd 

Street

#200 

Skokie Illinois 60077 

City State Zip Code

Contact phone 8475306840 Email address

ben@windycitylawgroup.com

6295667 

Bar number

Illinois 

State

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

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

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

relief available under each chapter for which the person is eligible. I also certify that I have delivered to the

debtor(s) the notice required by 11 U.S.C. § 342(b) and, in a case in which § 707(b)(4)(D) applies, certify

that I have no knowledge after an inquiry that the information in the schedules filed with the petition is

incorrect.

Ben Schneider

Printed name

The Law Offices of Schneider & Stone

Firm name

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 15 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

12/15

■ you filed Initial Statement About an Eviction Judgment Against You (Official Form 101A); and

■ you served a copy of Form 101A on your landlord; and

■ you want to stay in your rented residence for more than 30 days after you file your Voluntary Petition

for Individuals Filing for Bankruptcy (Official Form 101).

Official Form 101B Statement About Payment of an Eviction Judgment Against You

Official Form 101B

Statement About Payment of an Eviction Judgment Against You

Fill out this form only if:

File this form within 30 days after you file your Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101).

Also serve a copy on your landlord within that same time period.

Part 1: Certification About Applicable Law and Payment of Eviction Judgment

I certify under penalty of perjury that (Check all that apply):

Under the state or other nonbankruptcy law that applies to the judgment for possession (eviction

judgment), I have the right to stay in my residence by paying my landlord the entire delinquent amount.

Within 30 days after I filed my Voluntary Petition for Individuals Filing for Bankruptcy (Official

Form 101), I have paid my landlord the entire amount I owe as stated in the judgment for possession

(eviction judgment).

û /s/ Evan Grossman

Signature of Debtor 1

û

Signature of Debtor 2

Date 8/2/2016

MM/DD/YYYY

Date

MM/DD/YYYY

You must serve your landlord with a copy of this form.

Check the Bankruptcy Rules (www.uscourts.gov/rulesandpolicies/rules.aspx) and the court’s local website (go to

http://www.uscourts.gov/Court_Locator.aspx to find your court’s website) for any specific requirements that you might have to

meet to serve this statement.

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 Document Page 16 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

$10,000.00

$12,318.00

$22,318.00

$5,829.00

$0.00

$40,271.45

Your total liabilities $46,100.45

$1,267.10

$1,140.00

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1

Official Form 106Sum

Summary of Your Assets and Liabilities and Certain Statistical Information

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 ........................

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 22, Column A, of Schedule J................................................................

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 Document Page 17 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

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.

$0.00

Total claim

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 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 8-10 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.

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

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.

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 Document Page 18 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

Street address, if available, or other description

418 E. Vaughn St. 

Number Street

Ironwood Michigan 49938 

City State Zip Code

Gogebic 

County Other 

Current value of the

entire property?

$10000.00

Current value of the

portion you own?

$10000.00

Street address, if available, or other description

Number Street

City State Zip Code Other 

Current value of the

entire property?

Current value of the

portion you own?

Official Form 106A/B Schedule A/B: Property page 1

Official Form 106A/B

Schedule A/B: Property

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

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

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

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Describe the nature of your ownership

interest (such as fee simple, tenancy by

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

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

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

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

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Describe the nature of your ownership

interest (such as fee simple, tenancy by

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

Check if this is community property

(see instructions)

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

property identification number: 

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 Document Page 19 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Street address, if available, or other description

Number Street

City State Zip Code Other 

Current value of the

entire property?

Current value of the

portion you own?

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. ................................................................................................... ▶

$10000.00 

Current value of the

entire property?

$9033.00

Current value of the

portion you own?

$9033.00

Current value of the

entire property?

Current value of the

portion you own?

Official Form 106A/B Schedule A/B: Property page 2

1.3

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

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

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Describe the nature of your ownership

interest (such as fee simple, tenancy by

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

Check if this is community property

(see instructions)

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

property identification number: 

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 Kia 

Model: Optima 

Year: 2012 

Approximate mileage: 90000 

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.

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.

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Current value of the

entire property?

Current value of the

portion you own?

Current value of the

entire property?

Current value of the

portion you own?

Current value of the

entire property?

Current value of the

portion you own?

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 ................................................................................................... ▶

$9033.00

Official Form 106A/B 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.

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.

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: 

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.

4.2 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.

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 21 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Yes. Describe...

Yes. Describe... Television; Samsung Note 5 $50.00

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Describe... Clothes $100.00

Yes. Describe...

Yes. Describe...

Yes. Describe...

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 .......................................................................................................................... ▶

$150.00 

Official Form 106A/B 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

7. Electronics

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

No

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

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

10. Firearms

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

No

11. Clothes

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

No

12. Jewelry

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

gold, silver

No

13. Non-farm animals

Examples: Dogs, cats, birds, horses

No

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

No

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Yes .................................................................................................... $1000.00

Yes

Yes

Yes. Give specific

information about

them

Name of entity % of ownership:

Official Form 106A/B 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

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

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:

MB Financial 

Nicholet National Bank 

$130.00 

$5.00 

18. Bonds, mutual funds, or publicly traded stocks

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

No

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

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 Document Page 23 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Yes. Give specific

information about

them.....

Yes. List each

account separately.

Yes....

Yes....

Official Form 106A/B 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

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

Type of account:

401(k) or similar plan:

Pension plan:

IRA:

Retirement account:

Keogh:

Additional account:

Additional account:

Institution name:

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

Electric:

Gas:

Heating oil:

Security deposit on rental unit:

Prepaid rent:

Telephone:

Water:

Rented furniture:

Other:

Institution name:

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

No

Issuer name and description:

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 24 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Yes....

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Give specific information

about them, including whether

you already filed the returns

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

Yes. Give specific information......

Yes. Describe...

Official Form 106A/B 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

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

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

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

No

27. Licenses, franchises, and other general intangibles

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

No

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

Federal:

State:

Local:

$0.00 

$0.00 

$0.00 

29. Family support

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

No

Alimony:

Maintenance:

Support:

Divorce settlement:

Property settlement:

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

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

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 Document Page 25 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Yes. Name the insurance company

of each policy and list its value.....

Company name: Beneficiary:

Prudential Evan Grossman 

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Go to line 38.

Yes. Describe...

Yes. Describe...

Official Form 106A/B 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

Surrender or refund value:

$2000.00 

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

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

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

to set off claims

No

35. Any financial assets you did not already list

No

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 ................................................................................................................▶

$3135.00 

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. Current value of the

portion you own?

Do not deduct secured claims

or exemptions

38. Accounts receivable or commissions you already earned

No

39. Office equipment, furnishings, and supplies

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

No

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 Document Page 26 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Yes. Describe...

Yes. Describe...

Yes. Give specific

information about

them

Name of entity: % of ownership:

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

Yes. Describe........

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 ............................................................................................................................................... ▶

Part 6:

Yes. Go to line 47.

Yes. Describe...

Official Form 106A/B Schedule A/B: Property page 9

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

No

41. Inventory

No

42. Interests in partnerships or joint ventures

No

43. Customer lists, mailing lists, or other compilations

No

No

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

No

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. Current value of the

portion you own?

Do not deduct secured

claims

or exemptions

47. Farm animals

Examples: Livestock, poultry, farm-raised fish

No

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 27 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Describe...

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 .................................................................................................................................▶

Yes. Give specific

information

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

Official Form 106A/B Schedule A/B: Property page 10

48. Crops-either growing or harvested

No

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

No

50. Farm and fishing supplies, chemicals, and feed

No

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

No

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

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

55. Part 1: Total real estate, line 2 ...........................................................................................................................................▶ $10000.00 

56. part 2 total vehicles, line 5 $9033.00

57.Part 3: Total personal and household items, line 15 $150.00 

58.Part 4: Total financial assets, line 36 $3135.00 

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. .................... $12318.00 

Copy personal property total ▶

+ $12318.00 

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

$22318.00 

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 28 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

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)

$2,400.00

100% of fair market value, up to any

applicable statutory limit

$50.00

100% of fair market value, up to any

applicable statutory limit

No

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

No

Yes

Official Form 106C Schedule C: The Property You Claim as Exempt page 1

Official Form 106C

Schedule C: The Property You Claim as Exempt

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.

