Check if this is an

amended filing

12/15

1.

2.

3. xxx - xx- 2152

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

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

Chapter 7

Chapter 11

Chapter 12

Chapter 13

Fill in this information to identify your case:

United States Bankruptcy Court for the:

Northern District of: Illinois

(State)

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy

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

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

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

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

the forms.

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

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

Part 1: Identify Yourself

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

Your full name

Write the name that is on

your government-issued

picture identification (for

example, your driver's

license or passport

Bring your picture

identification to your meeting

with the trustee.

Flora

First name

Middle name

Clemons

Last name

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

First name

Middle name

Last name

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

All other names you

have used in the last

8 years

Include your married or

maiden names.

First name

Middle name

Last name

First name

Middle name

Last name

First name

Middle name

Last name

First name

Middle name

Last name

Only the last 4 digits

of your Social

Security number or

federal Individual

Taxpayer

Identification

number (ITIN)

OR OR

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 9 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

4.

5.

1208 W. 78th St. 

Number Street

Chicago Illinois 60620 

City State Zip Code

Cook 

County

Number Street

City State Zip Code

Number Street

City State Zip Code

County

Number Street

City State Zip Code

6.

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

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

Any business names

and Employer

Identification

Numbers (EIN) you

have used in the last

8 years

Include trade names and

doing business as names

I have not used any business names or EINs.

Business name

Business name

EIN

EIN

I have not used any business names or EINs.

Business name

Business name

EIN

EIN

Where you live

Apt. 1 

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

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

mailing address.

If Debtor 2 lives at a different address:

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

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

address.

Why you are

choosing this

district to file for

bankruptcy

Check one:

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

in this district longer than in any other district.

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

Check one:

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

in this district longer than in any other district.

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

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 10 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

7.

8.

9.

Yes. District When

MM / DD / YYYY

Case number

District When

MM / DD / YYYY

Case number

District When

MM / DD / YYYY

Case number

10.

Yes. Debtor Relationship to you

District When

MM / DD / YYYY

Case number, if known

Debtor Relationship to you

District When

MM / DD / YYYY

Case number, if known

11. No. Go to line 12.

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

No. Go to line 12.

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

this bankruptcy petition.

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

Part 2: Tell the Court About Your Bankruptcy Case

The chapter of the

Bankruptcy Code

you are choosing to

file under

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

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

Chapter 7

Chapter 11

Chapter 12

Chapter 13

How you will pay the

fee

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

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

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

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

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

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

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

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

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

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

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

Have you filed for

bankruptcy within

the last 8 years?

No.

Are any bankruptcy

cases pending or

being filed by a

spouse who is not

filing this case with

you, or by a

business partner, or

by an affiliate?

No.

Do you rent your

residence?

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 11 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

12. No. Go to Part 4.

Yes. Name and location of business

Number Street

City State Zip Code

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

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

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

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

None of the above

13.

No. I am not filing under Chapter 11.

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

Bankruptcy Code.

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

14.

Yes.

Number Street

City State Zip Code

What is the hazard?

If immediate attention is needed, why is it needed?

Where is the property?

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

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

Are you a sole

proprietor of any

full- or part-time

business?

A sole proprietorship is

a business you

operate as an

individual, and is not a

separate legal entity

such as a corporation,

partnership, or LLC.

If you have more than

one sole

proprietorship, use a

separate sheet and

attach it to this

petition.

Name of business, if any

Check the appropriate box to describe your business:

Are you filing under

Chapter 11 of the

Bankruptcy Code

and are you a small

business debtor?

For a definition of

small business debtor,

see 11 U.S.C. §

101(51D).

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

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

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

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

Do you own or have

any property that

poses or is alleged

to pose a threat of

imminent and

identifiable hazard

to public health or

safety? Or do you

own any property

that needs

immediate attention?

For example, do you

own perishable goods,

or livestock that must

be fed, or a building

that needs urgent

repairs?

No.

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 12 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

15.

Incapacity. I have a mental illness or a mental

deficiency that makes me incapable of

realizing or making rational decisions

about finances.

Disability. My physical disability causes me to be

unable to participate in a briefing in

person, by phone, or through the

internet, even after I reasonably tried to

do so.

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

military combat zone.

Incapacity. I have a mental illness or a mental

deficiency that makes me incapable of

realizing or making rational decisions

about finances.

Disability. My physical disability causes me to be

unable to participate in a briefing in

person, by phone, or through the

internet, even after I reasonably tried to

do so.

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

military combat zone.

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

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

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

Tell the court

whether you have

received briefing

about credit

counseling.

The law requires that

you receive a briefing

about credit

counseling before you

file for bankruptcy.

You must truthfully

check one of the

following choices. If

you cannot do so,

you are not eligible to

file.

If you file anyway,

the court can dismiss

your case, you will

lose whatever filing

fee you paid, and

your creditors can

begin collection

activities again.

You must check one:

I received a briefing from an approved credit

counseling agency within the 180 days before I filed this

bankruptcy petition, and I received a certificate of

completion.

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

that you developed with the agency.

I received a briefing from an approved credit

counseling agency within the 180 days before I filed this

bankruptcy petition, but I do not have a certificate of

completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

I certify that I asked for credit counseling services from

an approved agency, but was unable to obtain those

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

exigent circumstances merit a 30-day temporary waiver

of the requirement.

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

attach a separate sheet explaining what efforts you made to

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

filed for bankruptcy, and what exigent circumstances required

you to file this case.

Your case may be dismissed if the court is dissatisfied with

your reasons for not receiving a briefing before you filed for

bankruptcy.

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

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

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

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

case may be dismissed.

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

and is limited to a maximum of 15 days.

I am not required to receive a briefing about credit

counseling because of:

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

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

counseling with the court.

You must check one:

I received a briefing from an approved credit

counseling agency within the 180 days before I filed this

bankruptcy petition, and I received a certificate of

completion.

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

that you developed with the agency.

I received a briefing from an approved credit

counseling agency within the 180 days before I filed this

bankruptcy petition, but I do not have a certificate of

completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

I certify that I asked for credit counseling services from

an approved agency, but was unable to obtain those

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

exigent circumstances merit a 30-day temporary waiver

of the requirement.

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

attach a separate sheet explaining what efforts you made to

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

filed for bankruptcy, and what exigent circumstances required

you to file this case.

Your case may be dismissed if the court is dissatisfied with

your reasons for not receiving a briefing before you filed for

bankruptcy.

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

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

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

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

case may be dismissed.

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

and is limited to a maximum of 15 days.

I am not required to receive a briefing about credit

counseling because of:

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

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

counseling with the court.

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 13 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

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

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

No. Go to line 16b.

Yes. Go to line 17.

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

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

investment.

No. Go to line 16c.

Yes. Go to line 17.

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

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

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

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

No.

Yes.

