United States Bankruptcy Court for the : 

_____NORTHERN_____ District of _ILLINOIS__

 (State)

Case Number (If known): __________________________ Chapter you are filing under:

 

Fill in this information to identify your case:

Check if this is an 

amended filing

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 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.

Chapter 7

Chapter 11

Chapter 12

Chapter 13

Part 1:

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

Identify Yourself

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)

Kimberly

J

Larsen

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

XXX - XX - ________________

OR

9XX - XX - ____ ____ ____ ____

XXX - XX - ________________

OR

9XX - XX - ____ ____ ____ ____

2992

Official Form 101 Record # 715543 Voluntary Petition for Individuals Filing for Bankruptcy page 1

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 1 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

______________________________________________

Number Street

______________________________________________

______________________________________________

City State ZIP Code

______________________________________________

County

______________________________________________

Number Street

______________________________________________

P.O. Box

______________________________________________

City State ZIP Code

______________________________________________

Number Street

______________________________________________

P.O. Box

______________________________________________

City State ZIP Code

______________________________________________

Number Street

______________________________________________

______________________________________________

City State ZIP Code

______________________________________________

County

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. I have not used any business names or EINs.

______________________________________________

Business name

______________________________________________

Business name

___ ___ - ___ ___ ___ ___ ___ ___ ___ 

EIN

___ ___ - ___ ___ ___ ___ ___ ___ ___ 

EIN

______________________________________________

Business name

______________________________________________

Business name

___ ___ - ___ ___ ___ ___ ___ ___ ___ 

EIN

___ ___ - ___ ___ ___ ___ ___ ___ ___ 

EIN

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

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's mailing address is different from 

the one above, fill it in here. Note that the court 

will send any notices this mailing address.

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

______________________________________________

______________________________________________

______________________________________________

______________________________________________

LAKE

1301 Canopy Drive

104

Round Lake IL 60073

Unit

Official Form 101 Record # 715543 Voluntary Petition for Individuals Filing for Bankruptcy page 2

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 Document Page 2 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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 

parter, or by 

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.

None

None

Official Form 101 Record # 715543 Voluntary Petition for Individuals Filing for Bankruptcy page 3

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 Document Page 3 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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, partnerhsip, or

LLC.

If you have more than one

sole proprietorship, use a

separate sheed 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

indentifiable 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

Official Form 101 Record # 715543 Voluntary Petition for Individuals Filing for Bankruptcy page 4

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 4 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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):

 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: You must check one:

 I received a briefing from an approved credit 

 counseling agency within the 180 days before I 

 filed this bankruptcy petition, and I received a 

 certificate of completion. 

 Attach a copy of the certificate and the payment 

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

 I received a briefing from an approved credit 

 counseling agency within the 180 days before I 

 filed this bankruptcy petition, but I do not have a 

 certificate of completion. 

 Within 14 days after you file this bankruptcy petition,

 you MUST file a copy of the certificate and payment 

 plan, if any.

 I certify that I asked for credit counseling 

 services from an approved agency, but was 

 unable to obtain those services during the 7 

 days after I made my request, and exigent 

 circumstances merit a 30-day temporary waiver 

 of the requirement. 

 To ask for a 30-day temporary waiver of the 

 requirement, attach a separate sheet explaining 

 what efforts you made to obtain the briefing, why 

 you were unable to obtain it before you filed for 

 bankruptcy, and what exigent circumstances 

 required you to file this case.

 Your case may be dismissed if the court is 

 dissatisfied with your reasons for not receiving a 

 briefing before you filed for bankruptcy.

 If the court is satisfied with your reasons, you must 

 still receive a briefing within 30 days after you file. 

 You must file a certificate from the approved 

 agency, along with a copy of the payment plan you 

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

 may be dismissed.

 Any extension of the 30-day deadline is granted 

 only for cause and is limited to a maximum of 15 

 days. 

 I am not required to receive a briefing about 

 credit counseling because of:

Incapacity. I have a mental illness or a mental 

 deficiency that makes me 

 incapable of realizing or making 

 rational decisions about finances. 

Disability. My physical disability causes me 

 to be unable to participate in a 

 briefing in person, by phone, or 

 through the internet, even after I 

 reasonably tried to do so.

Active duty. I am currently on active military 

 duty in a military combat zone. 

 If you believe you are not required to receive a 

 briefing about credit counseling, you must file a 

 motion for waiver of credit counseling with the court.

Official Form 101 Record # 715543 Voluntary Petition for Individuals Filing for Bankruptcy page 5

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 5 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

Part 6:

 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.

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

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?

18. How many creditors do

you estimate that you

owe?

1-49 1,000-5,000 25,001-50,000

50-99 5,001-10,000 50,001-100,000

100-199 10,001-25,000 More than 100,000

200-999

19. How much do you

estimate your assets to

be worth?

$0-$50,000 $1,000,001-$10 million $500,000,001-$1 billion

$50,001-$100,000 $10,000,001-$50 million $1,000,000,001-$10 billion

$100,001-$500,000 $50,000,001-$100 million $10,000,000,001-$50 billion

$500,001-$1 million $100,000,001-$500 million More than $50 billion

20. How much do you

estimate your liabilities

to be?

$0-$50,000 $1,000,001-$10 million $500,000,001-$1 billion

$50,001-$100,000 $10,000,001-$50 million $1,000,000,001-$10 billion

$100,001-$500,000 $50,000,001-$100 million $10,000,000,001-$50 billion

$500,001-$1 million $100,000,001-$500 million More than $50 billion

08/17/2016

/s/ Kimberly J Larsen

Part 7: Sign Below

For you

û û

Official Form 101 Record # 715543 Voluntary Petition for Individuals Filing for Bankruptcy page 6

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 Document Page 6 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen 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.

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.

Geraci Law L.L.C.

55 E. Monroe St., #3400

Chicago IL 60603

312-332-1800 ndil@geracilaw.com

û Date: 08/18/2016

Marc Adam Affolter

/s/ Marc Adam Affolter

6312227 IL

________________________________________ Date _______________________

Signature of Attorney for Debtor MM / DD / YYYY

_______________________________________________________________________________

Printed name

_______________________________________________________________________________

Firm name

_______________________________________________________________________________

Number Street

_______________________________________________________________________________

_____________________________________________ __________ ____________________

City State ZIP Code

Contact Phone ________________________________ Email address ___________________

______________________________________________ ___________

Bar number State

Official Form 101 Record # 715543 Voluntary Petition for Individuals Filing for Bankruptcy page 7

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 Document Page 7 of 54
Check if this is an 

amended filing

Official Form 106Sum

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

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

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

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

Fill in this information to identify your case:

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

Part 1:

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

Summarize Your Assets

Your assets

Value of what you own

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 Liabilities

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

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

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

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

$ 0

$ 13,674

$2,739.58

$2,736.00

$0

$102,095

$9,892

$ 13,674

Official Form 106Sum Record # 715543 Summary of Your Assets and Liabilities and Certain Statistical Information page 1

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 8 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

EntriesDescription AssetsAmount LiabilitiesAmount

Part 4: Answer These Questions for Administrative and Statistical Records

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

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

 Yes

7. What kind of debt do you have?

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

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

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

 this form to the court with your other schedules .