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: Kia, Optima, 2012

Line from

Schedule A/B: 03

$9,033.00

735 ILCS 5/12-1001(c)

Brief

description:

Television; Samsung

Note 5

Line from

Schedule A/B: 07

$50.00

735 ILCS 5/12-1001(b)

3. Are you claiming a homestead exemption of more than $160,375?

(Subject to adjustment on 4/01/19 and every 3 years after that for cases filed on or after the date of adjustment.)

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 29 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

$100.00

100% of fair market value, up to any

applicable statutory limit

$1,000.00

100% of fair market value, up to any

applicable statutory limit

$130.00

100% of fair market value, up to any

applicable statutory limit

$2,000.00

100% of fair market value, up to any

applicable statutory limit

$4,000.00

100% of fair market value, up to any

applicable statutory limit

Official Form 106C Schedule C: The Property You Claim as Exempt page 2

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: Clothes

Line from

Schedule A/B: 11

$100.00

735 ILCS 5/12-1001(a)

Brief

description: Cash

Line from

Schedule A/B: 16

$1,000.00

735 ILCS 5/12-1001(b)

Brief

description: MB Financial

Line from

Schedule A/B: 17

$130.00

735 ILCS 5/12-1001(b)

Brief

description: Prudential

Line from

Schedule A/B: 31

$2,000.00

735 ILCS 5/12-1001(b)

Brief

description:

418 E. Vaughn St.,

Ironwood, MI 49938

Line from

Schedule A/B: 01

$10,000.00

735 ILCS 5/12-1001(b)

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 30 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

1.

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.

Do any creditors have claims secured by your property?

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 9/1/2014 

Contingent

Unliquidated

Disputed

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)

Last 4 digits of account

number

5225

Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1

Official Form 106D

Schedule D: Creditors Who Have Claims Secured by Property

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).

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 BK OF AMER 

Creditor's Name

PO BOX 1598 

Number Street

NORFOLK Virginia 23501

City State ZIP Code

Who owes the debt? Check one.

Describe the property that secures the claim:

048 Automobile 

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

Nature of lien. Check all that apply.

$5,829.00 $9,033.00 $0.00

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

here:

$5,829.00

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

 Check if this is an amended filing

12/15

No. Go to Part 2.

Yes.

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

Official Form 106E/F

Schedule E/F: Creditors Who Have Unsecured Claims

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 A/B: 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 Hold 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).

Part 1: List All of Your PRIORITY Unsecured Claims

1. Do any creditors have priority unsecured claims against you?

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. If a claim has both priority and nonpriority amounts, list that claim here and show both priority and nonpriority amounts. As much as

possible, list the claims in alphabetical order according to the creditor's name. If you have more than two priority unsecured claims, fill out the Continuation Page of

Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.

(For an explanation of each type of claim, see the instructions for this form in the instruction booklet.)

Total

claim

Priority

amount

Nonpriority

amount

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 32 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

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

Yes.

ALLIANCE COLLECTION AG 

Nonpriority Creditor's Name

3916 S BUSINESS PARK AVE 

Number Street

MARSHFIELD Wisconsin 54449 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify

001 Collection; Collecting for ORIGINAL

CREDITOR: MEDICAL PAYMENT

DATA; MEDICAL 

AMEX 

Nonpriority Creditor's Name

P O BOX 7871 

Number Street

FORT

LAUDERDAL 

Florida 33329 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify CreditCard 

BK OF AMER 

Nonpriority Creditor's Name

PO BOX 1598 

Number Street

NORFOLK Virginia 23501 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify CreditCard 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 2

Part 2: List All of Your NONPRIORITY Unsecured Claims

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

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. 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. Do not list claims already included in Part 1.

If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than four priority unsecured claims fill out the Continuation Page of

Part 2.

Total claim

4.1

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 9459

When was the debt incurred? 12/1/2015

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

Type of NONPRIORITY unsecured claim:

$159.00

4.2

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number

When was the debt incurred? 10/1/2007

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

Type of NONPRIORITY unsecured claim:

$8,756.00

4.3

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 9141

When was the debt incurred? 11/1/2008

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

Type of NONPRIORITY unsecured claim:

$5,197.00

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

CAPITAL ONE 

Nonpriority Creditor's Name

11013 W BROAD ST 

Number Street

GLEN ALLEN Virginia 23060 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify CreditCard 

CELCO 

Nonpriority Creditor's Name

Po Box 932756 

Number Street

Cleveland Ohio 44193 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify

Collection; Collecting for ORIGINAL

CREDITOR: 04 BERRIEN COUNTY 

CELCO 

Nonpriority Creditor's Name

Po Box 932756 

Number Street

Cleveland Ohio 44193 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Nonpriority 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 3

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

After listing any entries on this page, number them beginning with 4.5, followed by 4.6, and so forth. Total claim

4.4

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 6735

When was the debt incurred? 1/1/2006

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

Type of NONPRIORITY unsecured claim:

$3,124.00

4.5

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 3722

When was the debt incurred? 7/1/2015

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

Type of NONPRIORITY unsecured claim:

$1,806.00

4.6

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 3722

When was the debt incurred? 7/23/2015

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

Type of NONPRIORITY unsecured claim:

$1,806.00

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Chase 

Nonpriority Creditor's Name

Attn: Bankruptcy Dpt. 

Number Street

Kennesaw Georgia 30156 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify CreditCard 

CITI 

Nonpriority Creditor's Name

701 E 60TH ST N, IBS CDV DISPUTES 

Number Street

SIOUX FALLS South Dakota 57104 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify CreditCard 

City of Ironwood 

Nonpriority Creditor's Name

Memorial Building 

Number Street

Ironwood Michigan 49938 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify None 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 4

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

After listing any entries on this page, number them beginning with 4.5, followed by 4.6, and so forth. Total claim

4.7

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 1095

When was the debt incurred? 2/1/2013

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

Type of NONPRIORITY unsecured claim:

$2,120.00

4.8

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 3066

When was the debt incurred? 6/1/2012

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

Type of NONPRIORITY unsecured claim:

$3,579.00

4.9

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 0-05

When was the debt incurred? 5/27/2015

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

Type of NONPRIORITY unsecured claim:

$585.45

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

DISCOVERBANK 

Nonpriority Creditor's Name

POB 15316 

Number Street

WILMINGTON Delaware 19850 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

Other. Specify CreditCard 

MERCANTILE ADJMNT BUR 

Nonpriority Creditor's Name

6390 MAIN ST S-160 

Number Street

WILLIAMVILLE New York 14221 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

Other. Specify

001 Collection; Collecting for ORIGINAL

CREDITOR: AMERICAN ELECTRIC

POWER 

SYNCB/BP 

Nonpriority Creditor's Name

C/O PO BOX 965024 

Number Street

ORLANDO Florida 32896 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

Other. Specify CreditCard 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 5

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

After listing any entries on this page, number them beginning with 4.5, followed by 4.6, and so forth. Total claim

4.10

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 6666

When was the debt incurred? 12/1/2012

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

Type of NONPRIORITY unsecured claim:

$3,456.00

4.11

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 9426

When was the debt incurred? 3/1/2016

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

Type of NONPRIORITY unsecured claim:

$1,038.00

4.12

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 2439

When was the debt incurred? 3/1/1979

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

Type of NONPRIORITY unsecured claim:

$2,198.00

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

US BANK 

Nonpriority Creditor's Name

4325 17TH AVE SW 

Number Street

FARGO North Dakota 58125 

City State Zip Code

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

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

Other. Specify CreditCard 

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 6

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

After listing any entries on this page, number them beginning with 4.5, followed by 4.6, and so forth. Total claim

4.13

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number

When was the debt incurred? 6/1/2011

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

Type of NONPRIORITY unsecured claim:

$6,447.00

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

6a. Domestic support obligations. 6a.