18. 1-49

50-99

100-199

200-999

1,000-5,000

5,001-10,000

10,001-25,000

25,001-50,000

50,001-100,000

More than 100,000

19. $0-$50,000

$50,001-$100,000

$100,001-$500,000

$500,001-$1 million

$1,000,001-$10 million

$10,000,001-$50 million

$50,000,001-$100 million

$100,000,001-$500 million

$500,000,001-$1 billion

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

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

More than $50 billion

20. $0-$50,000

$50,001-$100,000

$100,001-$500,000

$500,001-$1 million

$1,000,001-$10 million

$10,000,001-$50 million

$50,000,001-$100 million

$100,000,001-$500 million

$500,000,001-$1 billion

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

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

More than $50 billion

For you

û /s/ Flora Clemons

Signature of Debtor 1

û

Signature of Debtor 2

Executed on 8/22/2016

MM / DD / YYYY

Executed on 

MM / DD / YYYY

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

Part 6: Answer These Questions for Reporting Purposes

What kind of debts

do you have?

Are you filing under

Chapter 7?

Do you estimate that

after any exempt

property is excluded

and administrative

expenses are paid that

funds will be available

for distribution to

unsecured creditors?

How many creditors

do you estimate that

you owe?

How much do you

estimate your assets

to be worth?

How much do you

estimate your

liabilities to be?

Part 7: Sign Below

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

and correct.

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

or 13 of title 11, United States Code. I understand the relief available under each chapter, and I choose to

proceed under Chapter 7.

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

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

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

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

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

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

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 14 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

For your attorney, if

you are represented by

one

If you are not

represented by an

attorney, you do not

need to file this page. û /s/ Jaime Torres

Signature of Attorney for Debtor

Date 8/22/2016

MM / DD / YYYY

11101 S. Western Avenue 

Street

Chicago Illinois 60643 

City State Zip Code

Contact phone 3122542096 Email address jtorres@semradlaw.com

Bar number State

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

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

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

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

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

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

incorrect.

Jaime Torres

Printed name

Semrad Law Firm

Firm name

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 15 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

$0.00

$1,521.00

$1,521.00

$0.00

$0.00

$10,622.64

Your total liabilities $10,622.64

$3,345.33

$3,350.00

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

Official Form 106Sum

Summary of Your Assets and Liabilities and Certain Statistical Information

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

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

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

Part 1: Summarize Your Assets

Your assets

Value of what you own

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

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

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

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

Part 2: Summarize Your Liabilities

Your liabilities

Amount you owe

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

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

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

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

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

Part 3: Summarize Your Income and Expenses

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

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

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

Copy your monthly expenses from line 22, Column A, of Schedule J................................................................

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 16 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

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

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

$2,312.00

Total claim

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

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

Part 4: Answer These Questions for Administrative and Statistical Records

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

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

Yes.

7. What kind of debt do you have?

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

family, or household purpose. 11 U.S.C. § 101(8). Fill out lines 8-10 for statistical purposes. 28 U.S.C. § 159.

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

this form to the court with your other schedules.

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

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

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

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

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

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

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

priority claims. (Copy line 6g.)

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

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

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 17 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

Street address, if available, or other description

Number Street

City State Zip Code Other 

Current value of the

entire property?

Current value of the

portion you own?

Street address, if available, or other description

Number Street

City State Zip Code Other 

Current value of the

entire property?

Current value of the

portion you own?

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

Official Form 106A/B

Schedule A/B: Property

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

category where you think it fits best. Be as complete and accurate as possible. If two married people are filing together, both are equally

responsible for supplying correct information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages,

write your name and case number (if known). Answer every question.

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

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

No. Go to Part 2

Yes. Where is the property?

1.1

What is the property? Check all that apply.

Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Describe the nature of your ownership

interest (such as fee simple, tenancy by

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

Check if this is community property

(see instructions)

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

property identification number: 

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

1.2

What is the property? Check all that apply.

Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Describe the nature of your ownership

interest (such as fee simple, tenancy by

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

Check if this is community property

(see instructions)

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

property identification number: 

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 18 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Street address, if available, or other description

Number Street

City State Zip Code Other 

Current value of the

entire property?

Current value of the

portion you own?

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

you have attached for Part 1. Write that number here. ................................................................................................... ▶

Current value of the

entire property?

Current value of the

portion you own?

Current value of the

entire property?

Current value of the

portion you own?

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

1.3

What is the property? Check all that apply.

Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Describe the nature of your ownership

interest (such as fee simple, tenancy by

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

Check if this is community property

(see instructions)

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

property identification number: 

Part 2: Describe Your Vehicles

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

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

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

No

Yes

3.1 Make 

Model: 

Year: 

Approximate mileage: 

Other information:

Who has an interest in the property? Check

one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

3.2 Make 

Model: 

Year: 

Approximate mileage: 

Other information:

Who has an interest in the property? Check

one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 19 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Current value of the

entire property?

Current value of the

portion you own?

Current value of the

entire property?

Current value of the

portion you own?

Current value of the

entire property?

Current value of the

portion you own?

Current value of the

entire property?

Current value of the

portion you own?

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

you have attached for Part 2. Write that number here ................................................................................................... ▶

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

3.3 Make 

Model: 

Year: 

Approximate mileage: 

Other information:

Who has an interest in the property? Check

one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

3.4 Make 

Model: 

Year: 

Approximate mileage: 

Other information:

Who has an interest in the property? Check

one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

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

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

No

Yes

4.1 Make 

Model: 

Year: 

Approximate mileage: 

Other information:

Who has an interest in the property? Check

one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

4.2 Make 

Model: 

Year: 

Approximate mileage: 

Other information:

Who has an interest in the property? Check

one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 20 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Yes. Describe... Misc. Household Furniture $250.00

Yes. Describe... Misc. Electronics $150.00

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Describe... Used Clothing $250.00

Yes. Describe... Misc. Jewelry $50.00

Yes. Describe...

Yes. Describe...

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

for Part 3. Write that number here .......................................................................................................................... ▶

$700.00 

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

Part 3: Describe Your Personal and Household Items

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

Current value of the

portion you own?

Do not deduct secured claims

or exemptions.

6. Household goods and furnishings

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

No

7. Electronics

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

No

8. Collectibles of value

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

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

No

9. Equipment for sports and hobbies

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

and kayaks; carpentry tools; musical instruments

No

10. Firearms

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

No

11. Clothes

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

No

12. Jewelry

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

gold, silver

No

13. Non-farm animals

Examples: Dogs, cats, birds, horses

No

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

No

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 21 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Yes .................................................................................................... $1.00

Yes

Yes

Yes. Give specific

information about

them

Name of entity % of ownership:

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

Part 4: Describe Your Financial Assets

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

Current value of the

portion you own?

Do not deduct secured claims

or exemptions.

16. Cash

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

No

Cash: .................................

17. Deposits of money

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

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

No

Institution name:

17.1. Checking account:

17.2. Checking account:

17.3. Savings account:

17.4. Savings account:

17.5. Certificates of deposit:

17.6. Other financial account:

17.7. Other financial account:

17.8. Other financial account:

17.9. Other financial account:

Bank of America 

Bank of America 

$300.00 

$520.00 

18. Bonds, mutual funds, or publicly traded stocks

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

No

Institution or issuer name:

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

an LLC, partnership, and joint venture

No

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 22 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Yes. Give specific

information about

them.....

