Fill in this information to identify your case:

United States Bankruptcy Court for the:

NORTHERN DISTRICT OF ILLINOIS

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

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13  Check if this 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.

Part 1: Identify Yourself

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

1. Your full name

Write the name that is on

your government-issued

picture identification (for

example, your driver's

license or passport).

Bring your picture

identification to your

meeting with the trustee.

Shawn Angela

First name First name

L. L.

Middle name Middle name

Ortgiesen Ortgiesen

Last name and Suffix (Sr., Jr., II, III) Last name and Suffix (Sr., Jr., II, III)

2. All other names you have

used in the last 8 years

Include your married or

maiden names.

3. Only the last 4 digits of

your Social Security

number or federal

Individual Taxpayer

Identification number

(ITIN)

xxx-xx-0350 xxx-xx-4582

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

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

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

 I have not used any business name or EINs.  I have not used any business name or EINs.

Include trade names and

doing business as names

Business name(s) Business name(s)

EINs EINs

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

202 Tamarack Drive

Dixon, IL 61021

Number, Street, City, State & ZIP Code Number, Street, City, State & ZIP Code

Ogle

County County

If your mailing address is different from the one

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

notices to you at this mailing address.

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

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

mailing address.

Number, P.O. Box, Street, City, State & ZIP Code Number, P.O. Box, Street, City, State & ZIP Code

6. Why you are choosing

this district to file for

bankruptcy

Check one:

 Over the last 180 days before filing this petition,

I have lived in this district longer than in any

other district.

 I have another reason.

Explain. (See 28 U.S.C. § 1408.)

Check one:

 Over the last 180 days before filing this petition, I

have lived in this district longer than in any other

district.

 I have another reason.

Explain. (See 28 U.S.C. § 1408.)

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

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen 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

District When Case number

District When Case number

10. Are any bankruptcy

cases pending or being

filed by a spouse who is

not filing this case with

you, or by a business

partner, or by an

affiliate?

 No

 Yes.

Debtor Relationship to you

District When Case number, if known

Debtor Relationship to you

District When Case number, if known

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.

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

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen 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?

 No. Go to Part 4.

 Yes. Name and location of business

A sole proprietorship is a

business you operate as

an individual, and is not a

separate legal entity such

as a corporation,

partnership, or LLC.

Name of business, if any

If you have more than one

sole proprietorship, use a

separate sheet and attach

it to this petition.

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?

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).

For a definition of small

business debtor, see 11

U.S.C. § 101(51D).

 No. I am not filing under Chapter 11.

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

Code.

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

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

14. Do you own or have any

property that poses or is

alleged to pose a threat

of imminent and

identifiable hazard to

public health or safety?

Or do you own any

property that needs

immediate attention?

 No.

 Yes.

What is the hazard?

If immediate attention is

needed, why is it needed?

For example, do you own

perishable goods, or

livestock that must be fed,

or a building that needs

urgent repairs?

Where is the property?

Number, Street, City, State & Zip Code

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

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

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

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

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.

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, 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 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 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:

 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.

 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.

 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.

 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 credit counseling with the court.

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 Voluntary Petition for Individuals Filing for Bankruptcy page 5

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number

(if known)  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.

Part 1: Summarize Your Assets

Your assets

Value of what you own

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

1a. Copy line 55, Total real estate, from Schedule A/B................................................................................................ $ 190,000.00

1b. Copy line 62, Total personal property, from Schedule A/B..................................................................................... $ 28,610.00

1c. Copy line 63, Total of all property on Schedule A/B............................................................................................... $ 218,610.00

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... $ 185,012.47

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................................. $ 0.00

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F............................ $ 213,491.95

Your total liabilities $ 398,504.42

Part 3: Summarize Your Income and Expenses

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

Copy your combined monthly income from line 12 of Schedule I................................................................................ $ 6,535.00

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

Copy your monthly expenses from line 22c of Schedule J.......................................................................... $ 4,508.00

Part 4: Answer These Questions for Administrative and Statistical Records

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

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

 Yes

7. What kind of debt do you have?

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

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

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

the court with your other schedules.

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

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

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

122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14. $ 9,145.00

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

Total claim

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

9a. Domestic support obligations (Copy line 6a.) $ 0.00

9b. Taxes and certain other debts you owe the government. (Copy line 6b.) $ 0.00

9c. Claims for death or personal injury while you were intoxicated. (Copy line 6c.) $ 0.00

9d. Student loans. (Copy line 6f.) $ 0.00

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

priority claims. (Copy line 6g.) $ 0.00

9f. Debts to pension or profit-sharing plans, and other similar debts. (Copy line 6h.) +$ 0.00

9g. Total. Add lines 9a through 9f. $ 0.00

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

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

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

Debtor 1 Shawn L. Ortgiesen

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number  Check if this is an

amended filing

Official Form 106A/B

Schedule A/B: Property 12/15

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

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

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

Answer every question.

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

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

 No. Go to Part 2.

 Yes. Where is the property?

1.1 What is the property? Check all that apply

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

202 Tamarack Dr 





Single-family home

Duplex or multi-unit building

Condominium or cooperative

Street address, if available, or other description

Dixon IL 61021-0000





Manufactured or mobile home

Land

Current value of the

entire property?

Current value of the

portion you own?

City State ZIP Code  Investment property $190,000.00 $190,000.00

 Timeshare

Describe the nature of your ownership interest

(such as fee simple, tenancy by the entireties, or

a life estate), if known.

 Other

Who has an interest in the property? Check one

 Debtor 1 only

Ogle  Debtor 2 only

County  Debtor 1 and Debtor 2 only

 Check if this is community property  At least one of the debtors and another (see instructions)

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

property identification number:

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

pages you have attached for Part 1. Write that number here...........................................................................=> $190,000.00

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.

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

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

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

 No

 Yes

3.1 Make: Chevrolet Who has an interest in the property? Check one Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Model: Traverse  Debtor 1 only Creditors Who Have Claims Secured by Property.

Year: 2011  Debtor 2 only Current value of the

entire property?

Current value of the

Approximate mileage: 87000  Debtor 1 and Debtor 2 only portion you own?

Other information:  At least one of the debtors and another

 Check if this is community property $8,500.00 $8,500.00

 (see instructions)

3.2 Make: Nissan Who has an interest in the property? Check one Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Model: Altima  Debtor 1 only Creditors Who Have Claims Secured by Property.

Year: 2000  Debtor 2 only Current value of the

entire property?

Current value of the

Approximate mileage: 150000  Debtor 1 and Debtor 2 only portion you own?

Other information:  At least one of the debtors and another

 Check if this is community property $1,500.00 $1,500.00

 (see instructions)

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

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

 No

 Yes

5

.

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

pages you have attached for Part 2. Write that number here.............................................................................=> $10,000.00

Part 3: Describe Your Personal and Household Items

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

portion you own?

Do not deduct secured

claims or exemptions.

6. Household goods and furnishings

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

 No

 Yes. Describe.....

Normal complement of household goods $5,000.00

7. Electronics

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

including cell phones, cameras, media players, games

 No

 Yes. Describe.....