6b. Taxes and certain other debts you owe the government 6b.

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

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

amount here.

6d.

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

6f. Student loans 6f.

6g. Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

6g.

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

debts

6h.

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 page 7

Part 4: Add the Amounts for Each Type of Unsecured Claim

6.

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 claims

Total claims

from Part 1

$0.00

$0.00

$0.00

$0.00

$0.00

Total claims

Total claims

from Part 2

$0.00

$0.00

$0.00

$40,271.45

$40,271.45

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

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.

Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases

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).

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

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

Official Form 106H Schedule H: Your Codebtors page 1

Official Form 106H

Schedule H: Your Codebtors

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:

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is:

 An amended filing

A supplement showing post-petition chapter 13

expenses as of the following date:

MM / DD / YYYY

12/15

Burr Ridge Illinois 60527 

City State Zip Code

Official Form 106I Schedule I: Your Income page 1

Official Form 106I

Schedule I: Your Income

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

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.

1.

Employment status

Occupation

Employer's name

Employer's address

How long employed there?

Debtor 1

Employed

Not Employed

A+ Home Remodeling

150 Shore Dr

Number Street

Debtor 2

Employed

Not Employed

Number Street

City State Zip Code

Part 2: Give Details About Monthly Income

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

are separated.

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

a separate sheet to this form.

For Debtor 1 For Debtor 2 or

non-filing spouse

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

deductions.) If not paid monthly, calculate what the monthly wage would be.

2. $1,706.60

3. Estimate and list monthly overtime pay. 3. + $0.00

4. Calculate gross income. Add line 2 + line 3. 4. $1,706.60

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Official Form 106I Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or

non-filing spouse

Copy line 4 here 

➔

4. $1,706.60

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a. $439.50

5b. Mandatory contributions for retirement plans 5b. $0.00

5c. Voluntary contributions for retirement plans 5c. $0.00

5d. Required repayments of retirement fund loans 5d. $0.00

5e. Insurance 5e. $0.00

5f. Domestic support obligations 5f. $0.00

5g. Union dues 5g. $0.00

5h. Other deductions. Specify: 5h. + $0.00 +

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g +5h. 6. $439.50

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $1,267.10

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. $0.00

8b. Interest and dividends 8b. $0.00

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. $0.00

8d. Unemployment compensation 8d. $0.00

8e. Social Security 8e. $0.00

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. $0.00

8g. Pension or retirement income 8g. $0.00

8h. Other monthly income. Specify: 8h. + $0.00 +

9. Add all other income Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h. 9. $0.00

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. $1,267.10 + = $1,267.10

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. + $0.00

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 Schedules and Statistical Summary of Certain Liabilities and Related Data, if it applies

12.

$1,267.10

Combined

monthly income

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

 No.

 Yes. Explain: 

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 42 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is:

 An amended filing

A supplement showing post-petition chapter 13

expenses as of the following date:

MM / DD / YYYY

12/15

3. Do your expenses include

expenses of people other

than

yourself and your

dependents?

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 B 106I.) Your expenses

4.

$0.00

4a $0.00

4b. $0.00

4c. $0.00

4d. $0.00

Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J

Schedule J: Your Expenses

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 Forms 106J-2, Expenses for Separate Household of Debtor 2.

2. Do you have dependents? No

Do not list Debtor 1 and

Debtor 2.

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

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.

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

4b. Property, homeowner's, or renter's insurance

4c. Home maintenance, repair, and upkeep expenses

4d. Homeowner's association or condominium dues

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Your expenses

5. $0.00

6a. $0.00

6b. $0.00

6c. $0.00

6d $0.00

7. $300.00

8. $0.00

9. $150.00

10. $40.00

11. $100.00

12. $80.00

13. $100.00

14. $0.00

15a $0.00

15b $0.00

15c $150.00

15d $0.00

16

$0.00

17a $220.00

17b $0.00

17c $0.00

17d $0.00

18.

$0.00

19. $0.00

20a $0.00

20b $0.00

20c $0.00

20d $0.00

20e $0.00

Official Form 106J Schedule J: Your Expenses page 2

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

6. Utilities:

6a. Electricity, heat, natural gas

6b. Water, sewer, garbage collection

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

6d. Other. Specify:

7. Food and housekeeping supplies

8. Childcare and children's education costs

9. Clothing, laundry, and dry cleaning

10. Personal care products and services

11. Medical and dental expenses

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

Do not include car payments

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

14. Charitable contributions and religious donations

15. Insurance.

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

15a. Life insurance

15b. Health insurance

15c. Vehicle insurance

15d. Other insurance. Specify:

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

Specify:

17. Installment or lease payments:

17a. Car payments for Vehicle 1

17b. Car payments for Vehicle 2

17c. Other. Specify:

17d. Other. Specify:

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).

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

Specify:

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

20b. Real estate taxes.

20c. Property, homeowner's, or renter's insurance

20d. Maintenance, repair, and upkeep expenses.

20e. Homeowner's association or condominium dues

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

21 $0.00

$1,140.00

$0.00

$1,140.00

22.

23a $1,267.10

23b $1,140.00

23c

$127.10

Official Form 106J Schedule J: Your Expenses page 3

21.Other. Specify:

22. Calculate your monthly expenses.

22a. Add lines 4 through 21.

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

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

23.Calculate your monthly net income.

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

23b. Copy your monthly expenses from line 22 above.

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

The result is your monthly net income.

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: 

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

Yes. Name of person Attach Bankruptcy Petition Preparer's Notice, Declaration, and

Signature (Official Form 119).

Official Form 106Dec Declaration About an Individual Debtor's Schedules page 1

Official Form 106Dec

Declaration About an Individual Debtor's Schedules

If two married people are filing together, both are equally responsible for supplying correct information.

You must file this form whenever you file bankruptcy schedules or amended schedules. 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.

Part 1: Sign Below

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

No

Under penalty of perjury, I declare that I have read the summary and schedules filed with this declaration and

that they are true and correct.

û /s/ Evan Grossman

Signature of Debtor 1

û

Signature of Debtor 2

Date 8/2/2016

MM/DD/YYYY

Date

MM/DD/YYYY

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

Married

Not married

No

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

Same as Debtor 1 Same as Debtor 1

PO Box 1084 

Number Street Number Street

Eagle River Wisconsin 54521 

City State Zip Code City State Zip Code

Same as Debtor 1 Same as Debtor 1

Number Street Number Street

City State Zip Code City State Zip Code

No

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

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

Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy

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?

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

Debtor 1: Dates Debtor 1 lived

there

Debtor 2: Dates Debtor 2 lived

there

From 7/1/2015 From

To 3/1/2016 To

From From

To 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.)

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Wages,

commissions,

bonuses, tips

Operating a

business

Wages,

commissions,

bonuses, tips

Operating a

business

YYYY

Wages,

commissions,

bonuses, tips

Operating a

business

Wages,

commissions,

bonuses, tips

Operating a

business

YYYY

Wages,

commissions,

bonuses, tips

Operating a

business

Wages,

commissions,

bonuses, tips

Operating a

business

No

Yes. Fill in the details.

YYYY

YYYY

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

Part 2: Explain the Sources of Your Income

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.

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:

$3413.19 

For last calendar year:

(January 1 to December 31, 2015 )

$5000.00 

For the calendar year before that:

(January 1 to December 31, 2014 )

$9000.00 

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.

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, 2015 )

For the calendar year before that:

(January 1 to December 31, 2014 )

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No.

Yes. List below each creditor to whom you paid a total of $6,425* 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.

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 $6,425* or more?

No. Go to line 7.

* Subject to adjustment on 4/01/19 and every 3 years after that for cases filed on or after the date of adjustment.

Yes.

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.

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.

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

Creditor's Name

Number Street

City State Zip Code

Mortgage

Car

Credit card

Loan repayment

Suppliers or

vendors

Other

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

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

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

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

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. List all payments to an insider.