Yes. List each

account separately.

Yes....

Yes....

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

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

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

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

No

Issuer name:

21. Retirement or pension accounts

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

No

Type of account:

401(k) or similar plan:

Pension plan:

IRA:

Retirement account:

Keogh:

Additional account:

Additional account:

Institution name:

22. Security deposits and prepayments

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

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

companies, or others

No

Electric:

Gas:

Heating oil:

Security deposit on rental unit:

Prepaid rent:

Telephone:

Water:

Rented furniture:

Other:

Institution name:

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

No

Issuer name and description:

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 23 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Yes....

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Give specific information

about them, including whether

you already filed the returns

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

Yes. Give specific information......

Yes. Describe...

Official Form 106A/B Schedule A/B: Property page 7

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

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

No

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

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

exercisable for your benefit

No

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

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

No

27. Licenses, franchises, and other general intangibles

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

No

Money or property owed to you? Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

28. Tax refunds owed to you

No

Federal:

State:

Local:

$0.00 

$0.00 

$0.00 

29. Family support

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

No

Alimony:

Maintenance:

Support:

Divorce settlement:

Property settlement:

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

30. Other amounts someone owes you

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

Social Security benefits; unpaid loans you made to someone else

No

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 24 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Yes. Name the insurance company

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

Company name: Beneficiary:

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Go to line 38.

Yes. Describe...

Yes. Describe...

Official Form 106A/B Schedule A/B: Property page 8

31. Interests in insurance policies

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

No

Surrender or refund value:

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

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

property because someone has died.

No

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

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

No

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

to set off claims

No

35. Any financial assets you did not already list

No

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

for Part 4. Write that number here ................................................................................................................▶

$821.00 

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

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

No. Go to Part 6. Current value of the

portion you own?

Do not deduct secured claims

or exemptions

38. Accounts receivable or commissions you already earned

No

39. Office equipment, furnishings, and supplies

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

No

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 25 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Yes. Describe...

Yes. Describe...

Yes. Give specific

information about

them

Name of entity: % of ownership:

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

Yes. Describe........

Yes. Give specific

information .......

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

for Part 5. Write that number here ............................................................................................................................................... ▶

Part 6:

Yes. Go to line 47.

Yes. Describe...

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

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

No

41. Inventory

No

42. Interests in partnerships or joint ventures

No

43. Customer lists, mailing lists, or other compilations

No

No

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

No

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

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

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

No. Go to Part 7. Current value of the

portion you own?

Do not deduct secured

claims

or exemptions

47. Farm animals

Examples: Livestock, poultry, farm-raised fish

No

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 26 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Yes. Describe...

Yes. Describe...

Yes. Describe...

Yes. Describe...

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

for Part 6. Write that number here .................................................................................................................................▶

Yes. Give specific

information

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

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

48. Crops-either growing or harvested

No

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

No

50. Farm and fishing supplies, chemicals, and feed

No

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

No

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

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

Examples: Season tickets, country club membership

No

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

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

56. part 2 total vehicles, line 5

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

58.Part 4: Total financial assets, line 36 $821.00 

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

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

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

62. Total personal property. Add lines 56 through 61. .................... $1521.00 

Copy personal property total ▶

+ $1521.00 

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

$1521.00 

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 27 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

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

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

$300.00

100% of fair market value, up to any

applicable statutory limit

$520.00

100% of fair market value, up to any

applicable statutory limit

No

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

No

Yes

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

Official Form 106C

Schedule C: The Property You Claim as Exempt

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

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

claim as exempt. If more space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On

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

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

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

exempted up to the amount of any applicable statutory limit. Some exemptions—such as those for health aids, rights to

receive certain benefits, and tax-exempt retirement funds—may be unlimited in dollar amount. However, if you claim an

exemption of 100% of fair market value under a law that limits the exemption to a particular dollar amount and the value of the

property is determined to exceed that amount, your exemption would be limited to the applicable statutory amount.

Part 1: Identify the Property You Claim as Exempt

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

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

Brief description of the property and line

on Schedule A/B that lists this property

Current value of

the portion you

own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption.

Specific laws that allow exemption

Brief

description: Bank of America

Line from

Schedule A/B: 17

$300.00

735 ILCS 5/12-1001(b)

Brief

description: Bank of America

Line from

Schedule A/B: 17

$520.00

735 ILCS 5/12-1001(b)

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

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

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 28 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

$250.00

100% of fair market value, up to any

applicable statutory limit

$250.00

100% of fair market value, up to any

applicable statutory limit

$150.00

100% of fair market value, up to any

applicable statutory limit

$1.00

100% of fair market value, up to any

applicable statutory limit

$50.00

100% of fair market value, up to any

applicable statutory limit

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

Part 2: Additional Page

Brief description of the property and line

on Schedule A/B that lists this property

Current value of

the portion you

own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption.

Specific laws that allow exemption

Brief

description:

Misc. Household

Furniture

Line from

Schedule A/B: 06

$250.00

735 ILCS 5/12-1001(b)

Brief

description: Used Clothing

Line from

Schedule A/B: 11

$250.00

735 ILCS 5/12-1001(a)

Brief

description: Misc. Electronics

Line from

Schedule A/B: 07

$150.00

735 ILCS 5/12-1001(b)

Brief

description: Cash on Hand

Line from

Schedule A/B: 16

$1.00

735 ILCS 5/12-1001(b)

Brief

description: Misc. Jewelry

Line from

Schedule A/B: 12

$50.00

735 ILCS 5/12-1001(b)

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 29 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

1.

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

Yes. Fill in all of the information below.

Do any creditors have claims secured by your property?

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

Official Form 106D

Schedule D: Creditors Who Have Claims Secured by Property

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

correct information. If more space is needed, copy the Additional Page, fill it out, number the entries, and attach it to this

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

Part 1: List All Secured Claims

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

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

as possible, list the claims in alphabetical order according to the creditor's name.

Column A

Amount of claim

Do not deduct the

value of collateral.

Column B

Value of collateral

that supports

this claim

Column C

Unsecured

portion

If any

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 30 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

 Check if this is an amended filing

12/15

No. Go to Part 2.

Yes.

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

Official Form 106E/F

Schedule E/F: Creditors Who Have Unsecured Claims

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

party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule A/B: Property (Official Form

106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any creditors with partially secured claims that

are listed in Schedule D: Creditors Who Hold Claims Secured by Property. If more space is needed, copy the Part you need, fill it out, number the entries in

the boxes on the left. Attach the Continuation Page to this page. On the top of any additional pages, write your name and case number (if known).

Part 1: List All of Your PRIORITY Unsecured Claims

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

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

identify what type of claim it is. If a claim has both priority and nonpriority amounts, list that claim here and show both priority and nonpriority amounts. As much as

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

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

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

Total

claim

Priority

amount

Nonpriority

amount

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 31 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

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

Yes.