Normal complement of home electronics $1,000.00

8. Collectibles of value

Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects; stamp, coin, or baseball card collections;

other collections, memorabilia, collectibles

 No

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

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

 Yes. Describe.....

9. Equipment for sports and hobbies

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

musical instruments

 No

 Yes. Describe.....

10. Firearms

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

 No

 Yes. Describe.....

1 shotgun $200.00

11. Clothes

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

 No

 Yes. Describe.....

Normal complement of clothing $500.00

12. Jewelry

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

 No

 Yes. Describe.....

Wedding rings and misc jewelry $2,000.00

13. Non-farm animals

Examples: Dogs, cats, birds, horses

 No

 Yes. Describe.....

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

 No

 Yes. Give specific information.....

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

for Part 3. Write that number here .............................................................................. $8,700.00

Part 4: Describe Your Financial Assets

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

portion you own?

Do not deduct secured

claims or exemptions.

16. Cash

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

 No

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

Cash $20.00

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

Official Form 106A/B Schedule A/B: Property page 3

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

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

17.1. Checking Midland States Bank $50.00

18. Bonds, mutual funds, or publicly traded stocks

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

 No

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

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

joint venture

 No

 Yes. Give specific information about them...................

Name of entity: % of ownership:

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

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

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

 No

 Yes. Give specific information about them

Issuer name:

21. Retirement or pension accounts

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

 No

 Yes. List each account separately.

Type of account: Institution name:

401(k) Principal Financial Group from Fehr-Graham $9,000.00

Pension IMRF $838.00

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 companies, or others

 No

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

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

 No

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

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

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

 No

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

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

 No

 Yes. Give specific information about them...

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

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

 No

 Yes. Give specific information about them...

27. Licenses, franchises, and other general intangibles

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

 No

 Yes. Give specific information about them...

Official Form 106A/B Schedule A/B: Property page 4

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

Money or property owed to you? Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

28. Tax refunds owed to you

 No

 Yes. Give specific information about them, including whether you already filed the returns and the tax years.......

29. Family support

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

 No

 Yes. Give specific information......

30. Other amounts someone owes you

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

benefits; unpaid loans you made to someone else

 No

 Yes. Give specific information..

31. Interests in insurance policies

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

 No

 Yes. Name the insurance company of each policy and list its value.

Company name: Beneficiary: Surrender or refund

value:

American Family Insurance - term

insurance Spouse $1.00

Employer provided term insurance Spouse $1.00

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. Give specific information..

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

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

 No

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

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

 No

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

35. Any financial assets you did not already list

 No

 Yes. Give specific information..

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

for Part 4. Write that number here..................................................................................................................... $9,910.00

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

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

 No. Go to Part 6.

Official Form 106A/B Schedule A/B: Property page 5

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

 Yes. Go to line 38.

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

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

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

 No. Go to Part 7.

 Yes. Go to line 47.

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

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

Examples: Season tickets, country club membership

 No

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

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

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

55. Part 1: Total real estate, line 2 ...................................................................................................................... $190,000.00

56. Part 2: Total vehicles, line 5 $10,000.00

57. Part 3: Total personal and household items, line 15 $8,700.00

58. Part 4: Total financial assets, line 36 $9,910.00

59. Part 5: Total business-related property, line 45 $0.00

60. Part 6: Total farm- and fishing-related property, line 52 $0.00

61. Part 7: Total other property not listed, line 54 + $0.00

62. Total personal property. Add lines 56 through 61... $28,610.00 Copy personal property total $28,610.00

63. Total of all property on Schedule A/B. Add line 55 + line 62 $218,610.00

Official Form 106A/B Schedule A/B: Property page 6

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number

(if known)  Check if this is an

amended filing

Official Form 106C

Schedule C: The Property You Claim as Exempt 4/16

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

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

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

case number (if known).

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

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

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

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

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

to the applicable statutory amount.

Part 1: Identify the Property You Claim as Exempt

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

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

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

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

Brief description of the property and line on

Schedule A/B that lists this property

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption.

Specific laws that allow exemption

202 Tamarack Dr Dixon, IL 61021

Ogle County

Line from Schedule A/B: 1.1

$190,000.00  $30,000.00 735 ILCS 5/12-901

 100% of fair market value, up to

any applicable statutory limit

2011 Chevrolet Traverse 87000 miles

Line from Schedule A/B: 3.1

$8,500.00  $2,400.00 735 ILCS 5/12-1001(c)

 100% of fair market value, up to

any applicable statutory limit

2000 Nissan Altima 150000 miles

Line from Schedule A/B: 3.2

$1,500.00  $1,500.00 735 ILCS 5/12-1001(c)

 100% of fair market value, up to

any applicable statutory limit

Normal complement of household

goods

Line from Schedule A/B: 6.1

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

 100% of fair market value, up to

any applicable statutory limit

Normal complement of home

electronics

Line from Schedule A/B: 7.1

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

 100% of fair market value, up to

any applicable statutory limit

Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of 2

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

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

Normal complement of clothing

Line from Schedule A/B: 11.1

$500.00  $500.00 735 ILCS 5/12-1001(a)

 100% of fair market value, up to

any applicable statutory limit

Wedding rings and misc jewelry

Line from Schedule A/B: 12.1

$2,000.00  $2,000.00 735 ILCS 5/12-1001(b)

 100% of fair market value, up to

any applicable statutory limit

401(k): Principal Financial Group

from Fehr-Graham

Line from Schedule A/B: 21.1

$9,000.00  $9,000.00 735 ILCS 5/12-1006

 100% of fair market value, up to

any applicable statutory limit

Pension: IMRF

Line from Schedule A/B: 21.2

$838.00  $838.00 735 ILCS 5/12-1006

 100% of fair market value, up to

any applicable statutory limit

American Family Insurance - term

insurance

Beneficiary: Spouse

Line from Schedule A/B: 31.1

$1.00  $1.00 215 ILCS 5/238

 100% of fair market value, up to

any applicable statutory limit

Employer provided term insurance

Beneficiary: Spouse

Line from Schedule A/B: 31.2

$1.00  $1.00 215 ILCS 5/238

 100% of fair market value, up to

any applicable statutory limit

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

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

 No

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

 No

 Yes

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

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number

(if known)  Check if this is an

amended filing

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 creditor’s name.

Column A

Amount of claim

Do not deduct the

value of collateral.

Column B

Value of collateral

that supports this

claim

Column C

Unsecured

portion

If any

2.1 BMO Harris Bank, N.A. Describe the property that secures the claim: $8,613.07 $190,000.00 $0.00

Creditor's Name 202 Tamarack Dr Dixon, IL 61021

Ogle County Second Mortgage

200 West Monroe Street

Floor 19

Chicago, IL 60606-5075

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

apply.

 Contingent

Number, Street, City, State & Zip Code  Unliquidated

 Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply.