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

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

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

Total claim

From Part 4 of 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.

$______________________

$______________________

$______________________

$______________________

$______________________

$______________________

$______________________

 0.00

 0.00

 0.00

 0.00

 0.00

 0.00

 0.00

$ 3,750.00

Official Form 106Sum Record # 715543 Summary of Your Assets and Liabilities and Certain Statistical Information page 2

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 9 of 54
Fill in this information to identify your case and this filing:

Check if this is an 

amended filing

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

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.

12/15

Part 1: Describe Each Residence, Building, Land, or Other Real Esate You Own or Have an Interest In

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

No.

Yes. Describe.....

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

 you have attached for Part 1. Write that number here ............................................................................................................. --> $0.00

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.

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

No.

Yes. Describe.....

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property

Current value of the

entire property?

$________________

Current value of the

portion you own?

$________________

Make: ____________

Model: ____________

Year: ____________

Approximate Mileage: ____________

Other information:

2005

Cat

Arctic

 1,170.00 585.00

 3,000

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property

Current value of the

entire property?

$________________

Current value of the

portion you own?

$________________

Make: ____________

Model: ____________

Year: ____________

Approximate Mileage: ____________

Other information:

2012

Malibu

Chevrolet

 10,750.00 10,750.00

 72,000

04. 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. Describe.....

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

 you have attached for Part 2. Write that number here ................................................................................................ -->

$ 11,335.00

Official Form 106A/B Record # 715543 Schedule A/B: Property Page 1 of 6

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 Document Page 10 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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

Part 3: Describe Your Personal and Household Items

Current value of the

portion you own?

Do not deduct secured claims

or exemptions

06. Household goods and furnishings

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

No.

Yes. Describe.....

 Furniture, linens, small appliances, table & chairs, bedroom set $1,000

$____________ 1,000.00

07. Electronics

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

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

No.

Yes. Describe.....

 Flat screen TV, computer, printer, music collection, cell phone $750

$____________ 750.00

08. Collectibles of value

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

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

No.

Yes. Describe.....

$____________ 0.00

09. Equipment for sports and hobbies

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

and kayaks; carpentry tools; musical instruments

No.

Yes. Describe.....

$____________ 0.00

10. Firearms

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

No.

Yes. Describe.....

$____________ 0.00

11. Clothes

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

No.

Yes. Describe.....

 Everyday clothes $250

$____________ 250.00

12. Jewelry

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

gold, silver

No.

Yes. Describe.....

 Everyday jewelry, costume jewelry $100

$____________ 100.00

13. Non-farm animals

Examples: Dogs, cats, birds, horses

No.

Yes. Describe.....

 1 dog. $0

$____________ 0.00

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

No.

Yes. Describe.....

$____________ 0.00

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 .................................................................................................................................... -->

$2,100.00

Official Form 106A/B Record # 715543 Schedule A/B: Property Page 2 of 6

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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

Part 4: Describe Your Financial Assets

Current value of the

portion you own?

Do not deduct secured claims

or exemptions

16. Cash

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

No.

Yes. Describe.....

$____________ 0.00

17. Deposits of money

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

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

No.

Yes. Describe..... Account Type: Institution name:

Checking Account Chase $____________ 33.00

Checking Account Chase $____________ 48.00

Savings Account Chase $____________ 158.00

$____________ 239.00

18. Bonds, mutual funds, or publicly traded stocks

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

No.

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

$____________ 0.00

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

No.

Yes. Describe..... Name of Entity and Percent of Ownership:

$____________ 0.00

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

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

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

No.

Yes. Describe..... Issuer name:

$____________ 0.00

21. Retirement or pension accounts

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

No.

Yes. Describe..... Type of account and Institution name:

$____________ 0.00

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

No.

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

$____________ 0.00

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

No.

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

$____________ 0.00

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

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

No.

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

$____________ 0.00

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

No.

Yes. Describe.....

$____________ 0.00

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

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

No.

Yes. Describe.....

$____________ 0.00

Official Form 106A/B Record # 715543 Schedule A/B: Property Page 3 of 6

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

27. Licenses, franchises, and other general intangibles

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

No.

Yes. Describe.....

$____________ 0.00

Money or property owed to you? Current value of the

portion you own?

Do not deduct secured claims

or exemptions

28. Tax refunds owed to you

No.

Yes. Describe.....

$____________ 0.00

29. Family support

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

No.

Yes. Describe.....

$____________ 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.

Yes. Describe.....

$____________ 0.00

31. Interest in insurance policies

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

No.

Yes. Describe.....

Company Name & Beneficiary:

$____________ 0.00

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.

Yes. Describe.....

$____________ 0.00

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

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

No.

Yes. Describe.....

$____________ 0.00

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

No.

Yes. Describe.....

$____________ 0.00

35. Any financial assets you did not already list

No.

Yes. Describe.....

$____________ 0.00

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 ..................................................................................................................................... --> $239.00

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.

Yes.

Current value of the

portion you own?

Do not deduct secured claims

or exemptions

Official Form 106A/B Record # 715543 Schedule A/B: Property Page 4 of 6

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

38. Accounts receivable or commissions you already earned

No.

Yes. Describe.....

$____________ 0.00

39. Office equipment, furnishings, and supplies

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

No.

Yes. Describe.....

$____________ 0.00

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

No.

Yes. Describe.....

$____________ 0.00

41. Inventory

No.

Yes. Describe.....

$____________ 0.00

42. Interests in partnerships or joint ventures

No.

Yes. Describe.....

Name of Entity and Percent of Ownership:

$____________ 0.00

43. Customer lists, mailing lists, or other compilations

No.

Yes. Describe.....

$____________ 0.00

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

No.

Yes. Describe.....

$____________ 0.00

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 .................................................................................................................................... --> $ 0.00

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

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

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

No.

Yes. Describe.....

$____________ 0.00

47. Farm animals

Examples: Livestock, poultry, farm-raised fish

No.

Yes. Describe.....

$____________ 0.00

48. Crops—either growing or harvested

No.

Yes. Describe.....

$____________ 0.00

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

No.

Yes. Describe.....

$____________ 0.00

50. Farm and fishing supplies, chemicals, and feed

No.

Yes. Describe.....

$____________ 0.00

Official Form 106A/B Record # 715543 Schedule A/B: Property Page 5 of 6

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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

No.

Yes. Describe.....

$____________ 0.00

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 .................................................................................................................................... --> $0.00

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

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

Examples: Season tickets, country club membership

No.

Yes. Describe.....

