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

Official Form 101 

Voluntary Petition for Individuals Filing for Bankruptcy 12/15

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

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

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

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

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

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

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

(if known). Answer every question. 

Part 1: Identify Yourself

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

1. Your full name

Write the name that is on your

government-issued picture

identification (for example,

your driver’s license or

passport).

Bring your picture

identification to your meeting

with the trustee.

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

___________________________ 

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

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

___________________________ 

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

2. All other names you

have used in the last 8

years

Include your married or

maiden names.

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

__________________________________________________ 

First name 

__________________________________________________ 

Middle name 

__________________________________________________ 

Last name 

3. Only the last 4 digits of

your Social Security

number or federal

Individual Taxpayer

Identification number

(ITIN)

xxx – xx – ____ ____ ____ ____ 

OR 

9 xx – xx – ____ ____ ____ ____

xxx – xx – ____ ____ ____ ____ 

OR 

9 xx – xx – ____ ____ ____ ____

United States Bankruptcy Court for the: 

__________ District of __________ 

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

 Chapter 7 

 Chapter 11 

 Chapter 12 

 Chapter 13 

 Fill in this information to identify your case: 

 Check if this is an

amended filing

Northern District of Illinois ✔

Keith V

Elzey 3 4 2 7

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

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

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

4. Any business names

and Employer

Identification Numbers

(EIN) you have used in

the last 8 years

Include trade names and

doing business as names

 I have not used any business names or EINs.

_________________________________________________ 

Business name

_________________________________________________ 

Business name 

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN 

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN 

 I have not used any business names or EINs.

_________________________________________________ 

Business name

_________________________________________________ 

Business name 

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN 

___ ___ – ___ ___ ___ ___ ___ ___ ___ 

EIN 

5. Where you live

_________________________________________________ 

Number Street 

_________________________________________________ 

_________________________________________________ 

City State ZIP Code 

_________________________________________________ 

County 

If your mailing address is different from the one 

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

any notices to you at this mailing address.

_________________________________________________ 

Number Street 

_________________________________________________ 

P.O. Box 

_________________________________________________ 

City State ZIP Code 

If Debtor 2 lives at a different address: 

_________________________________________________ 

Number Street 

_________________________________________________ 

_________________________________________________ 

City State ZIP Code

_________________________________________________ 

County 

If Debtor 2’s mailing address is different from 

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

any notices to this mailing address.

_________________________________________________ 

Number Street 

_________________________________________________ 

P.O. Box 

_________________________________________________ 

City State ZIP Code

6. Why you are choosing

this district to file for

bankruptcy

Check one: 

 Over the last 180 days before filing this petition,

I have lived in this district longer than in any

other district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

________________________________________

________________________________________

________________________________________

________________________________________

Check one: 

 Over the last 180 days before filing this petition,

I have lived in this district longer than in any

other district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

________________________________________

________________________________________

________________________________________

________________________________________

Keith V Elzey Kema Real Estate Investment and Counseling, LLC 4 6 2 8 2 5 8 1 0

11939 S. Lawndale Unit 4C-2 Alsip IL 60803 Cook ✔

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

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

Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the

Bankruptcy Code you

are choosing to file

under

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

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

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

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

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

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

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

with a pre-printed address. 

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

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

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

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

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

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

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

9. Have you filed for

bankruptcy within the

last 8 years?

 No

 Yes. District __________________________ When _______________ Case number ___________________________

MM / DD / YYYY

District __________________________ When _______________ Case number ___________________________

MM / DD / YYYY

District __________________________ When _______________ Case number ___________________________ 

MM / DD / YYYY

10. Are any bankruptcy

cases pending or being

filed by a spouse who is

not filing this case with

you, or by a business

partner, or by an

affiliate?

 No

 Yes. Debtor _________________________________________________ Relationship to you _____________________

District __________________________ When _______________ Case number, if known____________________ 

MM / DD / YYYY

 Debtor _________________________________________________ Relationship to you _____________________ 

District __________________________ When _______________ Case number, if known____________________

MM / DD / YYYY

11. Do you rent your

residence?

 No. Go to line 12.

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

residence?

 No. Go to line 12.

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

this bankruptcy petition.

Keith V Elzey ✔

✔

✔ N District of IL 05/20/2016 16-17042 ✔

✔

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

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

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

12. Are you a sole proprietor

of any full- or part-time

business?

A sole proprietorship is a

business you operate as an

individual, and is not a

separate legal entity such as

a corporation, partnership, or

LLC.

If you have more than one

sole proprietorship, use a

separate sheet and attach it

to this petition.

 No. Go to Part 4.

 Yes. Name and location of business

_______________________________________________________________________________________ 

Name of business, if any 

_______________________________________________________________________________________ 

Number Street 

_______________________________________________________________________________________ 

_______________________________________________ _______ __________________________ 

City State ZIP Code

Check the appropriate box to describe your business: 

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

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

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

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

 None of the above

13. Are you filing under

Chapter 11 of the

Bankruptcy Code and

are you a small business

debtor?

For a definition of small

business debtor, see

11 U.S.C. § 101(51D).

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

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

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

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

 No. I am not filing under Chapter 11.

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

the Bankruptcy Code. 

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

Bankruptcy Code. 

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

14. Do you own or have any

property that poses or is

alleged to pose a threat

of imminent and

identifiable hazard to

public health or safety?

Or do you own any

property that needs

immediate attention?

For example, do you own

perishable goods, or livestock

that must be fed, or a building

that needs urgent repairs?

 No

 Yes. What is the hazard? ________________________________________________________________________

________________________________________________________________________

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

________________________________________________________________________ 

Where is the property? ________________________________________________________________________ 

Number Street

________________________________________________________________________

________________________________________ _______ ____________________ 

City State ZIP Code 

Keith V Elzey ✔

✔

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

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

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

15. Tell the court whether

you have received a

briefing about credit

counseling.