 Debtor 1 only

 Debtor 2 only

 An agreement you made (such as mortgage or secured

car loan)

 Debtor 1 and Debtor 2 only  Statutory lien (such as tax lien, mechanic's lien)

 At least one of the debtors and another  Judgment lien from a lawsuit

 Check if this claim relates to a

community debt

 Other (including a right to offset) Winnebago County Case #16 SC 1507

Date debt was incurred 2012 Last 4 digits of account number 0572

2.2

Ocwen Loan Servicing

LLC Describe the property that secures the claim: $176,030.40 $190,000.00 $0.00

Creditor's Name 202 Tamarack Dr Dixon, IL 61021

Ogle County

P.O. Box 24738

West Palm Beach, FL

33416

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

apply.

 Contingent

Number, Street, City, State & Zip Code  Unliquidated

 Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply.

 Debtor 1 only

 Debtor 2 only

 An agreement you made (such as mortgage or secured

car loan)

 Debtor 1 and Debtor 2 only  Statutory lien (such as tax lien, mechanic's lien)

 At least one of the debtors and another  Judgment lien from a lawsuit

 Check if this claim relates to a

community debt

 Other (including a right to offset) First Mortgage

Date debt was incurred 2008 Last 4 digits of account number 0476

Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of 2

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Debtor 1 Shawn L. Ortgiesen Case number (if know)

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

First Name Middle Name Last Name

2.3

United Lost Lake

Property Owner's A Describe the property that secures the claim: $369.00 $190,000.00 $0.00

Creditor's Name 202 Tamarack Dr Dixon, IL 61021

Ogle County

903 Missouri Drive

Dixon, IL 61021

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

apply.

 Contingent

Number, Street, City, State & Zip Code  Unliquidated

 Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply.

 Debtor 1 only

 Debtor 2 only

 An agreement you made (such as mortgage or secured

car loan)

 Debtor 1 and Debtor 2 only  Statutory lien (such as tax lien, mechanic's lien)

 At least one of the debtors and another  Judgment lien from a lawsuit

 Check if this claim relates to a

community debt

 Other (including a right to offset) Annual Homeowners Assoc Fees

Date debt was incurred 2016 Last 4 digits of account number

Add the dollar value of your entries in Column A on this page. Write that number here: $185,012.47

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

Write that number here: $185,012.47

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

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

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

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

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

Name, Number, Street, City, State & Zip Code

Bayview Loan Servicing, LLC

PO Box 650091

Dallas, TX 75265-0091

On which line in Part 1 did you enter the creditor? 2.1 

Last 4 digits of account number 2572 

Name, Number, Street, City, State & Zip Code

Bayview Loan Servicing, LLC

4425 Ponce De Leon Boulevard

Coral Gables, FL 33146

On which line in Part 1 did you enter the creditor? 2.1 

Last 4 digits of account number 

Name, Number, Street, City, State & Zip Code

Matthew M Hevrin

Hinshaw & Culbertson, LLP

100 Park Avenue

Rockford, IL 61101

On which line in Part 1 did you enter the creditor? 2.1 

Last 4 digits of account number 

Name, Number, Street, City, State & Zip Code

Ocwen Federal Bank

Bankruptcy Department

12650 Ingenuity Drive

Orlando, FL 32826-2703

On which line in Part 1 did you enter the creditor? 2.2 

Last 4 digits of account number 0476 

Official Form 106D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page 2 of 2

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number

(if known)  Check if this is an

amended filing

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. If you have no information to report in a Part, do not file that Part. On the top of any additional pages, write your

name and case number (if known).

Part 1: List All of Your PRIORITY Unsecured Claims

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

 No. Go to Part 2.

 Yes.

Part 2: List All of Your NONPRIORITY Unsecured Claims

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.

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

4.1 Asst. U.S. Atty. John MacKenzie Last 4 digits of account number $0.00

Nonpriority Creditor's Name

U.S.Atty.Off.No.Dist.Ill.Western Di

327 South Church Street, #3300

Rockford, IL 61101

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify NOTICE ONLY

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 1 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

4.2 CGH Medical Center Last 4 digits of account number 0770 $1,434.00

Nonpriority Creditor's Name

Patient Accounts Office

1813 2nd Avenue

Sterling, IL 61081

When was the debt incurred? 2/16/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.3 Clerk of the U.S. District Court Last 4 digits of account number $0.00

Nonpriority Creditor's Name

211 South Court Street

#211

Rockford, IL 61101

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify NOTICE ONLY

4.4 Department of Treasury Last 4 digits of account number 7002 Unknown

Nonpriority Creditor's Name

Bureau of the Fiscal Service

Post Office Box 1686

Birmingham, AL 35201-1686

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify NOTICE ONLY

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 2 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

4.5 Discover Last 4 digits of account number 5576 $1,980.88

Nonpriority Creditor's Name

PO Box 30943

Salt Lake City, UT 84130-0943

When was the debt incurred? various

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Credit Card

4.6 Forest City Diagnostic Imaging Last 4 digits of account number 11CM $102.79

Nonpriority Creditor's Name

9960 West 191st Street

Suite A

Mokena, IL 60448-8642

When was the debt incurred? May 2016

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.7 Internal Revenue Service Last 4 digits of account number $0.00

Nonpriority Creditor's Name

Centralized Insolvency

PO Box 7346

Philadelphia, PA 19101-7346

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify NOTICE ONLY

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 3 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

4.8 Katherine Shaw Bethea Hospital Last 4 digits of account number $2,120.85

Nonpriority Creditor's Name

403 East First Street

Dixon, IL 61021

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.9 KSB Hospital Last 4 digits of account number 4291 $2,241.00

Nonpriority Creditor's Name

Post Office Box 590

Dixon, IL 61021

When was the debt incurred? 3/2/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.1

0 One Main Financial Last 4 digits of account number 1483 $18,089.52

Nonpriority Creditor's Name

P.O. Box 9001122

Louisville, KY 40290-1122

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Loan

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 4 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

4.1

1 OSF Healthcare Last 4 digits of account number 7960 $33.15

Nonpriority Creditor's Name

Common Business Office

PO Box 1806

Peoria, IL 61656-1806

When was the debt incurred? March2016

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.1

2 OSF Healthcare System Last 4 digits of account number 2343 $198.12

Nonpriority Creditor's Name

7978 Solution Center

Chicago, IL 60677-7009

When was the debt incurred? 1/18/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.1

3 Physicians Immediate Care Last 4 digits of account number 3610 $105.67

Nonpriority Creditor's Name

PO Box 8798

Carol Stream, IL 60197-8798

When was the debt incurred? December 2015

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 5 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

4.1

4 Progressive Eye Care Last 4 digits of account number O003 $227.15

Nonpriority Creditor's Name

3100 Ogden Avenue

Lisle, IL 60532

When was the debt incurred? 3/23/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.1

5 Rockford Associated Pathologists Last 4 digits of account number 1198 $14.42

Nonpriority Creditor's Name

P.O. Box 15785

Loves Park, IL 61132-5785

When was the debt incurred? 12/2/15

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.1

6 Rockford Radiology Last 4 digits of account number 9950 $36.22

Nonpriority Creditor's Name

P.O. Box 1790

Brookfield, WI 53008

When was the debt incurred? 3/2/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 6 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