$____________ 0.00

54. Add the dollar value of all of your entries from Part 7. Write that number here ..................................................... --> $0.00

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

55. Part 1: Total real estate, line 2

56. Part 2: Total vehicles, line 5

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

58. Part 4: Total financial assets, line 36

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

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

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

62. Total personal property. Add lines 56 through 61. .......................

63. Total of all property on Schedule A/B. Add line 55 + line 62 $13,674.00

$ 11,335.00

$ 2,100.00

$ 0.00

$ 0.00

$ 0.00

$ 239.00

$ 13,674.00

$ 0.00

$ 13,674.00

Official Form 106A/B Record # 715543 Schedule A/B: Property Page 6 of 6

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Fill in this information to identify your case:

Check if this is an 

amended filing

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

Official Form 106C

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

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

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

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

your name and case number (if known).

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

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

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

tax-exempt retirement funds-may be unlimited in dollar amount. However, if you claim an exemption of 100% of fair market value 

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

your exemption would be limited to the applicable statutory amount.

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

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

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

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

Brief description of the property and line on 

Schedule A/B that lists this property

Part 1: Identify the Property You Claim as Exempt

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption

Specific laws that allow exemption

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

2012 Chevrolet Malibu with over 

72,000 miles 10,750

735 ILCS 5/12-1001(c) - $2,400.00

735 ILCS 5/12-1001(b) - $574.00 2,974

03

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

Furniture, linens, small appliances, 

table & chairs, bedroom set 1,000

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

06

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

Flat screen TV, computer, printer, 

music collection, cell phone 750

735 ILCS 5/12-1001(b) - $750.00

07

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

Everyday clothes

 250

735 ILCS 5/12-1001(a),(e) - $0.00

11

Official Form 106C Record # 715543 Schedule C: The Property You Claim as Exempt Page 1 of 2

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 Document Page 16 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

Part 2: Additional Page

Brief description of the property and line on 

Schedule A/B that lists this property

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption

Specific laws that allow exemption

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

Everyday jewelry, costume jewelry

 100

735 ILCS 5/12-1001(b) - $100.00

12

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

1 dog.

 0

735 ILCS 5/12-1001(b) - $0.00

13

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

Checking Account, Chase, 33.00

 33

735 ILCS 5/12-1001(b) - $33.00

17

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

Checking Account, Chase, 48.00

 48

735 ILCS 5/12-1001(b) - $48.00

17

Brief

description: _________________________

Line from

Schedule A/B: ______

 

 $________________

 

 $ _________________________

 100% of fair market value, up to

 any applicable statutory limit

_____________________________

_____________________________

_____________________________

_____________________________

Savings Account, Chase, 158.00

 158

735 ILCS 5/12-1001(b) - $158.00

17

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

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

 No. 

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

 No

 Yes.

Official Form 106C Record # 715543 Schedule C: The Property You Claim as Exempt Page 2 of 2

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Column C

Unsecured

portion

If any

Fill in this information to identify your case:

Check if this is an 

amended filing

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

Official Form 106D

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

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

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

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

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

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

 Yes. Fill in all of the information below.

Part 1: List All Secured Claims

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

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

As much as possible, list the claims in alphabetical order according to the creditors name.

Column A

Amount of claim

Do not deduct the

value of collateral

Column A

Value of collateral

that supports this

claim

 Check if this claim relates to a

 community debt

Date Debt was incurred _____________

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

2.1

 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Describe the property that secures the claim:

Nature of Lien. Check all that apply.

 An agreement you made (such as mortgage or secured

 car loan)

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

 Judgment lien from a lawsuit

 Other (including a right to offset) ____________________

Last 4 digits of account number ____ ____ ____ ____

$_____________

_

 7,776.00 $______________ 10,750.00 $________ 0.00 Consumers COOP CRED UN

2016-01-14

2750 Washington St

Waukegan IL 60085

2703

2012 Chevrolet Malibu with over 72,000 miles

 Check if this claim relates to a

 community debt

Date Debt was incurred _____________

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

2.2

 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Describe the property that secures the claim:

Nature of Lien. Check all that apply.

 An agreement you made (such as mortgage or secured

 car loan)

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

 Judgment lien from a lawsuit

 Other (including a right to offset) ____________________

Last 4 digits of account number ____ ____ ____ ____

$_____________

_

 2,116.00 $______________ 585.00 $________ 1,531.00 Sheffield Financial CO

2012-2016

2554 Lewisville Clemmons

Clemmons NC 27012

1705

2005 Arctic Cat with over 3,000 miles

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

_

 9,892.00

Official Form 106D Record # 715543 Schedule D: Creditors Who Have Claims Secured by Property Page 1 of 2

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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

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

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

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

debts in Part 1, do not fill out or submit this page. 

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

_

 9,892.00

Official Form 106D Record # 715543 Schedule D: Creditors Who Have Claims Secured by Property Page 2 of 2

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 Document Page 19 of 54
Fill in this information to identify your case:

Check if this is an 

amended filing

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

Official Form 106E/F

Schedule E/F: Creditors Who Have Unsecured Claims 12/15

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

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

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 Have Claims Secured by Property. If more space is 

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

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

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

 No. Go to Part 2.

 Yes.

Part 1: List All of Your PRIORITY Unsecured Claims

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

Part 2:

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

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

 Yes.

List All of Your NONPRIORITY Unsecured Claims

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 

 nonpriority 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 three nonpriority unsecured 

 claims fill out the Continuation Page of Part 2.

Total claim

When was the debt incurred? ______________

 Check if this claim relates to a

 community debt

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

4.1 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Type of NONPRIORITY unsecured claim:

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 ______________________________________

Last 4 digits of account number ____ ____ ____ ____ $___________

2002-2014 Po Box 982238

El Paso TX 79998

Is the claim subject to offest?

 No

 Yes

BK OF AMER NULL 4,693.00

Credit Card or Credit Use

Official Form 106E/F Record # 715543 Schedule E/F: Creditors Who Have Unsecured Claims Page 1 of 5

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 Document Page 20 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth. Total Claim

When was the debt incurred? ______________

 Check if this claim relates to a

 community debt

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

4.2 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Type of NONPRIORITY unsecured claim:

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 ______________________________________

Last 4 digits of account number ____ ____ ____ ____ $___________

2005-2016 4909 Savarese Cir

Tampa FL 33634

Is the claim subject to offest?

 No

 Yes

BK OF AMER NULL 65,698.00

Debt Owed

When was the debt incurred? ______________

 Check if this claim relates to a

 community debt

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

4.3 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Type of NONPRIORITY unsecured claim:

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 ______________________________________

Last 4 digits of account number ____ ____ ____ ____ $___________

Box 965061

El Paso TX 32896

Is the claim subject to offest?

 No

 Yes

Care Credit/GEMB 0.00

Credit Card or Credit Use

When was the debt incurred? ______________

 Check if this claim relates to a

 community debt

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

4.4 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Type of NONPRIORITY unsecured claim:

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 ______________________________________

Last 4 digits of account number ____ ____ ____ ____ $___________

PO Box 523

Madison MS 39130

Is the claim subject to offest?

 No

 Yes

Chase Student Loan Servicing 2992 0.00

Official Form 106E/F Record # 715543 Schedule E/F: Creditors Who Have Unsecured Claims Page 2 of 5

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 21 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth. Total Claim

When was the debt incurred? ______________

 Check if this claim relates to a

 community debt

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

4.5 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Type of NONPRIORITY unsecured claim:

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 ______________________________________

Last 4 digits of account number ____ ____ ____ ____ $___________

2013-2016 Po Box 6241

Sioux Falls SD 57117

Is the claim subject to offest?