Comcast 

Nonpriority Creditor's Name

11621 E. Marginal Way # 5 

Number Street

Seattle Washington 98168 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Cable Bill 

CREDIT CNTRL 

Nonpriority Creditor's Name

5757 PHANTOM DR. SUITE 330 

Number Street

HAZELWOOD Montana 63042 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify

Collection; Collecting for ORIGINAL

CREDITOR: MEDICAL 

CREDITORS DISCOUNT & A 

Nonpriority Creditor's Name

415 E MAIN ST 

Number Street

STREATOR Illinois 61364 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify

001 Collection; Collecting for ORIGINAL

CREDITOR: MEDICAL PAYMENT

DATA 

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

Part 2: List All of Your NONPRIORITY Unsecured Claims

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

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

unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already included in Part 1.

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

Part 2.

Total claim

4.1

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number

When was the debt incurred? n/a

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

Type of NONPRIORITY unsecured claim:

$400.00

4.2

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 1932

When was the debt incurred? 2/1/2015

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

Type of NONPRIORITY unsecured claim:

$65.00

4.3

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 4183

When was the debt incurred? 11/1/2014

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

Type of NONPRIORITY unsecured claim:

$470.00

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 32 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

CREDITORS DISCOUNT & A 

Nonpriority Creditor's Name

415 E MAIN ST 

Number Street

STREATOR Illinois 61364 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify

001 Collection; Collecting for ORIGINAL

CREDITOR: MEDICAL PAYMENT

DATA 

FRANKLIN COLLECTION SV 

Nonpriority Creditor's Name

2978 W Jackson St 

Number Street

Tupelo Mississippi 38801 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify

001 Collection; Collecting for ORIGINAL

CREDITOR: AT T 

Jeffrey Building, Inc 

Nonpriority Creditor's Name

7102 S. Jeffrey Blvd 

Number Street

Chicago Illinois 60649 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Past Due Rent & Judgment 

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

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

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

4.4

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 4059

When was the debt incurred? 6/1/2015

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

Type of NONPRIORITY unsecured claim:

$215.00

4.5

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 1965

When was the debt incurred? 5/1/2016

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

Type of NONPRIORITY unsecured claim:

$369.00

4.6

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number

When was the debt incurred? n/a

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

Type of NONPRIORITY unsecured claim:

$2,022.64

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 Document Page 33 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

MBB 

Nonpriority Creditor's Name

1550 N NORTWEST HWY STE 403 

Number Street

PARK RIDGE Illinois 60068 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify

001 Collection; Collecting for ORIGINAL

CREDITOR: MEDICAL PAYMENT

DATA 

MBB 

Nonpriority Creditor's Name

1550 N NORTWEST HWY STE 403 

Number Street

PARK RIDGE Illinois 60068 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify

001 Collection; Collecting for ORIGINAL

CREDITOR: MEDICAL PAYMENT

DATA 

New Englewood Terrace Apartments 

Nonpriority Creditor's Name

6425 S Lowe Ave 

Number Street

Chicago Illinois 60621 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Past Due Rent 

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

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

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

4.7

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 3395

When was the debt incurred? 12/1/2014

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

Type of NONPRIORITY unsecured claim:

$368.00

4.8

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 0894

When was the debt incurred? 7/1/2015

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

Type of NONPRIORITY unsecured claim:

$100.00

4.9

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number

When was the debt incurred? n/a

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

Type of NONPRIORITY unsecured claim:

$1,050.00

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 34 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

NORTH SIDE L 

Nonpriority Creditor's Name

1011 W Lawrence Ave 

Number Street

Chicago Illinois 60640 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

Other. Specify 037 InstallmentLoan 

Speedy Cash - Cottage Grove 

Nonpriority Creditor's Name

8701 S Cottage Grove Ave 

Number Street

Chicago Illinois 60619 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

Other. Specify Payday Loan 

STATE COLLECTION SERVI 

Nonpriority Creditor's Name

2509 S STOUGHTON RD 

Number Street

MADISON Wisconsin 53716 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

Other. Specify

001 Collection; Collecting for ORIGINAL

CREDITOR: MEDICAL PAYMENT

DATA 

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

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

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

4.10

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 5194

When was the debt incurred? 8/1/2015

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

Type of NONPRIORITY unsecured claim:

$4,108.00

4.11

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number

When was the debt incurred? n/a

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

Type of NONPRIORITY unsecured claim:

$625.00

4.12

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number 4422

When was the debt incurred? 12/1/2014

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

Type of NONPRIORITY unsecured claim:

$180.00

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 35 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

T-Mobile 

Nonpriority Creditor's Name

PO Box 53410 

Number Street

Bellevue Washington 98015 

City State Zip Code

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community debt

No

Yes

Contingent

Unliquidated

Disputed

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

Other. Specify Cell Phone Bill 

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

Part 2: Your NONPRIORITY Unsecured Claims - Continuation Page

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

4.13

Who incurred the debt? Check one.

Is the claim subject to offset?

Last 4 digits of account number

When was the debt incurred? n/a

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

Type of NONPRIORITY unsecured claim:

$650.00

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 36 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

6a. Domestic support obligations. 6a.

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

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

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

amount here.

6d.

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

6f. Student loans 6f.

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

that you did not report as priority claims

6g.

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

debts

6h.

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

amount here.

6i.

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

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 7

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

6.

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

Add the amounts for each type of unsecured claim.

Total claims

Total claims

from Part 1

$0.00

$0.00

$0.00

$0.00

$0.00

Total claims

Total claims

from Part 2

$0.00

$0.00

$0.00

$10,622.64

$10,622.64

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 37 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

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

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

Racine LLC 

Name

7752 S. Racine 

Number Street

Chicago Illinois 60620 

City State Zip Code

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

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases

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

space is needed, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any additional pages, write your name and

case number (if known).

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

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

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

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

2.1 Residential Lease,

Debtor is Lessee,

Annual Lease

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 38 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

Official Form 106H Schedule H: Your Codebtors page 1

Official Form 106H

Schedule H: Your Codebtors

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

together, both are equally responsible for supplying correct information. If more space is needed, copy the Additional Page, fill it out, and number the entries

in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and case number (if known). Answer

every question.

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

No

Yes

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

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

No. Go to line 3.

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

No

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

Name of your spouse, former spouse, or legal equivalent

Number Street

 

City State Zip Code

3. In Column 1, list all of your codebtors. Do not include your spouse as a codebtor if your spouse is filing with you. List the person shown in line 2 again

as a codebtor only if that person is a guarantor or cosigner. Make sure you have listed the creditor on Schedule D (Official Form 106D), Schedule E/F

(Official Form 106E/F), or Schedule G (Official Form 106G). Use Schedule D, Schedule E/F, or Schedule G to fill out Column 2.

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

Check all schedules that apply:

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 39 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is:

 An amended filing

A supplement showing post-petition chapter 13

expenses as of the following date:

MM / DD / YYYY

12/15

Chicago Illinois 60601 

City State Zip Code

Official Form 106I Schedule I: Your Income page 1

Official Form 106I

Schedule I: Your Income

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

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

include information about your spouse. If you are separated and your spouse is not filing with you, do not include

information about your spouse. If more space is needed, attach a separate sheet to this form. On the top of any additional

pages, write your name and case number (if known). Answer every question.