4.1

7 Springleaf Financial Last 4 digits of account number 5593 $1,798.00

Nonpriority Creditor's Name

PO Box 790368

Saint Louis, MO 63179-0368

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Loan

4.1

8

Swedish American Home Health

Care Last 4 digits of account number 5446 $1,473.96

Nonpriority Creditor's Name

P.O. Box 1567

Rockford, IL 61110

When was the debt incurred? 4/1/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

4.1

9 U.S. Attorney Illinois-Northern Last 4 digits of account number $0.00

Nonpriority Creditor's Name

Attention: Financial Litigation Un

Everett McKinleyDirksen

Chicago, IL 60604-1702

When was the debt incurred? 4/27/16

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify NOTICE ONLY

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 7 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

4.2

0 U.S. Atty General Zachary Sardon Last 4 digits of account number $182,788.67

Nonpriority Creditor's Name

219 South Dearborn Street

Fifth Floor

Chicago, IL 60604

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Judgment entered 1/27/2015

4.2

1 U.S. Atty. General Loretta E. Lynch Last 4 digits of account number $0.00

Nonpriority Creditor's Name

U.S. Department of Justice

950 Pennsylvania Avenue NW

Washington, DC 20530-0001

When was the debt incurred?

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify NOTICE ONLY

4.2

2 United States of America Last 4 digits of account number $0.00

Nonpriority Creditor's Name

Department of the Treasury

Post Office Box 1686

Birmingham, AL 35201-1686

When was the debt incurred? January 27, 2015

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify NOTICE ONLY

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 8 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

4.2

3 Warren L. Lowry, M.D. Last 4 digits of account number 2069 $847.55

Nonpriority Creditor's Name

1340 Charles Street

Suite 200

Rockford, IL 61104

When was the debt incurred? March 31, 2016

Number Street City State ZIp Code As of the date you file, the claim is: Check all that apply

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

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

 Yes  Other. Specify Medical Services

Part 3: List Others to Be Notified About 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 and Address On which entry in Part 1 or Part 2 did you list the original creditor?

American Credit Systems, Inc.

400 W. Lake Street, Suite 111

PO Box 72849

Roselle, IL 60172-0849

Line 4.23 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

CGH Medical Center

101 East Miller Road

Sterling, IL 61081-1279

Line 4.2 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Clerk of the Court

Northern District of Illinois

219 South Dearborn Street, 20th

Chicago, IL 60604

Line 4.22 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Department of Treasury

Internal Revenue Service

Kansas City, MO 64999-0010

Line 4.22 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Discover

P.O. Box 6103

Carol Stream, IL 60197-6103

Line 4.5 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Internal Revenue Service

Centralized Insolvency

PO Box 7346

Philadelphia, PA 19101-7346

Line 4.22 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Michael A. Mellott Line 4.8 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 9 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

201 East 3rd St

Sterling, IL 61081

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Mutual Management Services

Department #14674

Post Office Box 1259

Oaks, PA 19456

Line 4.18 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Mutual Management Services Co.,

LLC

7177 Crimson Ridge Drive, Suite 10

PO Box 8740

Rockford, IL 61126-6235

Line 4.18 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

One Main Financial

3207 East Lincoln Way

Sterling, IL 61081

Line 4.10 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

OSF Healthcare System

Post Office Box 91011

Chicago, IL 60677-7009

Line 4.11 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Rockford Mercantile Agency

2502 S. Alpine Road

Rockford, IL 61108

Line 4.15 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

RRCA Accounts Management

201 East 3rd Street

Sterling, IL 61081

Line 4.8 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

RRCA Accounts Management

201 E. 3rd Street

Sterling, IL 61081

Line 4.2 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

Swedish American Hospital

P.O. Box 950

Waukegan, IL 60085

Line 4.18 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

U.S. Attorney Illinois-Northern

Attention: Financial Litigation Un

Everett McKinleyDirksen

Chicago, IL 60604-1702

Line 4.22 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

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

U.S. Attorney Illinois-Northern

Attention: Financial Litigation Un

Everett McKinleyDirksen

Chicago, IL 60604-1702

Line 4.4 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 10 of 11

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if know)

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

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

type of unsecured claim.

Total Claim

6a. Domestic support obligations 6a. $ 0.00

Total

claims

from Part 1 6b. Taxes and certain other debts you owe the government 6b. $ 0.00

6c. Claims for death or personal injury while you were intoxicated 6c. $ 0.00

6d. Other. Add all other priority unsecured claims. Write that amount here. 6d. $ 0.00

6e. Total Priority. Add lines 6a through 6d. 6e. $ 0.00

Total Claim

6f. Student loans 6f. $ 0.00

Total

claims

from Part 2 6g. Obligations arising out of a separation agreement or divorce that

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

6h. Debts to pension or profit-sharing plans, and other similar debts 6h. $ 0.00

6i. Other. Add all other nonpriority unsecured claims. Write that amount

here.

6i.

$ 213,491.95

6j. Total Nonpriority. Add lines 6f through 6i. 6j. $ 213,491.95

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 11 of 11

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number

(if known)  Check if this is an

amended filing

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 file this form with the court with your other schedules. You have nothing else to report on this form.

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

Name, Number, Street, City, State and ZIP Code

State what the contract or lease is for

2.1

Name

Number Street

City State ZIP Code

2.2

Name

Number Street

City State ZIP Code

2.3

Name

Number Street

City State ZIP Code

2.4

Name

Number Street

City State ZIP Code

2.5

Name

Number Street

City State ZIP Code

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

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number

(if known)  Check if this is an

amended filing

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, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)

 No. Go to line 3.

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

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

Name, Number, Street, City, State and ZIP Code

Column 2: The creditor to whom you owe the debt

Check all schedules that apply:

3.1  Schedule D, line

Name  Schedule E/F, line

 Schedule G, line

Number Street

City State ZIP Code

3.2  Schedule D, line

Name  Schedule E/F, line

 Schedule G, line

Number Street

City State ZIP Code

Official Form 106H Schedule H: Your Codebtors Page 1 of 1

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen

Debtor 2 Angela L. Ortgiesen

(Spouse, if filing)

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number Check if this is:

(If known)  An amended filing

 A supplement showing postpetition 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. Debtor 1 Debtor 2 or non-filing spouse

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.

Employment status

 Employed

 Not employed

 Employed

 Not employed

Occupation Project Manager Teacher's Aid

Employer's name Fehr-Graham & Associates Dixon Public Schools #170

Employer's address 221 East Main Street Suite 200

Freeport, IL 61032

1335 Franklin Grove Road

Dixon, IL 61021

How long employed there? 3 years 1 year

Part 2: Give Details About Monthly Income

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

spouse unless you are separated.

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

more space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or

non-filing spouse

2.