 No

 Yes

CITI NULL 380.00

Credit Card or Credit Use

When was the debt incurred? ______________

 Check if this claim relates to a

 community debt

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

4.6 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Type of NONPRIORITY unsecured claim:

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 ______________________________________

Last 4 digits of account number ____ ____ ____ ____ $___________

PO Box 183003

Columbus OH 43218

Is the claim subject to offest?

 No

 Yes

Comenity Bank 0.00

Credit Card or Credit Use

When was the debt incurred? ______________

 Check if this claim relates to a

 community debt

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

4.7 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Type of NONPRIORITY unsecured claim:

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 ______________________________________

Last 4 digits of account number ____ ____ ____ ____ $___________

PO Box 960023

Orlando FL 32896-0023

Is the claim subject to offest?

 No

 Yes

JC Penney 0.00

Credit Card or Credit Use

Official Form 106E/F Record # 715543 Schedule E/F: Creditors Who Have Unsecured Claims Page 3 of 5

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 22 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

When was the debt incurred? ______________

 Check if this claim relates to a

 community debt

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

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

 Contingent

 Unliquidated

 Disputed

4.8 _________________________________

 Creditor's Name

 _________________________________

 Number Street

 

 _________________________________

 _________________________________

 City State Zip Code

Type of NONPRIORITY unsecured claim:

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 ______________________________________

Last 4 digits of account number ____ ____ ____ ____ $___________

2012-2016 2215 S Oneida St

Green Bay WI 54304

Is the claim subject to offest?

 No

 Yes

North Shore BANK SSB 3623 31,324.00

Deficiency, Repo'd/Surr'd Auto

Part 3: List Others to Be Notified for a Debt That You Already Listed

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

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

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

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

 _______________________________________________

 Name

 _______________________________________________

 Number Street

 

 _______________________________________________

 _______________________________________________

 City State Zip Code

Last 4 digits of account number ____ ____ ____ ____

Box 182510

Victoria's Secret

Columbus OH 43218

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

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

Part 2: Creditors with Nonpriority Unsecured Claims

 6

 _______________________________________________

 Name

 _______________________________________________

 Number Street

 

 _______________________________________________

 _______________________________________________

 City State Zip Code

Last 4 digits of account number ____ ____ ____ ____

Victoria's Secret/WFNNB

PO Box 182128

Columbus OH 43218

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

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

Part 2: Creditors with Nonpriority Unsecured Claims

 6

 _______________________________________________

 Name

 _______________________________________________

 Number Street

 

 _______________________________________________

 _______________________________________________

 City State Zip Code

Last 4 digits of account number ____ ____ ____ ____

PO Box 965005

JC Penney/GECRB

Orlando FL 32896

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

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

Part 2: Creditors with Nonpriority Unsecured Claims

 7

Official Form 106E/F Record # 715543 Schedule E/F: Creditors Who Have Unsecured Claims Page 4 of 5

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 23 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

Part 4:

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.

Add the Amounts for Each Type of Unsecured Claim

Total claims

from Part 1

6a. Domestic support obligations

6b. Taxes and Certain other debts you owe the

 government

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

 intoxicated

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

 Write that amount here.

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

6a. 

6b. 

 

6c. 

 

6d. 

 

6e. 

Total claim

$______________________

$______________________

$______________________

$______________________

$______________________

Total claims

from Part 2

6f. Student loans

6g. Obligations arising out of a separation agreement

 or divorce that you did not report as priority

 claims

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

 similar debts

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

 Write that amount here.

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

6f. 

6g. 

 

6h. 

 

6i. 

 

6j. 

Total claim

$______________________

$______________________

$______________________

$______________________

$______________________

 0.00

 0.00

 0.00

 0.00

 0.00

 0.00

 0.00

 0.00

 102,095.00

 102,095.00

Official Form 106E/F Record # 715543 Schedule E/F: Creditors Who Have Unsecured Claims Page 5 of 5

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 24 of 54
Fill in this information to identify your case:

Check if this is an 

amended filing

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

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

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

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

 No. Check this box and 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 even if the contracts or leases are listed in Schedule A/B: Property (Official Form 106A/B)

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

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

 unexpired leases.

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

2.1

 __________________________________________________________________

 Name

 __________________________________________________________________

 Number Street

 

 __________________________________________________________________

 City State Zip Code

Coventry Glen Apartments

1399 Coventry Glen Dr

Round Lake IL 60073

2.2

 __________________________________________________________________

 Name

 __________________________________________________________________

 Number Street

 

 __________________________________________________________________

 City State Zip Code

2.3

 __________________________________________________________________

 Name

 __________________________________________________________________

 Number Street

 

 __________________________________________________________________

 City State Zip Code

2.4

 __________________________________________________________________

 Name

 __________________________________________________________________

 Number Street

 

 __________________________________________________________________

 City State Zip Code

2.5

 __________________________________________________________________

 Name

 __________________________________________________________________

 Number Street

 

 __________________________________________________________________

 City State Zip Code

Official Form 106G Record # 715543 Schedule G. Executory Contracts and Unexpired Leases Page 1 of 1

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 25 of 54
Fill in this information to identify your case:

Check if this is an 

amended filing

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

Official Form 106H

Schedule H: Your Codebtors 12/15

Codebtors are people or entities who are also liable for any debts you may have. Be as complete and accurate as possible. If two 

married people are filing together, both are equally responsible for supplying correct information. If more space is needed, copy 

the Additional Page, fill it out, and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of 

any Additional Pages, write your name and case number (if known). Answer every question.

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

 No. 

 Yes

2. Within the last 8 years, have you lived in a community property state or territory? (Community property states and territories include 

 Arizona, California, Idaho, Lousiiana, 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. Inwhich community state or territory did you live? __________________. Fill in the name and current address of that person.

_______________________________________________________________

Name of your spouse, former spouse or legal equivalent

_______________________________________________________________

Number Street

_______________________________________________________________

City State Zip Code

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

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

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

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

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

 Check all schedules that apply:

3.1

 _______________________________________________________________

 Name

 _______________________________________________________________

 Number Street

 _______________________________________________________________

 City State Zip Code

Schedule D, line __________

Schedule E/F, line __________

Schedule G, line __________

26100 W. Park View Dr.

Antioch IL 60002

Daniel Larsen 2

3.2 _______________________________________________________________

 Name

 _______________________________________________________________

 Number Street

 _______________________________________________________________

 City State Zip Code

Schedule D, line __________

Schedule E/F, line __________

Schedule G, line __________

3.3 _______________________________________________________________

 Name

 _______________________________________________________________

 Number Street

 _______________________________________________________________

 City State Zip Code

Schedule D, line __________

Schedule E/F, line __________

Schedule G, line __________

Official Form 106H Record # 715543 Schedule H: Your Codebtors Page 1 of 1

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 26 of 54
Fill in this information to identify your case:

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN DISTRICT OF ILLINOIS __

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

Check if this is:

 An amended filing

 A supplement showing post-petition

chapter 13 income as of the following date:

_______________

Official Form 106I MM / DD / YYYY

Schedule I: Your Income 12/15

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

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

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

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

Part 1: Describe Employment

1. Fill in your employment

information

If you have more than one job,

attach a separate page with

information about additional 

employers.