Insider's Name

Number Street

City State Zip Code

Insider's Name

Number Street

City State Zip Code

No

Yes. List all payments that benefited an insider.

Insider's Name

Number Street

City State Zip Code

Insider's Name

Number Street

City State Zip Code

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

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

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

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

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

such as child support and alimony.

Dates of

payment

Total amount

paid

Amount you still

owe

Reason for this payment

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.

Dates of

payment

Total amount

paid

Amount you still

owe

Reason for this payment

Include creditor's name

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Court Name

NumberStreet

City State Zip Code

Pending

On appeal

Concluded

Court Name

NumberStreet

City State Zip Code

Pending

On appeal

Concluded

No. Go to line 11.

Yes. Fill in the information below.

Creditor's Name

Number Street

City State Zip Code

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

Creditor's Name

Number Street

City State Zip Code

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

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

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

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

disputes.

Nature of the case Court or agency Status of the case

Case title

Case number

Case title

Case number

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.

Describe the property Date Value of the

property

Explain what happened

Describe the property Date Value of the

property

Explain what happened

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Creditor's Name

Number Street

City State Zip Code

No

Yes

No

Yes. Fill in the details for each gift.

Person to Whom You Gave the Gift

Number Street

City State Zip Code

Person to Whom You Gave the Gift

Number Street

City State Zip Code

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

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

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

Describe the action the creditor took Date action

was taken

Amount

Last 4 digits of account number: XXXX12. 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?

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?

Gifts with a total value of more than $600

per person

Describe the gifts Dates you

gave the

gifts

Value

Person's relationship to you

Person's relationship to you

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

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

Charity’s Name

Number Street

City State Zip Code

No

Yes. Fill in the details.

No

Yes. Fill in the details.

The Law Offices of Schneider & Stone 

Person Who Was Paid

20 South Clark Street 28th Floor 

Number Street

Chicago Illinois 60606 

City State Zip Code

Email or website address

Person Who Made the Payment, if Not You

Person Who Was Paid

Number Street

City State Zip Code

Email or website address

Person Who Made the Payment, if Not You

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

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

Gifts with a total value of more than $600

per person

Describe the gifts Dates you

gave the

gifts

Value

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?

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.

Description and value of any property transferred Date

payment or

transfer was

made

Amount of payment

Attorney’s Fee - 1500.00 8/2/2016 $1500.00

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Person Who Was Paid

Number Street

City State Zip Code

No

Yes. Fill in the details.

Person Who Received Transfer

Number Street

City State Zip Code

Person Who Received Transfer

Number Street

City State Zip Code

No

Yes. Fill in the details.

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

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.

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.

Description and value of any

property transferred

Describe any property or payments

received or debts paid in

exchange

Date transfer

was made

Person's relationship to you

Person's relationship to you

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.)

Description and value of the property transferred Date transfer

was made

Name of trust

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Person Who Was Paid

Number Street

City State Zip Code

Checking

Savings

Money market

Brokerage

Other

Person Who Was Paid

Number Street

City State Zip Code

Checking

Savings

Money market

Brokerage

Other

No

Yes. Fill in the details.

Name of Financial Institution

Number Street

City State Zip Code

Name

Number Street

City State Zip Code

No

Yes

No

Yes. Fill in the details.

Name of Storage Facility

Number Street

City State Zip Code

Name

Number Street

City State Zip Code

No

Yes

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

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.

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

XXXXXXXX21. 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?

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

have it?

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

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

have it?

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Owner’s Name

Number Street

City State Zip Code

Number Street

City State Zip Code

No

Yes. Fill in the details.

Name of site

Number Street

City State Zip Code

Governmental unit

Number Street

City State Zip Code

No

Yes. Fill in the details.

Name of site

Number Street

City State Zip Code

Governmental unit

Number Street

City State Zip Code

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

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.

Where is the property? Describe the contents Value

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?

Governmental unit Environmental law, if you know it Date of

notice

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

Governmental unit Environmental law, if you know it Date of

notice

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Case title

Case number

Court Name

Number Street

City State Zip Code

Pending

On appeal

Concluded

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

Business Name

Number Street

City State Zip Code

Business Name

Number Street

City State Zip Code

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

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

Court or agency Nature of the case Status of the

case

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?

Describe the nature of the business Employer Identification number Do not

include Social Security number or ITIN.

Name of accountant or bookkeeper

EIN:

Dates business existed

From To

Describe the nature of the business Employer Identification number Do not

include Social Security number or ITIN.

Name of accountant or bookkeeper

EIN:

Dates business existed

From To

Describe the nature of the business Employer Identification number Do not

include Social Security number or ITIN.

Name of accountant or bookkeeper

EIN:

Dates business existed

From To

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details below.

Name

Number Street

City State Zip Code

Yes. Name of person

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

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

creditors, or other parties.

Date issued

MM/DD/YYYY

Part 12: Sign Below

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

and correct. I understand that making a false statement, concealing property, or obtaining money or property by fraud in connection with a

bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

û /s/ Evan Grossman

Signature of Debtor 1

û

Signature of Debtor 2

Date 8/2/2016

Date

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

No

Yes

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

No

Attach the Bankruptcy Petition Preparer's Notice,

Declaration, and Signature (Official Form 119).

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Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

◼ creditors have claims secured by your property, or

◼ you have leased personal property and the lease has not expired.

Surrender the property.

Retain the property and redeem it.

Retain the property and enter into a

Reaffirmation Agreement.

Retain the property and [explain]:

No.

Yes.

Surrender the property.

Retain the property and redeem it.

Retain the property and enter into a

Reaffirmation Agreement.

Retain the property and [explain]:

No.

Yes.

Surrender the property.

Retain the property and redeem it.

Retain the property and enter into a

Reaffirmation Agreement.

Retain the property and [explain]:

No.

Yes.

Surrender the property.

Retain the property and redeem it.

Retain the property and enter into a

Reaffirmation Agreement.

Retain the property and [explain]:

No.

Yes.

Official Form 108 Statement of Intention for Individuals Filing Under Chapter 7 page 1

Official Form 108

Statement of Intention for Individuals Filing Under Chapter 7

If you are an individual filing under chapter 7, you must fill out this form if:

You must file this form with the court within 30 days after you file your bankruptcy petition or by the date set for the meeting of creditors,

whichever is earlier, unless the court extends the time for cause. You must also send copies to the creditors and lessors you list on the form.

If two married people are filing together in a joint case, both are equally responsible for supplying correct information.

Both debtors must sign and date the form.

Be as complete and accurate as possible. 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).

Part 1: List Your Creditors Who Have Secured Claims

1. For any creditors that you listed in Part 1 of Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D), fill in the information

below.

Identify the creditor and the property that is collateral What do you intend to do with the property that

secures a debt?

Did you claim the property

as exempt on Schedule C?

Creditor's

name: BK OF AMER

Description of

property

securing debt: 048 Automobile

Creditor's

name:

Description of

property

securing debt:

Creditor's

name:

Description of

property

securing debt:

Creditor's

name:

Description of

property

securing debt:

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Debtor

1

Evan L Grossman 

First Name Middle Name Last Name

Case number (if

known)

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Official Form 108 Statement of Intention for Individuals Filing Under Chapter 7 page 2

Part 2: List Your Unexpired Personal Property Leases

For any unexpired personal property lease that you listed in Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G), fill in the

information below. Do not list real estate leases. Unexpired leases are leases that are still in effect; the lease period has not yet ended. You may assume an

unexpired personal property lease if the trustee does not assume it. 11 U.S.C. § 365(p)(2).

Describe your unexpired personal property leases Will the lease be assumed?

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Part 3: Sign Below

Under penalty of perjury, I declare that I have indicated my intention about any property of my estate that secures a debt and any personal property

that is subject to an unexpired lease.