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

deductions). If not paid monthly, calculate what the monthly wage would be. 2. $ 8,180.00 $ 965.00

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

4. Calculate gross Income. Add line 2 + line 3. 4. $ 8,180.00 $ 965.00

Official Form 106I Schedule I: Your Income page 1

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

For Debtor 1 For Debtor 2 or

non-filing spouse

Copy line 4 here 4. $ 8,180.00 $ 965.00

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a. $ 1,541.00 $ 190.00

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

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

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

5e. Insurance 5e. $ 775.00 $ 0.00

5f. Domestic support obligations 5f. $ 0.00 $ 0.00

5g. Union dues 5g. $ 0.00 $ 0.00

5h. Other deductions. Specify: IMRF 5h.+ $ 0.00 + $ 42.00

Dixon Educ Support Pers. $ 0.00 $ 62.00

6. Add the payroll deductions. Add lines 5a+5b+5c+5d+5e+5f+5g+5h. 6. $ 2,316.00 $ 294.00

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $ 5,864.00 $ 671.00

8. List all other income regularly received:

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

profession, or farm

Attach a statement for each property and business showing gross

receipts, ordinary and necessary business expenses, and the total

monthly net income. 8a. $ 0.00 $ 0.00

8b. Interest and dividends 8b. $ 0.00 $ 0.00

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

regularly receive

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

settlement, and property settlement. 8c. $ 0.00 $ 0.00

8d. Unemployment compensation 8d. $ 0.00 $ 0.00

8e. Social Security 8e. $ 0.00 $ 0.00

8f. Other government assistance that you regularly receive

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

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

Nutrition Assistance Program) or housing subsidies.

Specify: 8f. $ 0.00 $ 0.00

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

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

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

10. Calculate monthly income. Add line 7 + line 9. 10. $ 5,864.00 + $ 671.00 = $ 6,535.00

Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse.

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

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

other friends or relatives.

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

Specify: 11. +$ 0.00

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

12. $ 6,535.00

Write that amount on the Summary of Schedules and Statistical Summary of Certain Liabilities and Related Data, if it

applies

Combined

monthly income

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

 No.

 Yes. Explain:

Official Form 106I Schedule I: Your Income page 2

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen Check if this is:

 An amended filing

Debtor 2 Angela L. Ortgiesen  A supplement showing postpetition chapter

(Spouse, if filing) 13 expenses as of the following date:

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS MM / DD / YYYY

Case number

(If known)

Official Form 106J

Schedule J: Your Expenses 12/15

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

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

number (if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

 Yes. Does Debtor 2 live in a separate household?

 No

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

2. Do you have dependents?  No

Do not list Debtor 1 and

Debtor 2.

 Yes. Fill out this information for

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

Dependent’s relationship to

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent

live with you?

Do not state the

dependents names. Daughter 6

 No

 Yes

Son 11

 No

 Yes

 No

 Yes

 No

 Yes

3. Do your expenses include

expenses of people other than

yourself and your dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

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

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

applicable date.

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

the value of such assistance and have included it on Schedule I: Your Income

(Official Form 106I.) Your expenses

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

payments and any rent for the ground or lot. 4. $ 1,154.00

If not included in line 4:

4a. Real estate taxes 4a. $ 0.00

4b. Property, homeowner’s, or renter’s insurance 4b. $ 0.00

4c. Home maintenance, repair, and upkeep expenses 4c. $ 200.00

4d. Homeowner’s association or condominium dues 4d. $ 31.00

5. Additional mortgage payments for your residence, such as home equity loans 5. $ 0.00

Official Form 106J Schedule J: Your Expenses page 1

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

6. Utilities:

6a. Electricity, heat, natural gas 6a. $ 390.00

6b. Water, sewer, garbage collection 6b. $ 199.00

6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $ 345.00

6d. Other. Specify: 6d. $ 0.00

7. Food and housekeeping supplies 7. $ 911.00

8. Childcare and children’s education costs 8. $ 50.00

9. Clothing, laundry, and dry cleaning 9. $ 200.00

10. Personal care products and services 10. $ 10.00

11. Medical and dental expenses 11. $ 200.00

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

Do not include car payments. 12. $ 350.00

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $ 200.00

14. Charitable contributions and religious donations 14. $ 20.00

15. Insurance.

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

15a. Life insurance 15a. $ 107.00

15b. Health insurance 15b. $ 0.00

15c. Vehicle insurance 15c. $ 141.00

15d. Other insurance. Specify: 15d. $ 0.00

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

Specify: 16. $ 0.00

17. Installment or lease payments:

17a. Car payments for Vehicle 1 17a. $ 0.00

17b. Car payments for Vehicle 2 17b. $ 0.00

17c. Other. Specify: 17c. $ 0.00

17d. Other. Specify: 17d. $ 0.00

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

deducted from your pay on line 5, Schedule I, Your Income (Official Form 106I). 18. $ 0.00

19. Other payments you make to support others who do not live with you. $ 0.00

Specify: 19.

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

20a. Mortgages on other property 20a. $ 0.00

20b. Real estate taxes 20b. $ 0.00

20c. Property, homeowner’s, or renter’s insurance 20c. $ 0.00

20d. Maintenance, repair, and upkeep expenses 20d. $ 0.00

20e. Homeowner’s association or condominium dues 20e. $ 0.00

21. Other: Specify: 21. +$ 0.00

22. Calculate your monthly expenses

22a. Add lines 4 through 21. $ 4,508.00

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

22c. Add line 22a and 22b. The result is your monthly expenses. $ 4,508.00

23. Calculate your monthly net income.

23a. Copy line 12 (your combined monthly income) from Schedule I. 23a. $ 6,535.00

23b. Copy your monthly expenses from line 22c above. 23b. -$ 4,508.00

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

The result is your monthly net income. 23c. $ 2,027.00

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

For example, do you expect to finish paying for your car loan within the year or do you expect your mortgage payment to increase or decrease because of a

modification to the terms of your mortgage?

 No.

 Yes. Explain here:

Official Form 106J Schedule J: Your Expenses page 2

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Fill in this information to identify your case:

Debtor 1 Shawn L. Ortgiesen

First Name Middle Name Last Name

Debtor 2 Angela L. Ortgiesen

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS

Case number

(if known)  Check if this is an

amended filing

Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy 4/16

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

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

number (if known). Answer every question.

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

1. What is your current marital status?

 Married

 Not married

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

 No

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

Debtor 1 Prior Address: Dates Debtor 1

lived there

Debtor 2 Prior Address: Dates Debtor 2

lived there

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

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

 No

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

Part 2 Explain the Sources of Your Income

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

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

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

 No

 Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income

Check all that apply.

Gross income

(before deductions and

exclusions)

Sources of income

Check all that apply.

Gross income

(before deductions

and exclusions)

From January 1 of current year until

the date you filed for bankruptcy:

 Wages, commissions,

bonuses, tips

 Operating a business

$56,632.65  Wages, commissions,

bonuses, tips

 Operating a business

$10,257.91

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

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

Debtor 1 Debtor 2

Sources of income

Check all that apply.

Gross income

(before deductions and

exclusions)

Sources of income

Check all that apply.