Part 1: Describe Employment

Fill in your employment

information.

If you have more than one

job,

attach a separate page with

information about additional

employers.

Include part time, seasonal,

or

self-employed work.

Occupation may include

student

or homemaker, if it applies.

1.

Employment status

Occupation

Employer's name

Employer's address

How long employed there?

Debtor 1

Employed

Not Employed

Rail Car Apprentice

CTA - Payroll Office

567 W. Lake St.

Number Street

3 years 6 months 

Debtor 2

Employed

Not Employed

Number Street

City State Zip Code

Part 2: Give Details About Monthly Income

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

are separated.

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

a separate sheet to this form.

For Debtor 1 For Debtor 2 or

non-filing spouse

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

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

2. $4,764.50

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

4. Calculate gross income. Add line 2 + line 3. 4. $4,764.50

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 40 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Official Form 106I Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or

non-filing spouse

Copy line 4 here 

➔

4. $4,764.50

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a. $472.33

5b. Mandatory contributions for retirement plans 5b. $483.17

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

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

5e. Insurance 5e. $253.50

5f. Domestic support obligations 5f. $0.00

5g. Union dues 5g. $67.17

5h. Other deductions. Specify: Healthcare 5h. + $143.00 +

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g +5h. 6. $1,419.17

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $3,345.33

8. List all other income regularly received:

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

profession, or farm

Attach a statement for each property and business showing gross

receipts, ordinary and necessary business expenses, and the total

monthly net income. 8a. $0.00

8b. Interest and dividends 8b. $0.00

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

dependent regularly receive

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

settlement, and property settlement. 8c. $0.00

8d. Unemployment compensation 8d. $0.00

8e. Social Security 8e. $0.00

8f. Other government assistance that you regularly receive

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

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

Supplemental Nutrition Assistance Program) or housing subsidies

Specify: 8f. $0.00

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

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

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

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

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

10. $3,345.33 + = $3,345.33

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

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

relatives.

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

Specify: 11. + $0.00

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

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

12.

$3,345.33

Combined

monthly income

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

 No.

 Yes. Explain: 

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 41 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is:

 An amended filing

A supplement showing post-petition chapter 13

expenses as of the following date:

MM / DD / YYYY

12/15

3. Do your expenses include

expenses of people other

than

yourself and your

dependents?

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

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

4.

$650.00

4a $0.00

4b. $0.00

4c. $35.00

4d. $0.00

Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J

Schedule J: Your Expenses

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

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

(if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case?

No. Go to line 2

Yes. Does Debtor 2 live in a separate household?

No

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

2. Do you have dependents? No

Do not list Debtor 1 and

Debtor 2.

Yes. Fill out this information for

each dependent 

Dependent's relationship to

Debtor 1 or Debtor 2

Dependent's

age

Does dependent live

with you?

Child 18 years No.

Yes.

Child 4 months No.

Yes.

No

Yes

Part 2: Estimate Your Ongoing Monthly Expenses

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

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

applicable date.

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

any rent for the ground or lot. 4.

If not included in line 4:

4a. Real estate taxes

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

4c. Home maintenance, repair, and upkeep expenses

4d. Homeowner's association or condominium dues

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 42 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

Your expenses

5. $0.00

6a. $300.00

6b. $0.00

6c. $200.00

6d $0.00

7. $650.00

8. $300.00

9. $200.00

10. $200.00

11. $115.00

12. $250.00

13. $0.00

14. $0.00

15a $0.00

15b $0.00

15c $0.00

15d $0.00

16

$0.00

17a $0.00

17b $0.00

17c $0.00

17d $0.00

18.

$0.00

19. $0.00

20a $0.00

20b $0.00

20c $0.00

20d $0.00

20e $0.00

Official Form 106J Schedule J: Your Expenses page 2

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

6. Utilities:

6a. Electricity, heat, natural gas

6b. Water, sewer, garbage collection

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

6d. Other. Specify:

7. Food and housekeeping supplies

8. Childcare and children's education costs

9. Clothing, laundry, and dry cleaning

10. Personal care products and services

11. Medical and dental expenses

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

Do not include car payments

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

14. Charitable contributions and religious donations

15. Insurance.

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

15a. Life insurance

15b. Health insurance

15c. Vehicle insurance

15d. Other insurance. Specify:

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

Specify:

17. Installment or lease payments:

17a. Car payments for Vehicle 1

17b. Car payments for Vehicle 2

17c. Other. Specify:

17d. Other. Specify:

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

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

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

Specify:

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

20a. Mortgages on other property

20b. Real estate taxes.

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

20d. Maintenance, repair, and upkeep expenses.

20e. Homeowner's association or condominium dues

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 43 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

21 $450.00

$3,350.00

$0.00

$3,350.00

22.

23a $3,345.33

23b $3,350.00

23c

($4.67)

Official Form 106J Schedule J: Your Expenses page 3

21.Other. Specify: Newborn Expenses

22. Calculate your monthly expenses.

22a. Add lines 4 through 21.

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

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

23.Calculate your monthly net income.

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

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

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

The result is your monthly net income.

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

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

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

No

Yes

Explain here: 

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 44 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

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

Signature (Official Form 119).

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

Official Form 106Dec

Declaration About an Individual Debtor's Schedules

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

You must file this form whenever you file bankruptcy schedules or amended schedules. Making a false statement, concealing property, or obtaining money or

property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341,

1519, and 3571.

Part 1: Sign Below

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

No

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

that they are true and correct.

û /s/ Flora Clemons

Signature of Debtor 1

û

Signature of Debtor 2

Date 8/22/2016

MM/DD/YYYY

Date

MM/DD/YYYY

Case 16-26848 Doc 1 Filed 08/22/16 Entered 08/22/16 11:06:09 Desc Main

 Document Page 45 of 68
Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

Married

Not married

No

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

Same as Debtor 1 Same as Debtor 1

6425 S. Lowe 

Number Street Number Street

Chicago Illinois 60621 

City State Zip Code City State Zip Code

Same as Debtor 1 Same as Debtor 1

Number Street Number Street

City State Zip Code City State Zip Code

No

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

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

Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy

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

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

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

1. What is your current marital status?

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

Debtor 1: Dates Debtor 1 lived

there

Debtor 2: Dates Debtor 2 lived

there

From 07/01/2013 From

To 03/31/2016 To

From From

To To

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

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

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Wages,

commissions,

bonuses, tips

Operating a

business

Wages,

commissions,

bonuses, tips

Operating a

business

YYYY

Wages,

commissions,

bonuses, tips

Operating a

business

Wages,

commissions,

bonuses, tips

Operating a

business

YYYY

Wages,

commissions,

bonuses, tips

Operating a

business

Wages,

commissions,

bonuses, tips

Operating a

business

No

Yes. Fill in the details.

YYYY

YYYY

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

Part 2: Explain the Sources of Your Income

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

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

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

Debtor 1 Debtor 2

Sources of income

Check all that apply.