û /s/ Evan Grossman

Signature of Debtor 1

û

Signature of Debtor 1

Date 8/2/2016

MM/DD/YYYY

Date

MM/DD/YYYY

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 60 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case: Check one box only as directed in this form and in

Form 122A-1Supp:

1. There is no presumption of abuse.

2. The calculation to determine if a presumption of

abuse applies will be made under Chapter 7

Means Test Calculation (Official Form 122A-2).

3. The Means Test does not apply now because of

qualified military service but it could apply later.

 Check if this is an amended filing

12/15

Living separately or are legally separated. Fill out Column A, lines 2-11; do not fill out Column B. By checking this box, you declare

under penalty of perjury that you and your spouse are legally separated under nonbankruptcy law that applies or that you and your

spouse are living apart for reasons that do not include evading the Means Test requirements. 11 U.S.C. § 707(b)(7)(B).

- -

- -

Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 1

Official Form 122A-1

Chapter 7 Statement of Your Current Monthly Income

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more space is needed,

attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any additional pages, write your name

and case number (if known). If you believe that you are exempted from a presumption of abuse because you do not have primarily consumer debts or

because of qualifying military service, complete and file Statement of Exemption from Presumption of Abuse Under § 707(b)(2) (Official Form 122A-1Supp)

with this form.

Part 1: Calculate Your Current Monthly Income

1.What is your marital and filing status? Check one only.

Not married. Fill out Column A, lines 2-11.

Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11.

Married and your spouse is NOT filing with you. You and your spouse are:

Living in the same household and are not legally separated. Fill out both Columns A and B, lines 2-11.

Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this

bankruptcy case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through

August 31. If the amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6.

Fill in the result. Do not include any income amount more than once. For example, if both spouses own the same rental property, put the

income from that property in one column only. If you have nothing to report for any line, write $0 in the space.

Column A

Debtor 1

Column B

Debtor 2 or

non-filing spouse

2. Your gross wages, salary, tips, bonuses, overtime, and commissions

(before all payroll deductions).

$0.00

3. Alimony and maintenance payments. Do not include payments from a spouse if

Column B is filled in.

$0.00

4. All amounts from any source which are regularly paid for household expenses

of you or your dependents, including child support. Include regular contributions

from an unmarried partner, members of your household, your dependents, parents,

and roommates. Include regular contributions from a spouse only if Column B is not

filled in. Do not include payments you listed on line 3. $0.00

5. Net income from operating a business, profession,

or farm Debtor 1 Debtor 2

Gross receipts (before all deductions) $0.00

Ordinary and necessary operating expenses $0.00

Net monthly income from a business, profession, or farm $0.00 copy

here→ $0.00

6.Net income from rental and other real property Debtor 1 Debtor 2

Gross receipts (before all deductions) $0.00

Ordinary and necessary operating expenses $0.00

Net monthly income from rental or other real property $0.00 copy

here→ $0.00

7. Interest, dividends, and royalties $0.00

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 61 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

For you $0.00

For your spouse $0.00

+ +

$0.00

Total current

monthly income

Copy line 11 here →

Fill in the state in which you live. Illinois

Fill in the number of people in your household. 1

Fill in the median family income for your state and size of household. $49,682.00

14a. 

14b. 

Official Form 122A-1 Chapter 7 Statement of Your Current Monthly Income page 2

Column A

Debtor 1

Column B

Debtor 2 or

non-filing spouse

8.Unemployment compensation

Do not enter the amount if you contend that the amount received was a benefit under the

Social Security Act. Instead, list it here: ↓

$0.00

9.Pension or retirement income. Do not include any amount received that was a

benefit under the Social Security Act.

$0.00

10.Income from all other sources not listed above.Specify the source and amount.

Do not include any benefits received under the Social Security Act or payments

received as a victim of a war crime, a crime against humanity, or international or

domestic terrorism. If necessary, list other sources on a separate page and put the

total below.

Total amounts from separate pages, if any. $0.00

11. Calculate your total current monthly income. Add lines 2 through 10 for each

column. Then add the total for Column A to the total for Column B.

$0.00 +

=

Part 2: Determine Whether the Means Test Applies to You

12. Calculate your current monthly income for the year. Follow these steps:

12a. Copy your total current monthly income from line 11. $0.00

Multiply by 12 (the number of months in a year). X 12

12b. The result is your annual income for this part of the form. 12b. $0.00

13 Calculate the median family income that applies to you. Follow these steps:

13.

To find a list of applicable median income amounts, go online using the link specified in the separate

instructions for this form. This list may also be available at the bankruptcy clerk’s office.

14. How do the lines compare?

Line 12b is less than or equal to line 13. On the top of page 1, check box 1, There is no presumption of abuse.

Go to Part 3.

Line 12b is more than line 13. On the top of page 1, check box 2, The presumption of abuse is determined by Form 122A-2.

Go to Part 3 and fill out Form 122A-2.

Part 3: Sign Below

By signing here, I declare under penalty of perjury that the information on this statement and in any attachments is true and correct.

û /s/ Evan Grossman

Signature of Debtor 1

û

Signature of Debtor 2

Date 8/2/2016

MM/DD/YYYY

Date 8/2/2016

MM/DD/YYYY

If you checked line 14a, do NOT fill out or file Form 122A-2.

If you checked line 14b, fill out Form 122A-2 and file it with this form.

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 62 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case: Check the appropriate box as directed in

lines 40 or 42:

According to the calculations required by

this Statement:

1. There is no presumption of abuse.

2. There is a presumption of abuse.

 Check if this is an amended filing

12/15

1. Copy your total current monthly income. Copy line 11 from Official Form 122A-1 here ➜ $0.00

3. Adjust your current monthly income by subtracting any part of your spouse's income not used to pay for the household expenses of

you or your dependents. Follow these steps:

Total $0.00 $0.00 Copy total here ➜  ̅

$0.00

$0.00

Official Form 122A-2 Chapter 7 Means Test Calculation page 1

Official Form 122A-2

Chapter 7 Means Test Calculation

To fill out this form, you will need your completed copy of Chapter 7 Statement of Your Current Monthly Income (Official Form 122A-1).

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more space is needed,

attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any additional pages, write your name

and case number (if known).

Part 1: Determine Your Adjusted Income

2. Did you fill out Column B in Part 1 of Form 122A-1?

No. Fill in $0 for the total on line 3.

Yes. Is your spouse filing with you?

No. Go to line 3.

Yes. Fill in $0 for the total on line 3.

On line 11, Column B of Form 122A-1, was any amount of the income you reported for your spouse NOT

regularly used for the household expenses of you or your dependents?

No. Fill in 0 for the total on line 3.

Yes. Fill in the information below:

State each purpose for which the income was used

For example, the income is used to pay your spouse's tax debt or to support

people other than you or your dependents

Fill in the amount you

are subtracting from

your spouse's income

4. Adjust your current monthly income. Subtract the total on line 3 from line 1.

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 Document Page 63 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

National Standards You must use the IRS National Standards to answer the questions in lines 6-7.

Total. Add lines 7c and 7f. $54.00

Official Form 122A-2 Chapter 7 Means Test Calculation page 2

Part 2: Calculate Your Deductions from Your Income

The Internal Revenue Service (IRS) issues National and Local Standards for certain expense amounts. Use these amounts to answer

the questions in lines 6-15. To find the IRS standards, go online using the link specified in the separate instructions for this form.

This information may also be available at the bankruptcy clerk's office.

Deduct the expense amounts set out in lines 6-15 regardless of your actual expense. In later parts of the form, you will use some of your actual

expenses if they are higher than the standards. Do not deduct any amounts that you subtracted from your spouse's income in line 3 and do not

deduct any operating expenses that you subtracted from income in lines 5 and 6 of Form 122A-1.

If your expenses differ from month to month, enter the average expense.

Whenever this part of the form refers to you, it means both you and your spouse if Column B of Form 122A-1 is filled in.

5. The number of people used in determining your deductions from income

Fill in the number of people who could be claimed as exemptions on your federal income tax return,

plus the number of any additional dependents whom you support. This number may be different from

the number of people in your household.