Gross income

(before deductions

and exclusions)

For last calendar year:

(January 1 to December 31, 2015 )

 Wages, commissions,

bonuses, tips

 Operating a business

$91,490.00  Wages, commissions,

bonuses, tips

 Operating a business

$0.00

For the calendar year before that:

(January 1 to December 31, 2014 )

 Wages, commissions,

bonuses, tips

 Operating a business

$85,152.00  Wages, commissions,

bonuses, tips

 Operating a business

$0.00

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

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

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

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

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

 No

 Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income

Describe below.

Gross income from

each source

(before deductions and

exclusions)

Sources of income

Describe below.

Gross income

(before deductions

and exclusions)

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

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

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

individual primarily for a personal, family, or household purpose.”

During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,425* or more?

 No. Go to line 7.

 Yes List below each creditor to whom you paid a total of $6,425* or more in one or more payments and the total amount you

paid that creditor. Do not include payments for domestic support obligations, such as child support and alimony. Also, do

not include payments to an attorney for this bankruptcy case.

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

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

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

 No. Go to line 7.

 Yes List below each creditor to whom you paid a total of $600 or more and the total amount you paid that creditor. Do not

include payments for domestic support obligations, such as child support and alimony. Also, do not include payments to an

attorney for this bankruptcy case.

Creditor's Name and Address Dates of payment Total amount

paid

Amount you

still owe

Was this payment for ...

One Main Financial

3207 East Lincoln Way

Sterling, IL 61081

Monthly $990.00 $18,089.52  Mortgage

 Car

 Credit Card

 Loan Repayment

 Suppliers or vendors

 Other

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

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

Creditor's Name and Address Dates of payment Total amount

paid

Amount you

still owe

Was this payment for ...

Ocwen Loan Servicing LLC

P.O. Box 24738

West Palm Beach, FL 33416

Monthly $3,461.64 $176,030.40  Mortgage

 Car

 Credit Card

 Loan Repayment

 Suppliers or vendors

 Other

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

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

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

a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations, such as child support and

alimony.

 No

 Yes. List all payments to an insider.

Insider's Name and Address Dates of payment Total amount

paid

Amount you

still owe

Reason for this payment

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

insider?

Include payments on debts guaranteed or cosigned by an insider.

 No

 Yes. List all payments to an insider

Insider's Name and Address Dates of payment Total amount

paid

Amount you

still owe

Reason for this payment

Include creditor's name

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

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

modifications, and contract disputes.

 No

 Yes. Fill in the details.

Case title

Case number

Nature of the case Court or agency Status of the case

BMO/Harris Bank vs. Shawn and

Angela Ortgiesen

2016-SC-1507

Small Claims Winnebago County

400 West State Street

Rockford, IL

 Pending

 On appeal

 Concluded

RRCA Accounts Management, Inc.

vs. Shawn L. Ortgiesen

15 SC 508

Small Claims Lee County

309 South Galena Avenue

Dixon, IL 61021

 Pending

 On appeal

 Concluded

United States of America vs.

Shawn Ortgiesen

12 CR 50027

US District Court/No.

Illinois/Western

327 South Church Street

Rockford, IL 61101

 Pending

 On appeal

 Concluded

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

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

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

Check all that apply and fill in the details below.

 No. Go to line 11.

 Yes. Fill in the information below.

Creditor Name and Address Describe the Property

Explain what happened

Date Value of the

property

U.S. Attorney Illinois - Northern

Attn: Financial Litigation Unit

Everett McKinley Dirksen Bldg

Chicago, IL 60604-1702

2015 Tax refund seizure

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized or levied.

4/27/2016 $2,339.00

Clerk of the Court, Northern

District IL

219 South Dearborn Street, 20th

Floor

Chicago, IL 60604

Turn over order per 12 CR 50027

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized or levied.

Wage

Deduction

YTD

$5,515.54

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

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

 No

 Yes. Fill in the details.

Creditor Name and Address Describe the action the creditor took Date action was

taken

Amount

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

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

 No

 Yes

Part 5: List Certain Gifts and Contributions

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

 No

 Yes. Fill in the details for each gift.

Gifts with a total value of more than $600

per person

Person to Whom You Gave the Gift and

Address:

Describe the gifts Dates you gave

the gifts

Value

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

 No

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

Gifts or contributions to charities that total

more than $600

Charity's Name

Address (Number, Street, City, State and ZIP Code)

Describe what you contributed Dates you

contributed

Value

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

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

Part 6: List Certain Losses

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

or gambling?

 No

 Yes. Fill in the details.

Describe the property you lost and

how the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending

insurance claims on line 33 of Schedule A/B: Property.

Date of your

loss

Value of property

lost

Part 7: List Certain Payments or Transfers

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

consulted about seeking bankruptcy or preparing a bankruptcy petition?

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

 No

 Yes. Fill in the details.

Person Who Was Paid

Address

Email or website address

Person Who Made the Payment, if Not You

Description and value of any property

transferred

Date payment

or transfer was

made

Amount of

payment

Bernard J. Natale, Ltd

Edgebrook Office Center

1639 N. Alpine Road, Suite 401

Rockford, IL 61107

natalelaw@bjnatalelaw.com

Partial Attorney Fees plus Court Filing

Fees

07/2016 $810.00

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.

Person Who Was Paid

Address

Description and value of any property

transferred

Date payment

or transfer was

made

Amount of

payment

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

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

Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property). Do not

include gifts and transfers that you have already listed on this statement.

 No

 Yes. Fill in the details.

Person Who Received Transfer

Address

Person's relationship to you

Description and value of

property transferred

Describe any property or

payments received or debts

paid in exchange

Date transfer was

made

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

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

 No

 Yes. Fill in the details.

Name of trust Description and value of the property transferred Date Transfer was

made

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

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

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

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

sold, moved, or transferred?

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

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

 No

 Yes. Fill in the details.

Name of Financial Institution and

Address (Number, Street, City, State and ZIP

Code)

Last 4 digits of

account number

Type of account or

instrument

Date account was

closed, sold,

moved, or

transferred

Last balance

before closing or

transfer

Midland Bank

1901 S. 4th St

Effingham, IL 62401

XXXX-  Checking

 Savings

 Money Market

 Brokerage

 Other

04/2016 $0.00

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

cash, or other valuables?

 No

 Yes. Fill in the details.

Name of Financial Institution

Address (Number, Street, City, State and ZIP Code)

Who else had access to it?

Address (Number, Street, City,

State and ZIP Code)

Describe the contents Do you still

have it?

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

 No

 Yes. Fill in the details.

Name of Storage Facility

Address (Number, Street, City, State and ZIP Code)

Who else has or had access

to it?

Address (Number, Street, City,

State and ZIP Code)

Describe the contents 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.

 No

 Yes. Fill in the details.

Owner's Name

Address (Number, Street, City, State and ZIP Code)

Where is the property?

(Number, Street, City, State and ZIP

Code)

Describe 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.

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

Software Copyright (c) 1996-2016 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

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Debtor 1

Debtor 2

Shawn L. Ortgiesen

Angela L. Ortgiesen Case number (if known)

24. Has any governmental unit notified you that you may be liable or potentially liable under or in violation of an environmental law?

 No

 Yes. Fill in the details.