Include part-time, seasonal, or

self-employed work.

Occupation may Include student

or homemaker, if it applies.

 Debtor 1 Debtor 2 or non-filing spouse

Employment status

Employed

Not employed

Customer Service Representative

J. Steward & Co.

Buffalo Grove, IL 60089

1130 W. Lake-Cook Rd., Ste 320

1 year

, 

Employed

Not employed

X

Occupation

Employers name

Employers address

How long employed there?

Part 2: Give Details About Monthly Income

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

spouse unless you are separated. 

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

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

For Debtor 2 or 

non-filing spouse

For Debtor 1

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

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

3. Estimate and list monthly overtime pay.

4. Calculate gross income. Add line 2 + line 3.

$0.00

$0.00

$3,750.00 $0.00

$0.00

$3,750.00

Official Form 106I Record # 715543 Schedule I: Your Income Page 1 of 2

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 27 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

8h. Other monthly income. Specify: __________________________ 

For Debtor 2 or 

non-filing spouse

For Debtor 1

$3,750.00 $0.00

$702.24 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$308.19 $0.00

$0.00 $0.00

$0.00 $0.00

$2,739.58 $0.00

$1,010.42 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$2,739.58 $0.00 $2,739.58

$0.00 $0.00

$0.00 $0.00

$0.00

$2,739.58

X

$0.00 $0.00

+ =

4.

5a.

5b.

5c.

5d.

5e.

5f.

5g.

5h.

6.

7.

8a.

8b.

8c.

8d.

8e.

8f.

8g.

8h.

9.

10.

11.

12.

Copy line 4 here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 

5b. Mandatory contributions for retirement plans 

5c. Voluntary contributions for retirement plans 

5d. Required repayments of retirement fund loans 

5f. Domestic support obligations 

5g. Union dues

5h. Other deductions. Specify: ______________________________

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

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

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. 

8b. Interest and dividends

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.

8d. Unemployment compensation

8e. Social Security

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: ____________________________________________

8g. Pension or retirement income

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

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. 

5e. Insurance 

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: _______________________________________________________________________________

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

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

No.

Yes. Explain:

$ 0.00 $ 0.00

Official Form 106I Record # 715543 Schedule I: Your Income Page 2 of 2

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 28 of 54
Fill in this information to identify your case:

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN DISTRICT OF ILLINOIS __

Case Number ______________________________________________

 (If known)

Kimberly J Larsen Check if this is:

 An amended filing

 A supplement showing post-petition chapter 13 

income as of the following date:

_______________

MM / DD / YYYY

A separate filing for Debtor 2 because Debtor 2

Official Form 106J maintains a separate household.

Schedule J: Your Expenses 12/14

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 a separate Schedule J.

X

2. Do you have dependents?

Do not list Debtor 1 and

Debtor 2.

Do not state the dependents'

names.

X No

Yes. Fill out this information for

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

Dependent's relationship to

Debtor 1 or Debtor 2

Dependent's

age

Does dependent live

with you?

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

3. Do your expenses include

expenses of people other than

yourself and your dependents?

No

Yes

X

X

X

X

X

X

Part 2: Estimate Your Ongoing Monthly Expenses

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

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

the applicable date. 

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

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

$1,045.00

$0.00

$0.00

$0.00

$60.00

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

4.

4a.

4b.

4c.

4d.

any rent for the ground or lot.

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

Official Form 106J Record # 715543 Schedule J: Your Expenses Page 1 of 3

Case 16-26711 Doc 1 Filed 08/19/16 Entered 08/19/16 14:55:35 Desc Main

 Document Page 29 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

 Your expenses

$0.00

$90.00

$45.00

$175.00

$ 0.00

$350.00

$65.00

$0.00

$90.00

$0.00

$100.00

$200.00

$25.00

$0.00

$0.00

$416.00

$0.00

$0.00

$0.00

$0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$0.00

$45.00

$0.00

$0.00

5.

6a.

6b.

6c.

6d.

7.

8.

9.

10.

11.

12.

13.

14.

15a.

15b.

15c.

15d.

16.

17a.

17b.

17c.

17d.

18.

19.

20a.

20b.

20c.

20d.

20e.

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

Specify:_______________________________________________________

17d. Other. Specify:__________________________________________________________________ 

17c. Other. Specify:_______________________________________________ 

Specify: ________________________________________________________ 

15d. Other insurance. Specify:_______________________________________ 

6a. Electricity, heat, natural gas

6b. Water, sewer, garbage collection

6c. Telephone, cell phone, internet, satellite, and cable service

6. Utilities:

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 

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

17. Installment or lease payments:

17a. Car payments for Vehicle 1 

17b. Car payments for Vehicle 2 

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.

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 

$ 0.00

Official Form 106J Record # 715543 Schedule J: Your Expenses Page 2 of 3

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 Document Page 30 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

No

Yes. Explain Here:

X

$2,739.58

Pet Care ($30.00), $30.00

$2,736.00

$2,736.00

$3.58

-

21.

22.

23a.

23b.

23c.

21. Other. Specify: ________________________________________________________

22.. Your monthly expense: Add lines 4 through 21.

The result is your monthly expenses.

23. Calculate your monthly net income.

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

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

23c. Subtract your monthly expenses from your monthly 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?

The result is your monthly net income.

Official Form 106J Record # 715543 Schedule J: Your Expenses Page 3 of 3

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 Document Page 31 of 54
Check if this is an 

amended filing

Official Form 106 Dec

Declaration About an Individual Debtor's Schedules 12/15

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. 

Fill in this information to identify your case:

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

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

No

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

Signature (Official Form 119).

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. 

 ________________________________________ ______________________________________

 Signature of Debtor 1 Signature of Debtor 2

 Date _________________ Date _________________

 MM / DD / YYYY MM / DD / YYYY

Sign Below

08/17/2016

û /s/ Kimberly J Larsen û

Official Form 106Dec Record # 715543 Declaration About an Individual Debtor's Schedules page 1

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 Document Page 32 of 54
Fill in this information to identify your case:

Check if this is an 

amended filing

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN__ District of _ILLINOIS__

 (State)

Case Number ______________________________________________

 (If known)

Kimberly J Larsen

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.

12/15

Part 1: Give Details About Your Marital Status and Where You Lived Before

01. What is your current marital status?

 

 Married

 Not married

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

No.

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

Debtor 1 Dates Debtor 1 

lived there

Debtor 2: Dates Debtor 2

lived there

FROM 02/2014 

To 02/2016

290 Anita Ter 

Antioch IL 60002-2466

Same as Debtor 1 Same as Debtor 1

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

FROM 08/2013 

To 12/2013

4618 W Northfox Ln 

Mchenry IL 60050-4229

Same as Debtor 1 Same as Debtor 1

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

03 Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory? (Community 

property states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, 

and Wisconsin.)