1

6. Food, clothing, and other items: Using the number of people you entered in line 5 and the IRS National Standards, fill

in the dollar amount for food, clothing, and other items.

$570.00

7. Out-of-pocket health care allowance: Using the number of people you entered in line 5 and the IRS National Standards,

fill in the dollar amount for out-of-pocket health care. The number of people is split into two categories-people who are

under 65 and people who are 65 or older-because older people have a higher IRS allowance for health care costs. If your

actual expenses are higher than this IRS amount, you may deduct the additional amount on line 22.

People who are under 65 years of age

7a. Out-of-pocket health care allowance per person $54.00

7b. Number of people who are under 65 1

7c. Subtotal. Multiply line 7a by line 7b. $54.00 Copy here➜ $54.00

People who are 65 years of age or older

7d. Out-of-pocket health care allowance per person $130.00

7e. Number of people who are 65 or older 0

7f. Subtotal. Multiply line 7d by line 7e. $0.00 Copy here➜ +$0.00

7g. $54.00 Copy total here ➜

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 Document Page 64 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Local Standards You must use the IRS Local Standards to answer the questions in lines 8-15.

9a. Using the number of people you entered in line 5, fill in the dollar amount listed

for your county for mortgage or rent expenses. $1,480.00

9b. Total average monthly payment for all mortgages and other debts secured by your home.

Name of the creditor Average monthly

payment

+

Total average monthly payment Copy

here➜

-

9c. Net mortgage or rent expense.

Subtract line 9b (total average monthly payment) from line 9a (mortgage or

rent expense). If this amount is less than $0, enter $0.

$1,480.00 Copy

here➜

Explain

why:

 

Official Form 122A-2 Chapter 7 Means Test Calculation page 3

Based on information from the IRS, the U.S. Trustee Program has divided the IRS Local Standard for housing for

bankruptcy purposes into two parts:

Housing and utilities - Insurance and operating expenses

Housing and utilities - Mortgage or rent expenses

To find the chart, go online using the link specified in the separate instructions for this form.

This chart may also be available at the bankruptcy clerk's office.

8. Housing and utilities - Insurance and operating expenses: Using the number of people you entered in line 5, fill in the dollar amount

listed for your county for insurance and operating expenses. $450.00

9. Housing and utilities - Mortgage or rent expenses:

To calculate the total average monthly payment, add all amounts that are

contractually due to each secured creditor in the 60 months after you file for

bankruptcy. Then divide by 60.

$0.00 $0.00

Repeat this

amount on

line 33a.

$1,480.00

10. If you claim that the U.S. Trustee Program's division of the IRS Local Standard for housing is incorrect and affects the

calculation of your monthly expenses, fill in any additional amount you claim. $0.00

11. Local transportation expenses: Check the number of vehicles for which you claim an ownership or operating expense.

0. Go to line 14.

1. Go to line 12.

2 or more. Go to line 12.

12. Vehicle operation expense: Using the IRS Local Standards and the number of vehicles for which you claim the operating expenses, fill

in the Operating Costs that apply for your Census region or metropolitan statistical area. $191.00

Case 16-24859 Doc 1 Filed 08/02/16 Entered 08/02/16 16:17:02 Desc Main

 Document Page 65 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Vehicle 1 Describe Vehicle 1:

13a. Ownership or leasing costs using IRS Local Standard. $471.00

13b. Average monthly payment for all debts secured by Vehicle 1.

Do not include costs for leased vehicles.

To calculate the average monthly payment here and on line 13e, add all

amounts that are contractually due to each secured creditor in the 60 months

after you filed for bankruptcy. Then divide by 60.

Name of each creditor for Vehicle 1 Average monthly

payment

+

Total average monthly payment Copy here➜

13c. Net Vehicle 1 ownership or lease expense

Subtract line 13b from line 13a. If this amount is less than $0, enter $0. $254.00

Copy net

Vehicle 1

expense

here ➜

Official Form 122A-2 Chapter 7 Means Test Calculation page 4

13. Vehicle ownership or lease expense: Using the IRS Local Standards, calculate the net ownership or lease expense for each vehicle

below. You may not claim the expense if you do not make any loan or lease payments on the vehicle. In addition, you may not claim the

expense for more than two vehicles.

BK OF AMER $217.00

$217.00 - $217.00

Repeat this

amount on

line 33b.

$254.00

14. Public transportation expense: If you claimed 0 vehicles in line 11, using the IRS Local Standards, fill in the Public Transportation

expense allowance regardless of whether you use public transportation.

15. Additional public transportation expense: If you claimed 1 or more vehicles in line 11 and if you claim that you may also deduct a

public transportation expense, you may fill in what you believe is the appropriate expense, but you may not claim more than the IRS Local

Standard for Public Transportation.

$0.00

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 Document Page 66 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Other Necessary Expenses In addition to the expense deductions listed above, you are allowed your monthly expenses for

the following IRS categories.

Official Form 122A-2 Chapter 7 Means Test Calculation page 5

16. Taxes:The total monthly amount that you will actually owe for federal, state and local taxes, such as income taxes, self-employment taxes,

social security taxes, and Medicare taxes. You may include the monthly amount withheld from your pay for these taxes. However, if you

expect to receive a tax refund, you must divide the expected refund by 12 and subtract that number from the total monthly amount that is

withheld to pay for taxes.

Do not include real estate, sales, or use taxes.

$0.00

17. Involuntary deductions: The total monthly payroll deductions that your job requires, such as retirement contributions, union dues, and

uniform costs.

Do not include amounts that are not required by your job, such as voluntary 401(k) contributions or payroll savings.

$0.00

18. Life insurance: The total monthly premiums that you pay for your own term life insurance. If two married people are filing together,

include payments that you make for your spouse's term life insurance. Do not include premiums for life insurance on your dependents, for

a non-filing spouse's life insurance, or for any form of life insurance other than term. $0.00

19. Court-ordered payments: The total monthly amount that you pay as required by the order of a court or administrative agency, such as

spousal or child support payments.

Do not include payments on past due obligations for spousal or child support. You will list these obligations in line 35.

$0.00

20. Education: The total monthly amount that you pay for education that is either required:

as a condition for your job, or

for your physically or mentally challenged dependent child if no public education is available for similar services. $0.00

21. Childcare: The total monthly amount that you pay for childcare, such as babysitting, daycare, nursery, and preschool.

Do not include payments for any elementary or secondary school education.

$0.00

22. Additional health care expenses, excluding insurance costs: The monthly amount that you pay for health care that is required for the

health and welfare of you or your dependents and that is not reimbursed by insurance or paid by a health savings account. Include only the

amount that is more than the total entered in line 7. Payments for health insurance or health savings accounts should be listed only in line

25.

$0.00

23. Optional telephones and telephone services: The total monthly amount that you pay for telecommunication services for you and your

dependents, such as pagers, call waiting, caller identification, special long distance, or business cell phone service, to the extent

necessary for your health and welfare or that of your dependents or for the production of income, if it is not reimbursed by your employer..

Do not include payments for basic home telephone, internet and cell phone service. Do not include self-employment expenses, such as

those reported on line 5 of Official Form 122A-1, or any amount you previously deducted.

+$0.00

24. Add all of the expenses allowed under the IRS expense allowances.

Add lines 6 through 23. $2,999.00

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 Document Page 67 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Additional Expense Deductions These are additional deductions allowed by the Means Test.

Note: Do not include any expense allowances listed in lines 6-24.

Official Form 122A-2 Chapter 7 Means Test Calculation page 6

25. Health insurance, disability insurance, and health savings account expenses. The monthly expenses for health insurance,

disability insurance, and health savings accounts that are reasonably necessary for yourself, your spouse, or your

Health insurance $0.00

Disability insurance $0.00

Health savings account $0.00

Total $0.00 Copy total here➜ $0.00

Do you actually spend this total amount?

No. How much do you actually spend?