Name of site

Address (Number, Street, City, State and ZIP Code)

Governmental unit

Address (Number, Street, City, State and

ZIP Code)

Environmental law, if you

know it

Date of notice

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

 No

 Yes. Fill in the details.

Name of site

Address (Number, Street, City, State and ZIP Code)

Governmental unit

Address (Number, Street, City, State and

ZIP Code)

Environmental law, if you

know it

Date of notice

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

 No

 Yes. Fill in the details.

Case Title

Case Number

Court or agency

Name

Address (Number, Street, City,

State and ZIP Code)

Nature of the case Status of the

case

Part 11: Give Details About Your Business or Connections to Any Business

27. Within 4 years before you filed for bankruptcy, did you own a business or have any of the following connections to any business?

 A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time

 A member of a limited liability company (LLC) or limited liability partnership (LLP)

 A partner in a partnership

 An officer, director, or managing executive of a corporation

 An owner of at least 5% of the voting or equity securities of a corporation

 No. None of the above applies. Go to Part 12.

 Yes. Check all that apply above and fill in the details below for each business.

Business Name

Address

(Number, Street, City, State and ZIP Code)

Describe the nature of the business

Name of accountant or bookkeeper

Employer Identification number

Do not include Social Security number or ITIN.

Dates business existed

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 below.

Name

Address

(Number, Street, City, State and ZIP Code)

Date Issued

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

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS

RIGHTS AND RESPONSIBILITIES AGREEMENT BETWEEN

CHAPTER 13 DEBTORS AND THEIR ATTORNEYS

(Court-Approved Retention Agreement, Revised as of 4/20/2015)

Chapter 13 gives debtors important rights, such as the right to keep property that could

otherwise be lost through repossession or foreclosure, but Chapter 13 also puts burdens on

debtors, such as the burden of making complete and truthful disclosures of their financial

situation. It is important for debtors who file a Chapter 13 bankruptcy case to understand their

rights and responsibilities in bankruptcy. In this connection, the advice of an attorney is often

crucial. Debtors are entitled to certain services from their attorneys, but debtors also have

responsibilities to their attorneys. In order to assure that debtors and their attorneys understand

their rights and responsibilities in the Chapter 13 process, the judges of the Bankruptcy Court for

the Northern District of Illinois have approved this agreement, setting out the rights and

responsibilities of both debtors in Chapter 13 and their attorneys, including how their attorneys

will be paid for their services in the Chapter 13 case. By signing this agreement, debtors and

their attorneys accept these responsibilities.

The Bankruptcy Code may require a debtor's attorney to provide the debtor with certain

documents and agreements at the start of the representation. The terms of this court-approved

agreement take the place of any conflicting provision in an earlier agreement. This agreement

cannot be modified in any way by other agreements. Any provision of another agreement

between the debtors and the attorney that conflicts with this agreement is void.

A. BEFORE THE CASE IS FILED

THE DEBTOR AGREES TO:

1. Discuss with the attorney the debtor's objectives in filing the case.

2. Provide the attorney with full, accurate and timely information, financial and otherwise,

including properly documented proof of income.

THE ATTORNEY AGREES TO:

1. Personally counsel the debtor regarding the advisability of filing either a Chapter 13 or a Chapter 7

case, discuss both procedures (as well as non-bankruptcy options) with the debtor, and answer the

debtor's questions.

2. Personally explain to the debtor that the attorney is being engaged to represent the debtor on all

matters arising in the case, as required by Local Bankruptcy Rule, and explain how and when the

attorney's fees and the trustee's fees are determined and paid.

3. Personally review with the debtor and sign the completed petition, plan, statements, and schedules,

as well as all amendments thereto, whether filed with the petition or later. (The schedules may be

initially prepared with the help of clerical or paralegal staff of the attorney's office, but personal

attention of the attorney is required for the review and signing.)

4. Timely prepare and file the debtor's petition, plan, statements, and schedules.

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5. Explain to the debtor how, when, and where to make all necessary payments, including both

payments that must be made directly to creditors and payments that must be made to the Chapter 13

trustee, with particular attention to housing and vehicle payments.

6. Advise the debtor of the need to maintain appropriate insurance.

B. AFTER THE CASE IS FILED

THE DEBTOR AGREES TO:

1. Make the required payments to the trustee and to whatever creditors are being paid

directly, or, if required payments cannot be made, to notify the attorney immediately.

2. Appear punctually at the meeting of creditors (also called the "341 meeting") with recent

proof of income and a picture identification card. (If the identification card does not include

the debtor's social security number, the debtor must also bring to the meeting a social security

card.) The debtor must be present in time for check-in and when the case is called for the

actual examination.

3. Notify the attorney of any change in the debtor's address or telephone number.

4. Inform the attorney of any wage garnishments or liens or levies on assets that occur or

continue after the filing of the case.

5. Contact the attorney immediately if the debtor loses employment, has a significant change

in income, or experiences any other significant change in financial situation (such as serious

illness, marriage, divorce or separation, lottery winnings, or an inheritance).

6. Notify the attorney if the debtor is sued or wishes to file a lawsuit (including divorce.)

7. Inform the attorney if any tax refunds to which the debtor is entitled are seized or not

received when due from the IRS or Illinois Department of Revenue.

8. Contact the attorney before buying, refinancing, or selling real property, and before

entering into any loan agreement.

9. Supply the attorney with copies of all tax returns filed while the case is pending.

THE ATTORNEY AGREES TO:

1. Advise the debtor of the requirement to attend the meeting of creditors, and notify the

debtor of the date, time, and place of the meeting.

2. Inform the debtor that the debtor must be punctual and, in the case of a joint filing, that

both spouses must appear at the same meeting.

3. Provide knowledgeable legal representation for the debtor at the meeting of creditors (in

time for check-in and the actual examination) and, unless excused by the trustee, for the

confirmation hearing.

4. If the attorney will be employing another attorney to attend the 341 meeting or any court

hearing, personally explain to the debtor in advance, the role and identity of the other

2

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attorney and provide the other attorney with the file in sufficient time to review it and

properly represent the debtor.

5. Timely submit to the Chapter 13 trustee properly documented proof of income for the

debtor, including business reports for self-employed debtors.

6. Timely respond to objections to plan confirmation and, where necessary, prepare, file, and

serve an amended plan.

7. Timely prepare, file, and serve any necessary statements, amended statements, and

schedules and any change of address, in accordance with information provided by the debtor.

8. Monitor all incoming case information (including, but not limited to, Order Confirming

Plan, Notice of Intent to Pay Claims, and 6-month status reports) for accuracy and

completeness. Contact the trustee promptly regarding any discrepancies.

9. Be available to respond to the debtor’s questions throughout the term of the plan.

10. Prepare, file, and serve timely modifications to the plan after confirmation, when

necessary, including modifications to suspend, lower, or increase plan payments.

11. Prepare, file, and serve necessary motions to buy or sell property and to incur debt.

12. Object to improper or invalid claims.

13. Timely respond to the Chapter 13 trustee’s motions to dismiss the case, such as for

payment default, or unfeasibility, and to motions to increase the percentage payment to

unsecured creditors.