Gross income

(before deductions and

exclusions)

Sources of income

Check all that apply.

Gross income

(before deductions and

exclusions)

From January 1 of current year until

the date you filed for bankruptcy:

$21189.00 

For last calendar year:

(January 1 to December 31, 2015 )

$31475.00 

For the calendar year before that:

(January 1 to December 31, 2014 )

$30000.00 

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

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

benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and gambling and lottery winnings. If you are filing a joint case

and you have income that you received together, list it only once under Debtor 1.

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

Debtor 1 Debtor 2

Sources of income

Describe below.

Gross income from

each source

(before deductions and

exclusions)

Sources of income

Describe below.

Gross income from

each source

(before deductions and

exclusions)

From January 1 of current year until

the date you filed for bankruptcy:

Maternity Pay from

Sedgewick $1,150.00

For last calendar year:

(January 1 to December 31, 2015 )

Est. SSI $8,280.00

For the calendar year before that:

(January 1 to December 31, 2014 )

Est. SSI $8,280.00

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No.

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

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

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

Neither Debtor 1 nor Debtor 2 has primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8) as "incurred by an individual primarily

for a personal, family, or household purpose."

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

No. Go to line 7.

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

Yes.

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

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

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

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

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

No. Go to line 7.

Creditor's Name

Number Street

City State Zip Code

Mortgage

Car

Credit card

Loan repayment

Suppliers or

vendors

Other

Creditor's Name

Number Street

City State Zip Code

Mortgage

Car

Credit card

Loan repayment

Suppliers or

vendors

Other

Creditor's Name

Number Street

City State Zip Code

Mortgage

Car

Credit card

Loan repayment

Suppliers or

vendors

Other

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

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

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

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

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. List all payments to an insider.

Insider's Name

Number Street

City State Zip Code

Insider's Name

Number Street

City State Zip Code

No

Yes. List all payments that benefited an insider.

Insider's Name

Number Street

City State Zip Code

Insider's Name

Number Street

City State Zip Code

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

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

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

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

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

such as child support and alimony.

Dates of

payment

Total amount

paid

Amount you still

owe

Reason for this payment

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

insider?

Include payments on debts guaranteed or cosigned by an insider.

Dates of

payment

Total amount

paid

Amount you still

owe

Reason for this payment

Include creditor's name

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Cook County Circuit Court 

Court Name

50 West Washington Street 

NumberStreet

Chicago 

Illinois 60602 

City State Zip Code

Pending

On appeal

Concluded

Court Name

NumberStreet

City State Zip Code

Pending

On appeal

Concluded

No. Go to line 11.

Yes. Fill in the information below.

NORTH SIDE L 

Creditor's Name

1011 W Lawrence Ave 

Number Street

Chicago Illinois 60640 

City State Zip Code

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

Creditor's Name

Number Street

City State Zip Code

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

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

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

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

disputes.

Nature of the case Court or agency Status of the case

Case title

Jeffrey Building, Inc 

Case number

12 M1 174876 

Contract 

Case title

Case number

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

Check all that apply and fill in the details below.

Describe the property Date Value of the

property

Federal Credit Union Signature Loan 11/01/2015 $4000 

Explain what happened

Describe the property Date Value of the

property

Explain what happened

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Creditor's Name

Number Street

City State Zip Code

No

Yes

No

Yes. Fill in the details for each gift.

Person to Whom You Gave the Gift

Number Street

City State Zip Code

Person to Whom You Gave the Gift

Number Street

City State Zip Code

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

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

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

Describe the action the creditor took Date action

was taken

Amount

Last 4 digits of account number: XXXX12. Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of creditors, a court-appointed

receiver, a custodian, or another official?

Part 5: List Certain Gifts and Contributions

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

Gifts with a total value of more than $600

per person

Describe the gifts Dates you

gave the

gifts

Value

Person's relationship to you

Person's relationship to you

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

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

Charity’s Name

Number Street

City State Zip Code

No

Yes. Fill in the details.

No

Yes. Fill in the details.

The Semrad Law Firm, LLC 

Person Who Was Paid

303 Perimeter Center North 

Number Street

Atlanta Georgia 30346 

City State Zip Code

Email or website address

None 

Person Who Made the Payment, if Not You

Person Who Was Paid

Number Street

City State Zip Code

Email or website address

Person Who Made the Payment, if Not You

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

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

Gifts or contributions to charities

that total more than $600

Describe what you contributed Date you

contributed

Value

Part 6: List Certain Losses

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

gambling?

Describe the property you lost and

how the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List

pending insurance claims on line 33 of Schedule A/B:

Property.

Date of your

loss

Value of property

lost

Part 7: List Certain Payments or Transfers

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

seeking bankruptcy or preparing a bankruptcy petition?

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

Description and value of any property transferred Date

payment or

transfer was

made

Amount of payment

Suite 201 

Attorney’s Fee - 0.00 8/19/2016 $0.00

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Person Who Was Paid

Number Street

City State Zip Code

No

Yes. Fill in the details.

Person Who Received Transfer

Number Street

City State Zip Code

Person Who Received Transfer

Number Street

City State Zip Code

No

Yes. Fill in the details.

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

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

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

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

Description and value of any property transferred Date

payment or

transfer was

made

Amount of payment

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

ordinary course of your business or financial affairs?

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

transfers that you have already listed on this statement.

Description and value of any

property transferred

Describe any property or payments

received or debts paid in

exchange

Date transfer

was made

Person's relationship to you

Person's relationship to you

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

(These are often called asset-protection devices.)

Description and value of the property transferred Date transfer

was made

Name of trust

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Person Who Was Paid

Number Street

City State Zip Code

Checking

Savings

Money market

Brokerage

Other

Person Who Was Paid

Number Street

City State Zip Code

Checking

Savings

Money market

Brokerage

Other

No

Yes. Fill in the details.

Name of Financial Institution

Number Street

City State Zip Code

Name

Number Street

City State Zip Code

No

Yes

No

Yes. Fill in the details.

Name of Storage Facility

Number Street

City State Zip Code

Name

Number Street

City State Zip Code

No

Yes

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

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

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

or transferred?

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

cooperatives, associations, and other financial institutions.

Last 4 digits of account

number

Type of account or

instrument

Date

account was

closed, sold,

moved, or

transferred

Last balance

before

closing or

transfer

XXXXXXXX21. Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for securities, cash, or other

valuables?

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

have it?

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

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

have it?

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Owner’s Name

Number Street

City State Zip Code

Number Street

City State Zip Code

No

Yes. Fill in the details.

Name of site

Number Street

City State Zip Code

Governmental unit

Number Street

City State Zip Code

No

Yes. Fill in the details.

Name of site

Number Street

City State Zip Code

Governmental unit

Number Street

City State Zip Code

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

Part 9: Identify Property You Hold or Control for Someone Else

23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for, or hold in trust for someone.