Yes

26. Continuing contributions to the care of household or family members. The actual monthly expenses that you will continue to pay

for the reasonable and necessary care and support of an elderly, chronically ill, or disabled member of your household or member of your

immediate family who is unable to pay for such expenses. These expenses may include contributions to an account of a qualified ABLE

program. 26 U.S.C. § 529A(b).

$0.00

27. Protection against family violence. The reasonably necessary monthly expenses that you incur to maintain the safety of you and your

family under the Family Violence Prevention and Services Act or other federal laws that apply.

By law, the court must keep the nature of these expenses confidential.

$0.00

28. Additional home energy costs. Your home energy costs are included in your insurance and operating expenses on line 8.

If you believe that you have home energy costs that are more than the home energy costs included in expenses on line 8, then fill in the

excess amount of home energy costs.

You must give your case trustee documentation of your actual expenses, and you must show that the additional amount claimed is

reasonable and necessary.

$0.00

29. Education expenses for dependent children who are younger than 18. The monthly expenses (not more than $160.42* per child)

that you pay for your dependent children who are younger than 18 years old to attend a private or public elementary or secondary school.

You must give your case trustee documentation of your actual expenses, and you must explain why the amount claimed is reasonable and

necessary and not already accounted for in lines 6-23.

* Subject to adjustment on 4/01/19, and every 3 years after that for cases begun on or after the date of adjustment.

$0.00

30. Additional food and clothing expense. The monthly amount by which your actual food and clothing expenses are higher than the

combined food and clothing allowances in the IRS National Standards. That amount cannot be more than 5% of the food and clothing

allowances in the IRS National Standards.

To find a chart showing the maximum additional allowance, go online using the link specified in the separate instructions for this form.

This chart may also be available at the bankruptcy clerk's office.

You must show that the additional amount claimed is reasonable and necessary.

$0.00

31. Continuing charitable contributions. The amount that you will continue to contribute in the form of cash or financial instruments to a

religious or charitable organization. 26 U.S.C. § 170(c)(1)-(2).

+$0.00

32. Add all of the additional expense deductions.

Add lines 25 through 31. $0.00

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 Document Page 68 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Deductions for Debt Payment

33a. Copy line 9b here $0.00

33b. Copy line 13b here. $217.00

33c. Copy line 13e here. $0.00

33d. List other secured debts:

33e. Total average monthly payment. Add lines 33a through 33d. $217.00 $217.00

Yes. State any amount that you must pay to a creditor, in addition to the payments

listed in line 33, to keep possession of your property (called the cure amount).

Next, divide by 60 and fill in the information below.

$0.00 $0.00

Yes. Fill in the total amount of all of these priority claims. Do not include current or ongoing priority claims, such as those you listed

in line 19.

Total amount of all past-due priority claims $0.00 $0.00

Official Form 122A-2 Chapter 7 Means Test Calculation page 7

33. For debts that are secured by an interest in property that you own, including home mortgages, vehicle loans, and other

secured debt, fill in lines 33a through 33e. The monthly expenses for health insurance, disability

To calculate the total average monthly payment, add all amounts that are contractually due to each secured creditor in the 60 months after

you file for bankruptcy. Then divide by 60.

Mortgages on your home: Average monthly

payment

➜

Loans on your first two vehicles:

➜

➜

Name of each creditor for other

secured debt

Identify property that

secures the debt

Does payment

include taxes

or insurance?

Copy total

here➜

34. Are any debts that you listed in line 33 secured by your primary residence, a vehicle,

or other property necessary for your support or the support of your dependents?

No. Go to line 35.

Name of the creditor Identify property that

secures the debt

Total cure

amount

Monthly cure

amount

Total Copy total

here➜

35. Do you owe any priority claims such as a priority tax, child support, or alimony -

that are past due as of the filing date of your bankruptcy case? 11 U.S.C. § 507.

No. Go to line 36.

÷ 60 =

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 Document Page 69 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Yes. Fill in the following information.

$0.00

X0.0660

$0.00 $0.00

Add lines 33e through 36. $217.00

Total deductions $3,216.00

Copy here➜

Copy here➜

Official Form 122A-2 Chapter 7 Means Test Calculation page 8

36. Are you eligible to file a case under Chapter 13? 11 U.S.C. § 507.

For more information, go online using the link for Bankruptcy Basics specified in the separate instructions for this form. Bankruptcy

Basics may also be available at the bankruptcy clerk's office.

No. Go to line 37.

Projected monthly plan payment if you were filing under Chapter 13

Current multiplier for your district as stated on the list issued by the Administrative Office of

the United States Courts (for districts in Alabama and North Carolina) or by the Executive

Office for United States Trustees (for all other districts).

To find a list of district multipliers that includes your district, go online using the link specified

in the separate instructions for this form. This list may also be available at the bankruptcy

clerk's office.

Average monthly administrative expense if you were filing under Chapter 13 Copy total

here➜

37. Add all of the deductions for debt payment.

Total Deductions from Income

38. Add all of the allowed deductions.

Copy line 24, All of the expenses allowed under IRS

expense allowances $2,999.00

Copy line 32, All of the additional expense deductions $0.00

Copy line 37, All of the deductions for debt payment $217.00

$3,216.00 Copy total here ➜

Part 3: Determine Whether There Is a Presumption of Abuse

39. Calculate monthly disposable income for 60 months

39a. Copy line 4, adjusted current monthly income $0.00

39b. Copy line 38, Total deductions $3,216.00

39c. Monthly disposable income. 11 U.S.C. § 707(b)(2).

Subtract line 39b from line 39a.

($3,216.00) ($3,216.00)

For the next 60 months (5 years) x 60

39d. Total. Multiply line 39c by 60 ($192,960.00) ($192,960.00)

40. Find out whether there is a presumption of abuse. Check the box that applies:

The line 39d is less than $7,700*. On the top of page 1 of this form, check box 1, There is no presumption of abuse. Go to Part 5.

The line 39d is more than $12,850*. On the top of page 1 of this form, check box 2, There is a presumption of abuse. You may fill

out Part 4 if you claim special circumstances. Then go to Part 5.

The line 39d is at least $7,700*, but not more than $12,850*. Go to line 41.

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 Document Page 70 of 75
Debtor 1 Evan L Grossman 

First Name Middle Name Last Name

Case number (if known)

Copy

here ➜

43. Do you have any special circumstances that justify additional expenses or adjustments of current monthly income for which there is no

reasonable alternative? 11 U.S.C. § 707(b)(2)(B).

Yes. Fill in the following information. All figures should reflect your average monthly expense or income adjustment

for each item. You may include expenses you listed in line 25.

Official Form 122A-2 Chapter 7 Means Test Calculation page 9

41. 41a. Fill in the amount of your total nonpriority unsecured debt. If you filled out A Summary of Your

Assets and Liabilities and Certain Statistical Information Schedules (Official Form 106Sum), you may

refer to line 3b on that form

x .25

41b. 25% of your total nonpriority unsecured debt. 11 U.S.C. § 707(b)(2)(A)(i)(I).

Multiply line 41a by 0.25 

42. Determine whether the income you have left over after subtracting all allowed deductions

is enough to pay 25% of your unsecured, nonpriority debt.

Check the box that applies:

Line 39d is less than line 41b. On the top of page 1 of this form, check box 1, There is no presumption of abuse.

Go to Part 5.

Line 39d is equal to or more than line 41b. On the top of page 1 of this form, check box 2, There is a presumption

of abuse. You may fill out Part 4 if you claim special circumstances. Then go to Part 5.

Part 4: Give Details About Special Circumstances

No. Go to Part 5.

You must give a detailed explanation of the special circumstances that make the expenses or income

adjustments necessary and reasonable. You must also give your case trustee documentation of your

actual expenses or income adjustments.

Give a detailed explanation of the special circumstances Average monthly expense

or income adjustment

Part 5: Sign Below

By signing here, I declare under penalty of perjury that the information on this statement and in any attachments is true and correct.