14. Timely respond to motions for relief from stay.

15. Prepare, file, and serve all appropriate motions to avoid liens.

16. Provide any other legal services necessary for the administration of the case.

C. TERMINATION OR CONVERSION OF THE CASE AFTER ENTRY OF AN

ORDER APPROVING FEES AND EXPENSES

1. Approved fees and expenses paid under the provisions set out below are generally not

refundable in the event that the case is dismissed prior to its completion, unless the dismissal is

due to a failure by the attorney to comply with the duties set out in this agreement. If such a

dismissal is due to a failure by the attorney, the court may order a refund of fees on motion by

the debtor.

2. If the case is dismissed after approval of the fees and expenses but before payment of all

allowed fees and expenses, the order entered by the Bankruptcy Court allowing the fees and

expenses is not a judgment against the debtor for the unpaid fees and expenses based on contract

law or otherwise.

3. If the case is converted to a case under chapter 7 after approval of the fees and expenses under

this agreement but before the payment of all fees and expenses, the attorney will be entitled to an

administrative claim in the chapter 7 case for any unpaid fees and expenses, pursuant to section

3

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726(b) of the Bankruptcy Code, plus any conversion fee the attorney pays on behalf of the

debtor.

D. RETAINERS AND PREVIOUS PAYMENTS

1. The attorney may receive a retainer or other payment before filing the case but may not

receive fees directly from the debtor after the filing of the case. Unless the following provision is

checked and completed, any retainer received by the attorney will be treated as a security

retainer, to be placed in the attorney's client trust account until approval of a fee application by

the court.

The attorney seeks to have the retainer received by the attorney treated as an advance

payment retainer, which allows the attorney to take the retainer into income immediately.

The attorney hereby provides the following further information and representations:

(a) The special purpose for the advance payment retainer and why it is advantageous to

the debtor is as follows:

(b) The retainer will not be held in a client trust account and will become property of the

attorney upon payment and will be deposited into the attorney's general account;

(c) The retainer is a flat fee for the services to be rendered during the chapter 13 case

and will be applied for such services without the need for the attorney to keep

detailed hourly time records for the specific services performed for the debtor;

(d) Any portion of the retainer that is not earned or required for expenses will be

refunded to the client; and

(e) The attorney is unwilling to represent the debtor without receiving an advanced

payment retainer because of the nature of the chapter 13 case, the fact that the great

majority of services for such case are performed prior to its filing, and the risks

associated with the representation of debtors in bankruptcy cases in general.

2. In any application for compensation the attorney must disclose to the court any fees or other

compensation paid by the debtor to the attorney for any reason within the one year before the

case filing.

E. CONDUCT AND DISCHARGE

4

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}bk1{Credito AresMatix}bk{

American Credit Systems, Inc.

400 W. Lake Street, Suite 111

PO Box 72849

Roselle, IL 60172-0849

Asst. U.S. Atty. John MacKenzie

U.S.Atty.Off.No.Dist.Ill.Western Di

327 South Church Street, #3300

Rockford, IL 61101

Bayview Loan Servicing, LLC

PO Box 650091

Dallas, TX 75265-0091

Bayview Loan Servicing, LLC

4425 Ponce De Leon Boulevard

Coral Gables, FL 33146

BMO Harris Bank, N.A.

200 West Monroe Street

Floor 19

Chicago, IL 60606-5075

CGH Medical Center

Patient Accounts Office

1813 2nd Avenue

Sterling, IL 61081

CGH Medical Center

101 East Miller Road

Sterling, IL 61081-1279

Clerk of the Court

Northern District of Illinois

219 South Dearborn Street, 20th

Chicago, IL 60604

Clerk of the U.S. District Court

211 South Court Street

#211

Rockford, IL 61101

Department of Treasury

Bureau of the Fiscal Service

Post Office Box 1686

Birmingham, AL 35201-1686

Department of Treasury

Internal Revenue Service

Kansas City, MO 64999-0010

Discover

PO Box 30943

Salt Lake City, UT 84130-0943

Discover

P.O. Box 6103

Carol Stream, IL 60197-6103

Forest City Diagnostic Imaging

9960 West 191st Street

Suite A

Mokena, IL 60448-8642

Internal Revenue Service

Centralized Insolvency

PO Box 7346

Philadelphia, PA 19101-7346

Katherine Shaw Bethea Hospital

403 East First Street

Dixon, IL 61021

KSB Hospital

Post Office Box 590

Dixon, IL 61021

Matthew M Hevrin

Hinshaw & Culbertson, LLP

100 Park Avenue

Rockford, IL 61101

Michael A. Mellott

201 East 3rd St

Sterling, IL 61081

Mutual Management Services

Department #14674

Post Office Box 1259

Oaks, PA 19456

Mutual Management Services Co., LL

7177 Crimson Ridge Drive, Suite 10

PO Box 8740

Rockford, IL 61126-6235

Ocwen Federal Bank

Bankruptcy Department

12650 Ingenuity Drive

Orlando, FL 32826-2703

Ocwen Loan Servicing LLC

P.O. Box 24738

West Palm Beach, FL 33416

One Main Financial

P.O. Box 9001122

Louisville, KY 40290-1122

One Main Financial

3207 East Lincoln Way

Sterling, IL 61081

OSF Healthcare

Common Business Office

PO Box 1806

Peoria, IL 61656-1806

OSF Healthcare System

7978 Solution Center

Chicago, IL 60677-7009

OSF Healthcare System

Post Office Box 91011

Chicago, IL 60677-7009

Physicians Immediate Care

PO Box 8798

Carol Stream, IL 60197-8798

Progressive Eye Care

3100 Ogden Avenue

Lisle, IL 60532

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Rockford Associated Pathologists

P.O. Box 15785

Loves Park, IL 61132-5785

Rockford Mercantile Agency

2502 S. Alpine Road

Rockford, IL 61108

Rockford Radiology

P.O. Box 1790

Brookfield, WI 53008

RRCA Accounts Management

201 East 3rd Street

Sterling, IL 61081

RRCA Accounts Management

201 E. 3rd Street

Sterling, IL 61081

Springleaf Financial

PO Box 790368

Saint Louis, MO 63179-0368

Swedish American Home Health Care

P.O. Box 1567

Rockford, IL 61110

Swedish American Hospital

P.O. Box 950

Waukegan, IL 60085

U.S. Attorney Illinois-Northern

Attention: Financial Litigation Un

Everett McKinleyDirksen

Chicago, IL 60604-1702

U.S. Atty General Zachary Sardon

219 South Dearborn Street

Fifth Floor

Chicago, IL 60604

U.S. Atty. General Loretta E. Lynch

U.S. Department of Justice

950 Pennsylvania Avenue NW

Washington, DC 20530-0001

United Lost Lake Property Owner's A

903 Missouri Drive

Dixon, IL 61021

United States of America

Department of the Treasury

Post Office Box 1686

Birmingham, AL 35201-1686

Warren L. Lowry, M.D.

1340 Charles Street

Suite 200

Rockford, IL 61104

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