No.

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

Part 2: Explain the Sources of Your Income

Official Form 107 Record # 715543 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

04 Did you have any income from employment or from operating a business during this year or the two previous calendar years?

Fill in the total amount of income you received from all jobs and all businesses, including part-time activities. 

If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.

No.

Yes. Fill in the details

Gross income

(before deductions and 

exclusions)

Gross income

(before deductions and 

exclusions)

Debtor 1 Debtor 2

Sources of income

Check all that apply

Sources of income

Check all that apply

Wages, commissions, $27,693

bonuses, tips

Operating a business

From January 1 of current year until 

the date you filed for bankruptcy:

___________________ Wages, commissions, 

bonuses, tips

Operating a business

___________________

Wages, commissions, $50,872

bonuses, tips

Operating a business

For last calendar year:

(January 1 to December 31, 2015)

___________________ Wages, commissions, 

bonuses, tips

Operating a business

___________________

Wages, commissions, $50,000 approximately

bonuses, tips

Operating a business

For the calendar year before that:

(January 1 to December 31, 2014)

___________________ Wages, commissions, 

bonuses, tips

Operating a business

___________________

05 Did you receive any other income during this year or the two previous calendar years?

Include income regardless of whether that income is taxable. Examples of other income are alimony; child support; Social Security, unemployment, 

and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and gambling and lottery 

winnings. If you are filing a joint case and you have income that you received together, list it only once under Debtor 1.

List each source and the gross income from each source separately. Do not include income that you listed in line 4.

No.

Yes. Fill in the details

Gross income

(before deductions and 

exclusions)

Gross income

(before deductions and 

exclusions)

Debtor 1 Debtor 2

Sources of income

Describe below.

Sources of income

Describe below.

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

Official Form 107 Record # 715543 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 2

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 Document Page 34 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

06 Are either Debtor 1’s or Debtor 2’s debts primarily consumer debts?

 No. Neither Debtor 1 nor Debtor 2 has primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8) as 

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

 During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,225* or more?

 No. Go to line 7.

 Yes. List below each creditor to whom you paid a total of $6,225* or more in one or more payments and the 

 total amount you paid that creditor. Do not include payments for domestic support obligations, such as 

 child support and alimony. Also, do not include payments to an attorney for this bankruptcy case.

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

 Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts.

 During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more?

 No. Go to line 7.

 Yes. List below each creditor to whom you paid a total of $600 or more and the total amount you paid that 

 creditor. Do not include payments for domestic support obligations, such as child support and 

 alimony. Also, do not include payments to an attorney for this bankruptcy case.

Dates of 

payments

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

___________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

___________________________ 6/2016 ___________________

___________________________

___________________________

___________________________

Care Credit $4,000 $0

___________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

___________________________ Monthly ___________________

___________________________

___________________________

___________________________

Consumers COOP CRED UN 

2750 Washington St Waukegan 

IL 60085

$416 $7,776

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

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

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

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

such as child support and alimony.

 No. 

 Yes. List all payments to an insider.

Dates of 

payment

Amount you still 

owe

Total amount 

paid

Reason for this payment

Official Form 107 Record # 715543 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

08 Within 1 year before you filed for bankruptcy, did you make any payments or transfer any property on account of a debt that benefited 

an insider?

Include payments on debts guaranteed or cosigned by an insider.

 No. 

 Yes. List all payments to an insider.

Dates of 

payment

Amount you still 

owe

Total amount 

paid

Reason for this payment

Include creditor's name

Part 4: Identify Legal actions, Repossessions, and Foreclosures

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

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

modifications, and contract disputes.

 No. 

 Yes. Fill in the details.

Nature of the case Court or agency Status of the case

10 Within 1 year before you filed for bankruptcy, was any of your property repossessed, foreclosed, garnished, attached, seized, or levied?

Check all that apply and fill in the details below.

 No. Go to line 11

 Yes. Fill in the information below.

_________________________________ 2004 Gulfstream Ultra

_________________________________

_________________________________

_________________________________

North Shore BANK SSB

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

Explain what happened

8/2016 ___________________ $26,964

Describe the property Date Value of the property

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

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

 No. Go to line 11

 Yes. Fill in the information below.

12 Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of creditors, a 

court-appointed receiver, a custodian, or another official?

No.

Yes. 

Part 5: List Certain Gifts and Contributions

13 Within 2 years before you filed for bankruptcy, did you give any gifts with a total value of more than $600 per person?

 No. 

 Yes. Fill in the details for each gift.

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

 No. 

 Yes. Fill in the details for each gift.

Part 6: List Certain Losses

15 Within 1 year before you filed for bankruptcy or since you filed for bankruptcy, did you lose anything because of theft, fire, other disaster, or 

gambling?

 No. 

 Yes. Fill in the details for each gift.

Official Form 107 Record # 715543 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 4

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

Part 7: List Certain Payments or Transfers

16 Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone you consulted 

about seeking bankruptcy or preparing a bankruptcy petition?

Include any attorneys, bankruptcy petition preparers, or credit counseling agencies for services required in your bankruptcy.

 No. 

 Yes. Fill in the details

_________________________________ ___________________

_________________________________

_________________________________

_________________________________

Geraci Law L.L.C.

55 E. Monroe Street #3400

Chicago,IL 60603

Party Contact Info Description and value of any property transferred Date payment Amount of payment

or transfer 

Payment/Value:

$2,295.00: $865.00

paid prior to filing,

balance to be paid

after case filing.

___________________

Credit Counseling Services

_________________________________

_________________________________

_________________________________

_________________________________

Hananwill Credit Counseling

115 N. Cross St.

Robinson, IL 62454

Party Contact Info Description and value of any property transferred Date payment Amount of payment

or transfer 

2016 $25.00

17 Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone who 

promised to help you deal with your creditors or to make payments to your creditors?

Do not include any payment or transfer that you listed on line 16.

 No. 

 Yes. Fill in the details.

18 Within 2 years before you filed for bankruptcy, did you sell, trade, or otherwise transfer any property to anyone, other than property 

transferred in the ordinary course of your business or financial affairs?

Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property). 

Do not include gifts and transfers that you have already listed on this statement.

 No. 

 Yes. Fill in the details for each gift.

19 Within 10 years before you filed for bankruptcy, did you transfer any property to a self-settled trust or similar device of which you are a 

beneficiary? (These are often called asset-protection devices.)

 No. 

 Yes. Fill in the details for each gift.

Part 8: List Certain Financial Accounts, Instruments, Safe Deposit Boxes, and Storage Units

Official Form 107 Record # 715543 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 5

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

20 Within 1 year before you filed for bankruptcy, were any financial accounts or instruments held in your name, or for your benefit, closed, 

sold, moved, or transferred?

Include checking, savings, money market, or other financial accounts; certificates of deposit; shares in banks, credit unions, brokerage 

houses, pension funds, cooperatives, associations, and other financial institutions.