Where is the property? Describe the contents Value

Part 10: Give Details About Environmental Information

For the purpose of Part 10, the following definitions apply:

Environmental law means any federal, state, or local statute or regulation concerning pollution, contamination, releases of

hazardous or toxic substances, wastes, or material into the air, land, soil, surface water, groundwater, or other medium,

including statutes or regulations controlling the cleanup of these substances, wastes, or material.

Site means any location, facility, or property as defined under any environmental law, whether you now own, operate, or utilize it

or used to own, operate, or utilize it, including disposal sites.

Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance,

toxic substance, hazardous material, pollutant, contaminant, or similar term.

Report all notices, releases, and proceedings that you know about, regardless of when they occurred.

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

Governmental unit Environmental law, if you know it Date of

notice

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

Governmental unit Environmental law, if you know it Date of

notice

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details.

Case title

Case number

Court Name

Number Street

City State Zip Code

Pending

On appeal

Concluded

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

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

A partner in a partnership

An officer, director, or managing executive of a corporation

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

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

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

Business Name

Number Street

City State Zip Code

Business Name

Number Street

City State Zip Code

Business Name

Number Street

City State Zip Code

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

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

Court or agency Nature of the case Status of the

case

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

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

Describe the nature of the business Employer Identification number Do not

include Social Security number or ITIN.

Name of accountant or bookkeeper

EIN:

Dates business existed

From To

Describe the nature of the business Employer Identification number Do not

include Social Security number or ITIN.

Name of accountant or bookkeeper

EIN:

Dates business existed

From To

Describe the nature of the business Employer Identification number Do not

include Social Security number or ITIN.

Name of accountant or bookkeeper

EIN:

Dates business existed

From To

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Case number (if known)

No

Yes. Fill in the details below.

Name

Number Street

City State Zip Code

Yes. Name of person

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

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

creditors, or other parties.

Date issued

MM/DD/YYYY

Part 12: Sign Below

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

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

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

û /s/ Flora Clemons

Signature of Debtor 1

û

Signature of Debtor 2

Date 8/22/2016

Date

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

No

Yes

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

No

Attach the Bankruptcy Petition Preparer's Notice,

Declaration, and Signature (Official Form 119).

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Debtor 1 Flora Clemons 

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: Northern District of Illinois 

(State)

Case number

(If known)

Fill in this information to identify your case:

Check if this is an

amended filing

12/15

◼ creditors have claims secured by your property, or

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

Surrender the property.

Retain the property and redeem it.

Retain the property and enter into a

Reaffirmation Agreement.

Retain the property and [explain]:

No.

Yes.

Surrender the property.

Retain the property and redeem it.

Retain the property and enter into a

Reaffirmation Agreement.

Retain the property and [explain]:

No.

Yes.

Surrender the property.

Retain the property and redeem it.

Retain the property and enter into a

Reaffirmation Agreement.

Retain the property and [explain]:

No.

Yes.

Surrender the property.

Retain the property and redeem it.

Retain the property and enter into a

Reaffirmation Agreement.

Retain the property and [explain]:

No.

Yes.

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

Official Form 108

Statement of Intention for Individuals Filing Under Chapter 7

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

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

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

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

Both debtors must sign and date the form.

Be as complete and accurate as possible. If more space is needed, attach a separate sheet to this form. On the top of any additional pages,

write your name and case number (if known).

Part 1: List Your Creditors Who Have Secured Claims

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

below.

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

secures a debt?

Did you claim the property

as exempt on Schedule C?

Creditor's

name:

Description of

property

securing debt:

Creditor's

name:

Description of

property

securing debt:

Creditor's

name:

Description of

property

securing debt:

Creditor's

name:

Description of

property

securing debt:

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Debtor

1

Flora Clemons 

First Name Middle Name Last Name

Case number (if

known)

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

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

Part 2: List Your Unexpired Personal Property Leases

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

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

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

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

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Lessor's name:

Description of leased

property:

Part 3: Sign Below

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

that is subject to an unexpired lease.

û /s/ Flora Clemons

Signature of Debtor 1

û

Signature of Debtor 1

Date 8/22/2016

MM/DD/YYYY

Date

MM/DD/YYYY

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— Liquidation

— Reorganization

— Voluntary repayment plan

for family farmers or

fishermen

— Voluntary repayment plan

for individuals with regular

income

page 1

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

Individuals Filing for Bankruptcy (Form 2010)

This notice is for you if:

You are an individual filing for

bankruptcy,

and

Your debts are primarily consumer

debts.

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

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

a personal, family, or household purpose.”

The types of bankruptcy that are

available to individuals

Individuals who meet the qualifications may file under

one of four different chapters of the Bankruptcy Code:

Chapter 7

Chapter 11

Chapter 12

Chapter 13

You should have an attorney review your

decision to file for bankruptcy and the choice

of chapter.

Chapter 7: Liquidation

+

$245 filing fee

$75 administrative fee

$15 trustee surcharge

$335 total fee

Chapter 7 is for individuals who have financial

difficulty preventing them from paying their debts

and who are willing to allow their nonexempt

property to be used to pay their creditors. The

primary purpose of filing under chapter 7 is to have

your debts discharged. The bankruptcy discharge

relieves you after bankruptcy from having to pay

many of your pre-bankruptcy debts. Exceptions

exist for particular debts, and liens on property

may still be enforced after discharge. For example,

a creditor may have the right to foreclose a home

mortgage or repossess an automobile.

However, if the court finds that you have

committed certain kinds of improper conduct

described in the Bankruptcy Code, the court may

deny your discharge.

You should know that even if you file chapter 7 and

you receive a discharge, some debts are not

discharged under the law. Therefore, you may still

be responsible to pay:

most taxes;

most student loans;

domestic support and property settlement

obligations;

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

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page 2

most fines, penalties, forfeitures, and criminal

restitution obligations; and

certain debts that are not listed in your

bankruptcy papers.

You may also be required to pay debts arising from:

fraud or theft;

fraud or defalcation while acting in breach of

fiduciary capacity;

intentional injuries that you inflicted; and

death or personal injury caused by operating a

motor vehicle, vessel, or aircraft while intoxicated

from alcohol or drugs.

If your debts are primarily consumer debts, the court

can dismiss your chapter 7 case if it finds that you

have enough income to repay creditors a certain

amount. You must file Chapter 7 Statement of Your

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

you are an individual filing for bankruptcy under

chapter 7. This form will determine your current

monthly income and compare whether your income

is more than the median income that applies in your

state.

If your income is not above the median for your

state, you will not have to complete the other

chapter 7 form, the Chapter 7 Means Test

Calculation (Official Form 122A–2).

If your income is above the median for your state,

you must file a second form — the Chapter 7 Means

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

calculations on the form— sometimes called the

Means Test —deduct from your income living

expenses and payments on certain debts to determine

any amount available to pay unsecured creditors. If

your income is more than the median income for

your state of residence and family size, depending

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

bankruptcy administrator, or creditors can file a

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

Bankruptcy Code. If a motion is filed, the court

will decide if your case should be dismissed. To

avoid dismissal, you may choose to proceed under

another chapter of the Bankruptcy Code.