The law requires that you 

receive a briefing about credit 

counseling before you file for 

bankruptcy. You must 

truthfully check one of the 

following choices. If you 

cannot do so, you are not 

eligible to file. 

If you file anyway, the court 

can dismiss your case, you 

will lose whatever filing fee 

you paid, and your creditors 

can begin collection activities 

again. 

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

You must check one: 

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

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

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

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

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so. 

 Active duty. I am currently on active military

duty in a military combat zone. 

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court. 

You must check one: 

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

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

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

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

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so. 

 Active duty. I am currently on active military

duty in a military combat zone. 

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

Keith V Elzey ✔

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

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

Part 6: Answer These Questions for Reporting Purposes

16. What kind of debts do

you have?

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

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

 No. Go to line 16b.

 Yes. Go to line 17.

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

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

 No. Go to line 16c.

 Yes. Go to line 17.

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

 _______________________________________________________________ 

17. Are you filing under

Chapter 7?

Do you estimate that after

any exempt property is

excluded and

administrative expenses

are paid that funds will be

available for distribution

to unsecured creditors?

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

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

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

 No

 Yes

18. How many creditors do

you estimate that you

owe?

 1-49

 50-99

 100-199

 200-999

 1,000-5,000

 5,001-10,000

 10,001-25,000

 25,001-50,000

 50,001-100,000

 More than 100,000

19. How much do you

estimate your assets to

be worth?

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

20. How much do you

estimate your liabilities

to be?

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

Part 7: Sign Below

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

correct. 

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

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

under Chapter 7. 

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

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

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

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

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

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

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

 Executed on _________________ Executed on __________________ 

MM / DD / YYYY MM / DD / YYYY 

Keith V Elzey ✔

derived from Real Estate Investment ✔

✔

✔

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/s/Keith v Elzey 07/31/2016

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

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

For your attorney, if you are 

represented by one 

If you are not represented 

by an attorney, you do not 

need to file this page. 

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

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

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

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

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

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

_________________________________________________________________________________________________ 

Printed name 

_________________________________________________________________________________________________ 

Firm name 

_________________________________________________________________________________________________ 

Number Street 

_________________________________________________________________________________________________ 

______________________________________________________ ____________ ______________________________ 

City State ZIP Code

Contact phone _____________________________________ Email address ______________________________ 

______________________________________________________ ____________ 

Bar number State 

Keith V Elzey /s/Paul B. Molenda 07/31/2016 Paul B. Molenda Molenda Law Group 500 N Michigan Ste 600 Chicago IL 60611 (312) 204-7209 Michlawcenter@gmail.com P39929 MI

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

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 8

For you if you are filing this 

bankruptcy without an 

attorney 

If you are represented by 

an attorney, you do not 

need to file this page. 

The law allows you, as an individual, to represent yourself in bankruptcy court, but you 

should understand that many people find it extremely difficult to represent 

themselves successfully. Because bankruptcy has long-term financial and legal 

consequences, you are strongly urged to hire a qualified attorney.

To be successful, you must correctly file and handle your bankruptcy case. The rules are very 

technical, and a mistake or inaction may affect your rights. For example, your case may be 

dismissed because you did not file a required document, pay a fee on time, attend a meeting or 

hearing, or cooperate with the court, case trustee, U.S. trustee, bankruptcy administrator, or audit 

firm if your case is selected for audit. If that happens, you could lose your right to file another 

case, or you may lose protections, including the benefit of the automatic stay. 

You must list all your property and debts in the schedules that you are required to file with the 

court. Even if you plan to pay a particular debt outside of your bankruptcy, you must list that debt 

in your schedules. If you do not list a debt, the debt may not be discharged. If you do not list 

property or properly claim it as exempt, you may not be able to keep the property. The judge can 

also deny you a discharge of all your debts if you do something dishonest in your bankruptcy 

case, such as destroying or hiding property, falsifying records, or lying. Individual bankruptcy 

cases are randomly audited to determine if debtors have been accurate, truthful, and complete. 

Bankruptcy fraud is a serious crime; you could be fined and imprisoned. 

If you decide to file without an attorney, the court expects you to follow the rules as if you had 

hired an attorney. The court will not treat you differently because you are filing for yourself. To be 

successful, you must be familiar with the United States Bankruptcy Code, the Federal Rules of 

Bankruptcy Procedure, and the local rules of the court in which your case is filed. You must also 

be familiar with any state exemption laws that apply. 

Are you aware that filing for bankruptcy is a serious action with long-term financial and legal 

consequences? 

 No

 Yes

Are you aware that bankruptcy fraud is a serious crime and that if your bankruptcy forms are 

inaccurate or incomplete, you could be fined or imprisoned? 

 No

 Yes

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

 No

 Yes. Name of Person_____________________________________________________________________. 

Attach Bankruptcy Petition Preparer’s Notice, Declaration, and Signature (Official Form 119).

By signing here, I acknowledge that I understand the risks involved in filing without an attorney. I 

have read and understood this notice, and I am aware that filing a bankruptcy case without an 

attorney may cause me to lose my rights or property if I do not properly handle the case. 

_______________________________________________ ______________________________ Signature of Debtor 1 Signature of Debtor 2 

Date _________________ Date _________________ 

MM / DD / YYYY MM / DD / YYYY 

Contact phone ______________________________________ Contact phone ________________________________ 

Cell phone ______________________________________ Cell phone ________________________________ 

Email address ______________________________________ Email address ________________________________ 

Keith V Elzey ✔

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/s/Keith V Elzey 07/31/2016

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