 No. 

 Yes. Fill in the details.

Last 4 digits of account number Date account was 

closed, sold, moved, 

or transferred

Type of account or 

instrument

Last balance before 

closing or transfer

_____________________________ _________________

_____________________________

_____________________________

_____________________________

401k Debtor closed her 

401k in 6/2016 

and used the 

proceeds to try 

and pay off her 

debt.

XXX - ___ ___ ___ ___ Checking $6,000

Savings

Money market

Brokerage

Other_________

21 Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for securities, 

cash, or other valuables?

Describe the contents

 No. 

 Yes. Fill in the details.

Who else had access to it? 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?

Describe the contents

 No. 

 Yes. Fill in the details.

Who else has or had access to it? Do you still 

have it?

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.

Describe the property

 No. 

 Yes. Fill in the details.

Where is the property? 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?

Environmental law, if you know it

 No. 

 Yes. Fill in the details.

Governmental unit Date of notice

Official Form 107 Record # 715543 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 6

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Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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

Environmental law, if you know it

 No. 

 Yes. Fill in the details.

Governmental unit Date of notice

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

Nature of the case

 No. 

 Yes. Fill in the details.

Court or agency 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?

 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.

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.

 No. 

 Yes. Fill in the details.

Date issued

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.

________________________________________ ______________________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

 MM / DD / YYYY MM / DD / YYYY

08/17/2016

û /s/ Kimberly J Larsen û

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

 Yes. Name of person ___________________________________________________. Attach the Bankruptcy Petition Preparer's Notice,

 Declaration, and Signature (Official Form 119).

Official Form 107 Record # 715543 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 7

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 Document Page 39 of 54
Fill in this information to identify your case:

Check if this is an 

amended filing

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 __________________________________________________________________

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

 

United States Bankruptcy Court for the : __NORTHERN DISTRICT OF ILLINOIS EASTERN 

DIVISION__ District of _ILLINOIS__

 (State)

Kimberly J Larsen

Official Form 108

Statement of Intention for Individuals Filing Under Chapter 7 12/15

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

n creditors have claims secured by your property, or

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

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.

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?

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

Creditor's

name:

Description of

property

securing debt:

2012 Chevrolet Malibu with over 72,000 miles 

Consumers COOP CRED UN

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

Creditor's

name:

Description of

property

securing debt:

2005 Arctic Cat with over 3,000 miles 

Sheffield Financial CO

Surrender the property

Retain the property and redeem it

Retain the property and enter into a 

Reaffirmation Agreement.

Retain the property and [explain]: _______

____________________________________

Creditor's

name:

No

Yes

Description of

property

securing debt:

Surrender the property

Retain the property and redeem it

Retain the property and enter into a 

Reaffirmation Agreement.

Retain the property and [explain]: _______

____________________________________

Creditor's

name:

No

Yes

Description of

property

securing debt:

Official Form 108 Record # 715543 Statement of Intention for Individuals Filing Under Chapter 7 Page 1 of 2

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 Document Page 40 of 54
Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Kimberly J Larsen Case Number (if known) ______________________________

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?

No

Yes

Description of leased

property:

Lessor's name: Coventry Glen Apartments

No

Yes

Lessor's name:

Description of leased

property:

No

Yes

Lessor's name:

Description of leased

property:

No

Yes

Lessor's name:

Description of leased

property:

No

Yes

Lessor's name:

Description of leased

property:

No

Yes

Lessor's name:

Description of leased

property:

No

Yes

Lessor's name:

Description of leased

property:

Part 3:

 ________________________________________

 Signature of Debtor 2

 Date _________________

 MM / DD / YYYY

 ________________________________________

 Signature of Debtor 1

 Date _________________

 MM / DD / YYYY

Sign Below

Dated: 08/17/2016

û /s/ Kimberly J Larsen û

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. 

Official Form 108 Record # 715543 Statement of Intention for Individuals Filing Under Chapter 7 Page 2 of 2

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B2030 (Form 2030) (12/15)

United States Bankruptcy Court

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

Kimberly J Larsen / Debtor Case No:

Chapter: Chapter 7

CERTIFICATION

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

payment to 

me for representation of the debtor(s) in this bankruptcy proceedings.

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

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

compensation paid to me within one year before the filing of the petition in bankruptcy, or agreed to be paid to me, for services 

rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows:

For legal services, I have agreed to accept

Prior to the filing of this statement I have received

Balance Due

$865.00

$1,430.00

$2,295.00

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

Debtor(s) Other: (specify

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

Debtor(s) Other: (specify

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

case, including:

a. Analysis of the debtor' s financial situation, and rendering advice to the debtor in determining whether to file a petition in 

bankruptcy;

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

c. Representation of the debtor at the meeting of creditors and confirmation hearing, and any adjourned hearings thereof;

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

of my law firm.

I have agreed to share the above-disclosed compensation with a other person or persons who are not members or associates 

________________________________________ Geraci Law L.L.C.

Name of law firm

____________________________

Signature of Attorney

____________________________

Date

Date: 08/18/2016 /s/ Marc Adam Affolter

Fee does NOT include missed meeting or court dates, amendments to schedules, adversary complaints or conversions to another 

chapter, judicial lien avoidances, dischargeability actions, other contested matters except the first meeting of creditors. 

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

Record # 715543 Page 1 of 1

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION In re

Kimberly J Larsen / Debtor Bankruptcy Docket #:

Judge:

VERIFICATION OF CREDITOR MATRIX

The above named Debtor(s) hereby verify that the attached list of creditors is true and correct to the best of our knowledge.

Dated: 08/17/2016 /s/ Kimberly J Larsen X Date & Sign

Kimberly J Larsen 

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.

* Joint debtors must provide information for both spouses. Penalty for making a false statement or concealing property: Fine 

up to $500,000 or up to 5 years imprisonment or both. 18 U.S.C. 152 and 3571.

Record # 715543 B 1D (Official Form 1, Exh.D)(12/08) Page 1 of 1

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B 201A (Form 201A) (11/11) In re Kimberly J Larsen / Debtor

UNITED STATES BANKRUPTCY COURT

NOTICE TO CONSUMER DEBTOR(S) UNDER §342(b)

OF THE BANKRUPTCY CODE

In accordance with § 342(b) of the Bankruptcy Code, this notice to individuals with primarily consumer debts: (1) 

Describes briefly the services available from credit counseling services; (2) Describes briefly the purposes, benefits and 

costs of the four types of bankruptcy proceedings you may commence; and (3) Informs you about bankruptcy crimes and 

notifies you that the Attorney General may examine all information you supply in connection with a bankruptcy case.

You are cautioned that bankruptcy law is complicated and not easily described. Thus, you may wish to seek the 

advice of an attorney to learn of your rights and responsibilities should you decide to file a petition. Court employees 

cannot give you legal advice.