û /s/ Evan Grossman

Signature of Debtor 1

û

Signature of Debtor 2

Date 8/2/2016

MM/DD/YYYY

Date

MM/DD/YYYY

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 Document Page 71 of 75
— Liquidation

— Reorganization

— Voluntary repayment plan

for family farmers or

fishermen

— Voluntary repayment plan

for individuals with regular

income

page 1

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

Individuals Filing for Bankruptcy (Form 2010)

This notice is for you if:

You are an individual filing for

bankruptcy,

and

Your debts are primarily consumer

debts.

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

101(8) as “incurred by an individual primarily for

a personal, family, or household purpose.”

The types of bankruptcy that are

available to individuals

Individuals who meet the qualifications may file under

one of four different chapters of the Bankruptcy Code:

Chapter 7

Chapter 11

Chapter 12

Chapter 13

You should have an attorney review your

decision to file for bankruptcy and the choice

of chapter.

Chapter 7: Liquidation

+

$245 filing fee

$75 administrative fee

$15 trustee surcharge

$335 total fee

Chapter 7 is for individuals who have financial

difficulty preventing them from paying their debts

and who are willing to allow their nonexempt

property to be used to pay their creditors. The

primary purpose of filing under chapter 7 is to have

your debts discharged. The bankruptcy discharge

relieves you after bankruptcy from having to pay

many of your pre-bankruptcy debts. Exceptions

exist for particular debts, and liens on property

may still be enforced after discharge. For example,

a creditor may have the right to foreclose a home

mortgage or repossess an automobile.

However, if the court finds that you have

committed certain kinds of improper conduct

described in the Bankruptcy Code, the court may

deny your discharge.

You should know that even if you file chapter 7 and

you receive a discharge, some debts are not

discharged under the law. Therefore, you may still

be responsible to pay:

most taxes;

most student loans;

domestic support and property settlement

obligations;

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

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most fines, penalties, forfeitures, and criminal

restitution obligations; and

certain debts that are not listed in your

bankruptcy papers.

You may also be required to pay debts arising from:

fraud or theft;

fraud or defalcation while acting in breach of

fiduciary capacity;

intentional injuries that you inflicted; and

death or personal injury caused by operating a

motor vehicle, vessel, or aircraft while intoxicated

from alcohol or drugs.

If your debts are primarily consumer debts, the court

can dismiss your chapter 7 case if it finds that you

have enough income to repay creditors a certain

amount. You must file Chapter 7 Statement of Your

Current Monthly Income (Official Form 122A–1) if

you are an individual filing for bankruptcy under

chapter 7. This form will determine your current

monthly income and compare whether your income

is more than the median income that applies in your

state.

If your income is not above the median for your

state, you will not have to complete the other

chapter 7 form, the Chapter 7 Means Test

Calculation (Official Form 122A–2).

If your income is above the median for your state,

you must file a second form — the Chapter 7 Means

Test Calculation (Official Form 122A–2). The

calculations on the form— sometimes called the

Means Test —deduct from your income living

expenses and payments on certain debts to determine

any amount available to pay unsecured creditors. If

your income is more than the median income for

your state of residence and family size, depending

on the results of the Means Test, the U.S. trustee,

bankruptcy administrator, or creditors can file a

motion to dismiss your case under § 707(b) of the

Bankruptcy Code. If a motion is filed, the court

will decide if your case should be dismissed. To

avoid dismissal, you may choose to proceed under

another chapter of the Bankruptcy Code.

If you are an individual filing for chapter 7

bankruptcy, the trustee may sell your property to

pay your debts, subject to your right to exempt

the property or a portion of the proceeds from

the sale of the property. The property, and the

proceeds from property that your bankruptcy

trustee sells or liquidates that you are entitled to, is

called exempt property. Exemptions may enable

you to keep your home, a car, clothing, and

household items or to receive some of the

proceeds if the property is sold.

Exemptions are not automatic. To exempt

property, you must list it on Schedule C: The

Property You Claim as Exempt (Official Form

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

may sell it and pay all of the proceeds to your

creditors.

Chapter 11: Reorganization

+

$1,167 filing fee

$550 administrative fee

$1,717 total fee

Chapter 11 is often used for reorganizing a

business, but is also available to individuals. The

provisions of chapter 11 are too complicated to

summarize briefly.

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Read These Important Warnings

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

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

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

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

your family, your home, and your possessions.

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

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

may harm you. If you file without an attorney, you are still responsible for knowing and following all of the

legal requirements.

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

documents.

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

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

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

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

Chapter 12: Repayment plan for family

farmers or fishermen

+

$200 filing fee

$75 administrative fee

$275 total fee

Similar to chapter 13, chapter 12 permits family

farmers and fishermen to repay their debts over a

period of time using future earnings and to discharge

some debts that are not paid.

Chapter 13: Repayment plan for

individuals with regular

income

+

$235 filing fee

$75 administrative fee

$310 total fee

Chapter 13 is for individuals who have regular

income and would like to pay all or part of their

debts in installments over a period of time and to

discharge some debts that are not paid. You are

eligible for chapter 13 only if your debts are not

more than certain dollar amounts set forth in 11

U.S.C. § 109.

Under chapter 13, you must file with the court a

plan to repay your creditors all or part of the

money that you owe them, usually using your

future earnings. If the court approves your plan,

the court will allow you to repay your debts, as

adjusted by the plan, within 3 years or 5 years,

depending on your income and other factors.

After you make all the payments under your plan,

many of your debts are discharged. The debts that

are not discharged and that you may still be

responsible to pay include:

domestic support obligations,

most student loans,

certain taxes,

debts for fraud or theft,

debts for fraud or defalcation while acting in a

fiduciary capacity,

most criminal fines and restitution obligations,

certain debts that are not listed in your

bankruptcy papers,

certain debts for acts that caused death or

personal injury, and

certain long-term secured debts.

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

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Warning: File Your Forms on Time

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

you promptly file detailed information about your

creditors, assets, liabilities, income, expenses and

general financial condition. The court may dismiss

your bankruptcy case if you do not file this

information within the deadlines set by the Bankruptcy

Code, the Bankruptcy Rules, and the local rules of the

court

For more information about the documents and their

deadlines, go to:

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

s.html#procedure.

Bankruptcy crimes have serious

consequences

If you knowingly and fraudulently conceal assets

or make a false oath or statement under penalty

of perjury—either orally or in writing—in

connection with a bankruptcy case, you may be

fined, imprisoned, or both.

All information you supply in connection with a

bankruptcy case is subject to examination by the

Attorney General acting through the Office of the

U.S. Trustee, the Office of the U.S. Attorney, and

other offices and employees of the U.S.

Department of Justice.

Make sure the court has your

mailing address

The bankruptcy court sends notices to the mailing

address you list on Voluntary Petition for Individuals

Filing for Bankruptcy (Official Form 101). To ensure

that you receive information about your case,

Bankruptcy Rule 4002 requires that you notify the

court of any changes in your address.

A married couple may file a bankruptcy case

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

case and each spouse lists the same mailing address

on the bankruptcy petition, the bankruptcy court

generally will mail you and your spouse one copy

of each notice, unless you file a statement with

the court asking that each spouse receive separate

copies.

Understand which services you

could receive from credit

counseling agencies

The law generally requires that you receive a

credit counseling briefing from an approved credit

counseling agency. 11 U.S.C. § 109(h). If you are

filing a joint case, both spouses must receive the

briefing. With limited exceptions, you must

receive it within the 180 days before you file

your bankruptcy petition. This briefing is usually

conducted by telephone or on the Internet.

In addition, after filing a bankruptcy case, you

generally must complete a financial management

instructional course before you can receive a

discharge. If you are filing a joint case, both

spouses must complete the course.

You can obtain the list of agencies approved to

provide both the briefing and the instructional

course from:

http://www.justice.gov/ust/eo/hapcpa

/ccde/cc_approved.html

In Alabama and North Carolina, go to:

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

BankruptcyResources/ApprovedCredit

20AndDebtCounselors.aspx

If you do not have access to a computer, the clerk

of the bankruptcy court may be able to help you

obtain the list.

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

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