If you are an individual filing for chapter 7

bankruptcy, the trustee may sell your property to

pay your debts, subject to your right to exempt

the property or a portion of the proceeds from

the sale of the property. The property, and the

proceeds from property that your bankruptcy

trustee sells or liquidates that you are entitled to, is

called exempt property. Exemptions may enable

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

household items or to receive some of the

proceeds if the property is sold.

Exemptions are not automatic. To exempt

property, you must list it on Schedule C: The

Property You Claim as Exempt (Official Form

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

may sell it and pay all of the proceeds to your

creditors.

Chapter 11: Reorganization

+

$1,167 filing fee

$550 administrative fee

$1,717 total fee

Chapter 11 is often used for reorganizing a

business, but is also available to individuals. The

provisions of chapter 11 are too complicated to

summarize briefly.

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

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page 3

Read These Important Warnings

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

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

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

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

your family, your home, and your possessions.

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

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

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

legal requirements.

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

documents.

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

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

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

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

Chapter 12: Repayment plan for family

farmers or fishermen

+

$200 filing fee

$75 administrative fee

$275 total fee

Similar to chapter 13, chapter 12 permits family

farmers and fishermen to repay their debts over a

period of time using future earnings and to discharge

some debts that are not paid.

Chapter 13: Repayment plan for

individuals with regular

income

+

$235 filing fee

$75 administrative fee

$310 total fee

Chapter 13 is for individuals who have regular

income and would like to pay all or part of their

debts in installments over a period of time and to

discharge some debts that are not paid. You are

eligible for chapter 13 only if your debts are not

more than certain dollar amounts set forth in 11

U.S.C. § 109.

Under chapter 13, you must file with the court a

plan to repay your creditors all or part of the

money that you owe them, usually using your

future earnings. If the court approves your plan,

the court will allow you to repay your debts, as

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

depending on your income and other factors.

After you make all the payments under your plan,

many of your debts are discharged. The debts that

are not discharged and that you may still be

responsible to pay include:

domestic support obligations,

most student loans,

certain taxes,

debts for fraud or theft,

debts for fraud or defalcation while acting in a

fiduciary capacity,

most criminal fines and restitution obligations,

certain debts that are not listed in your

bankruptcy papers,

certain debts for acts that caused death or

personal injury, and

certain long-term secured debts.

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

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page 4

Warning: File Your Forms on Time

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

you promptly file detailed information about your

creditors, assets, liabilities, income, expenses and

general financial condition. The court may dismiss

your bankruptcy case if you do not file this

information within the deadlines set by the Bankruptcy

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

court

For more information about the documents and their

deadlines, go to:

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

s.html#procedure.

Bankruptcy crimes have serious

consequences

If you knowingly and fraudulently conceal assets

or make a false oath or statement under penalty

of perjury—either orally or in writing—in

connection with a bankruptcy case, you may be

fined, imprisoned, or both.

All information you supply in connection with a

bankruptcy case is subject to examination by the

Attorney General acting through the Office of the

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

other offices and employees of the U.S.

Department of Justice.

Make sure the court has your

mailing address

The bankruptcy court sends notices to the mailing

address you list on Voluntary Petition for Individuals

Filing for Bankruptcy (Official Form 101). To ensure

that you receive information about your case,

Bankruptcy Rule 4002 requires that you notify the

court of any changes in your address.

A married couple may file a bankruptcy case

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

case and each spouse lists the same mailing address

on the bankruptcy petition, the bankruptcy court

generally will mail you and your spouse one copy

of each notice, unless you file a statement with

the court asking that each spouse receive separate

copies.

Understand which services you

could receive from credit

counseling agencies

The law generally requires that you receive a

credit counseling briefing from an approved credit

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

filing a joint case, both spouses must receive the

briefing. With limited exceptions, you must

receive it within the 180 days before you file

your bankruptcy petition. This briefing is usually

conducted by telephone or on the Internet.

In addition, after filing a bankruptcy case, you

generally must complete a financial management

instructional course before you can receive a

discharge. If you are filing a joint case, both

spouses must complete the course.

You can obtain the list of agencies approved to

provide both the briefing and the instructional

course from:

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

/ccde/cc_approved.html

In Alabama and North Carolina, go to:

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

BankruptcyResources/ApprovedCredit

20AndDebtCounselors.aspx

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

of the bankruptcy court may be able to help you

obtain the list.

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

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B 203 (12/94)

In re Flora Clemons

Debtor

Case No.

(If known)

Chapter Chapter 7

$1,340.00

$0.00

$1,340.00

UNITED STATES BANKRUPTCY COURT

Northern District of Illinois

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

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

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

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

For legal services, I have agreed to accept

Prior to the filing of this statement I have received

Balance Due

1.

The source of the compensation paid to me was:

 Debtor Other (specify)

2.

The source of the compensation paid to me is:

 Debtor Other (specify)

3.

I have not agreed to share the above-disclosed compensation with any other person unless they are

members and associates of my law firm.

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

members or associates of my law firm. A copy of the agreement, together with a list of the names of

the people sharing in the compensation, is attached.

4.

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

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

bankruptcy;

a.

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

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

5.

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

CERTIFICATION

I certify that the foregoing is a complete statement of any agreement or arrangement for payment to me for representation of

the debtor(s) in this bankruptcy proceedings.

8/22/2016

Date

/s/ Jaime Torres

Signature of Attorney

Semrad Law Firm

Name of law firm

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UNITED STATES BANKRUPTCY COURT

Northern District of Illinois

In re: Clemons, Flora

Debtor(s)

Case No.

Chapter. Chapter7

VERIFICATION OF CREDITOR MATRIX

The above named Debtors hereby verify that the attached list of creditors is true and correct to the best of their knowledge.

Date: 8/22/2016 /s/ Clemons, Flora

Clemons, Flora

Signature of Debtor

1

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NORTH SIDE L

1011 W Lawrence Ave

Chicago , IL 60640

USA

CREDITORS DISCOUNT & A

415 E MAIN ST

STREATOR , IL 61364

USA

FRANKLIN COLLECTION SV

2978 W Jackson St

Tupelo , MS 38801

USA

MBB

1550 N NORTWEST HWY STE 403

PARK RIDGE , IL 60068

USA

CREDITORS DISCOUNT & A

415 E MAIN ST

STREATOR , IL 61364

USA

STATE COLLECTION SERVI

2509 S STOUGHTON RD

MADISON , WI 53716

USA

MBB

1550 N NORTWEST HWY STE 403

PARK RIDGE , IL 60068

USA

CREDIT CNTRL

5757 PHANTOM DR. SUITE 330

HAZELWOOD , MT 63042

USA

Comcast

11621 E. Marginal Way # 5

Bankruptcy Dept

Seattle , WA 98168

USA

New Englewood Terrace Apartments

6425 S Lowe Ave

Chicago , IL 60621

USA

Speedy Cash - Cottage Grove

8701 S Cottage Grove Ave

Chicago , IL 60619

USA

T-Mobile

P.O. Box 742596

Cincinnati , OH 45274

USA

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Jeffrey Building, Inc

7102 S. Jeffrey Blvd

Chicago , IL 60649

USA

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