Notices from the bankruptcy court are sent to the mailing address you list on your bankruptcy petition. In

order to ensure that you receive information about events concerning your case, Bankruptcy Rule 4002 requires that you 

notify the court of any changes in your address. If you are filing a joint case (a single bankruptcy case for two 

individuals married to each other), and each spouse lists the same mailing address on the bankruptcy petition, you and your 

spouse will generally receive a single copy of each notice mailed from the bankruptcy court in a jointly- addressed 

envelope, unless you file a statement with the court requesting that each spouse receive a separate copy of all notices.

1. Services Available from Credit Counseling Agencies

With limited exceptions, § 109(h) of the Bankruptcy Code requires that all individual debtors who file

for bankruptcy relief on or after October 17, 2005, receive a briefing that outlines the available opportunities 

for credit counseling and provides assistance in performing a budget analysis. The briefing must be given within 

180 days before the bankruptcy filing. The briefing may be provided individually or in a group (including briefings 

conducted by telephone or on the Internet) and must be provided by a nonprofit budget and credit counseling agency 

approved by the United States trustee or bankruptcy administrator. The clerk of the bankruptcy court has a list that you 

may consult of the approved budget and credit counseling agencies. Each debtor in a joint case must complete the 

briefing.

In addition, after filing a bankruptcy case, an individual debtor generally must complete a financial

management instructional course before he or she can receive a discharge. The clerk also has a list of approved 

financial management instructional courses. Each debtor in a joint case must complete the course.

2. The Four Chapters of the Bankruptcy Code Available to Individual Consumer Debtors

Chapter 7: Liquidation ($245 filing fee, $75 administrative fee, $15 trustee surcharge: Total fee $335

Chapter 7 is designed for debtors in financial difficulty who do not have the ability to pay their existing

debts. Debtors whose debts are primarily consumer debts are subject to a “means test” designed to determine whether the 

case should be permitted to proceed under chapter 7. If your income is greater than the median income for your state of 

residence and family size, in some cases, the United States trustee (or bankruptcy administrator), the trustee, or creditors 

have the right to file a motion requesting that the court dismiss your case under § 707(b) of the Code. It is up to the court 

to decide whether the case should be dismissed.

Under chapter 7, you may claim certain of your property as exempt under governing law. A trustee may have the 

right to take possession of and sell the remaining property that is not exempt and use the sale proceeds to pay your 

creditors.

The purpose of filing a chapter 7 case is to obtain a discharge of your existing debts. If, however, you are

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Form B 201A, Notice to Consumer Debtor(s) In re Kimberly J Larsen / Debtor Page 2

UNITED STATES BANKRUPTCY COURT

NOTICE TO CONSUMER DEBTOR(S) UNDER §342(b)

OF THE BANKRUPTCY CODE

In accordance with § 342(b) of the Bankruptcy Code, this notice to individuals with primarily consumer debts: (1) 

Describes briefly the services available from credit counseling services; (2) Describes briefly the purposes, benefits and 

costs of the four types of bankruptcy proceedings you may commence; and (3) Informs you about bankruptcy crimes and 

notifies you that the Attorney General may examine all information you supply in connection with a bankruptcy case.

You are cautioned that bankruptcy law is complicated and not easily described. Thus, you may wish to seek the 

advice of an attorney to learn of your rights and responsibilities should you decide to file a petition. Court employees 

cannot give you legal advice.

Notices from the bankruptcy court are sent to the mailing address you list on your bankruptcy petition. In

order to ensure that you receive information about events concerning your case, Bankruptcy Rule 4002 requires that you 

notify the court of any changes in your address. If you are filing a joint case (a single bankruptcy case for two 

individuals married to each other), and each spouse lists the same mailing address on the bankruptcy petition, you and your 

spouse will generally receive a single copy of each notice mailed from the bankruptcy court in a jointly- addressed 

envelope, unless you file a statement with the court requesting that each spouse receive a separate copy of all notices.

1. Services Available from Credit Counseling Agencies

found to have committed certain kinds of improper conduct described in the Bankruptcy Code, the court may deny your 

discharge and, if it does, the purpose for which you filed the bankruptcy petition will be defeated.

Even if you receive a general discharge, some particular debts are not discharged under the law. Therefore, you may 

still be responsible for most taxes and student loans; debts incurred to pay nondischargeable taxes; domestic support and 

property settlement obligations; most fines, penalties, forfeitures, and criminal restitution obligations; certain debts which are 

not properly listed in your bankruptcy papers; and debts for death or personal injury caused by operating a motor vehicle, 

vessel, or aircraft while intoxicated from alcohol or drugs. Also, if a creditor can prove that a debt arose from fraud, breach 

of fiduciary duty, or theft, or from a willful and malicious injury, the bankruptcy court may determine that the debt is not 

discharged.

Chapter 13: Repayment of All or Part of the Debts of an Individual with Regular Income ($235 filing

fee, $75 administrative fee: Total fee $310)

Chapter 13 is designed for individuals with regular income who would like to pay all or part of their debts in installments 

over a period of time. You are only eligible for chapter 13 if your debts do not exceed certain dollar amounts set forth in the 

Bankruptcy Code.

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, using your future earnings. The period allowed by the court to repay your debts may be three years or five years, 

depending upon your income and other factors. The court must approve your plan before it can take effect.

After completing the payments under your plan, your debts are generally discharged except for domestic support 

obligations; most student loans; certain taxes; most criminal fines and restitution obligations; certain debts which are not 

properly listed in your bankruptcy papers; certain debts for acts that caused death or personal injury; and certain long 

term secured obligations.

Chapter 11: Reorganization ($1,167 filing fee, $550 administrative fee: Total fee $1,717)

Chapter 11 is designed for the reorganization of a business but is also available to consumer debtors. Its provisions are 

quite complicated, and any decision by an individual to file a chapter 11 petition should be reviewed with an attorney.

Chapter 12: Family Farmer or Fisherman ($200 filing fee, $75 administrative fee: Total fee $275)

Chapter 12 is designed to permit family farmers and fishermen to repay their debts over a period of time from

future earnings and is similar to chapter 13. The eligibility requirements are restrictive, limiting its use to those whose 

income arises primarily from a family-owned farm or commercial fishing operation.

3. Bankruptcy Crimes and Availability of Bankruptcy Papers to Law Enforcement Officials

A person who knowingly and fraudulently conceals assets or makes a false oath or statement under penalty

of perjury, either orally or in writing, in connection with a bankruptcy case is subject to a fine, imprisonment, or both. All 

information supplied by a debtor in connection with a bankruptcy case is subject to examination by the Attorney General 

acting through the Office of the United States Trustee, the Office of the United States Attorney, and other components and 

employees of the Department of Justice.

WARNING: Section 521(a)(1) of the Bankruptcy Code requires that you promptly file detailed information regarding your creditors, 

assets, liabilities, income, expenses and general financial condition. Your bankruptcy case may be dismissed if this information is not 

filed with the court within the time deadlines set by the Bankruptcy Code, the Bankruptcy Rules, and the local rules of the court. The 

Kimberly J Larsen 

Dated: 08/17/2016 /s/ Kimberly J Larsen

Dated: 08/18/2016

Attorney: Marc Adam Affolter

/s/ Marc Adam Affolter

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