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

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is:

An amended filing

Chapter you are filing under:

Chapter 7

Chapter 11

Chapter 12

Chapter 13

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 12/15

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

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

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

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

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

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

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

number (if known). Answer every question.

Part 1: Identify Yourself

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

1. Your full name

Write the name that is on your

government-issued picture

identification (for example,

your driver’s license or

passport).

Bring your picture

identification to your meeting

with the trustee.

Jack

First name

K.

Middle name

Johnson

Last name

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

N/A

First name

Middle name

Last name

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

2. All other names you have

used in the last 8 years.

Include your married or

maiden names.

N/A

First name

Middle name

Last name

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

N/A

First name

Middle name

Last name

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

N/A

First name

Middle name

Last name

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

N/A

First name

Middle name

Last name

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

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Debtor 1 Jack K. Johnson Case number: 

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

3. Only the last 4 digits of

your Social Security

number or federal

Individual Taxpayer

Identification number

(ITIN)

XXX-XX-0177 N/A

4. Any business names and

Employer Identification

Numbers (EIN) you have

used in the last 8 years.

Include trade names and

doing business as names.

 I have not used any business names or EINs

N/A

Business name

N/A

Business name

 I have not used any business names or EINs

N/A

Business name

N/A

Business name

N/A

EIN

N/A

EIN

N/A

EIN

N/A

EIN

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

5828 S. Wabash

Number Street

Chicago IL 60637

City, State, Zip Code

Cook

County

If your mailing address is different from the one

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

any notices to you at this mailing address.

N/A

Number Street

 

City, State, Zip Code

N/A

EIN

6. Why you are choosing 

this district to file for

bankruptcy

Check one:

Over the last 180 days before filing this

petition, I have lived in this district longer

than in any other district.

I have another reason. Explain. (See 28

U.S.C. § 1408.)

N/A

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.)

N/A

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Debtor 1 Jack K. Johnson Case number: 

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

Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the

Bankruptcy Code you are

choosing to file under

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

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

Chapter 7

Chapter 11

Chapter 12

Chapter 13

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

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

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

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

a pre-printed address.

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

for Individuals to Pay 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.

9. Have you filed for

bankruptcy within the

last 8 years?

No

Yes District Northern District of Illinois When 05/08/2015

Case number 15-12905

MM/DD/YYYY

District Northern District of Illinois When 03/12/2010

Case number 10-10550

MM/DD/YYYY

District Northern District of Illinois When 02/25/2012

Case number 12-07018

MM/DD/YYYY

District Northern District of Illinois When 10/05/2012

Case number 12-39709

MM/DD/YYYY

District Northern District of Illinois When 02/11/2016

Case number 16-04120

MM/DD/YYYY

10. Are any bankruptcy

cases pending or being

filed by a spouse who is

not filing this case with

you, or by a business

partner, or by an

affiliate?

No

Yes Debtor N/A Relationship

District When Case number

MM/DD/YYYY

Debtor N/A Relationship

District When Case number

MM/DD/YYYY

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Debtor 1 Jack K. Johnson Case number: 

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

11. Do you rent your

residence?

No. Go to line 12.

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

residence?

No. Go to line 12.

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

with this bankruptcy petition.

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

12. Are you a sole proprietor

of any full- or part-time

business?

A sole proprietorship is a

business you operate as an

individual, and is not a

separate legal entity such as

a corporation, partnership, or

LLC.

No. Go to Part 4.

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

14. Do you own or have any

property that poses or

is alleged to pose a

threat of imminent and

identifiable hazard to

public health or

safety? Or do you own

any property that needs

immediate attention?

For example, do you own

perishable goods, or

livestock that must be fed,

or a building that needs

urgent repairs?

No.

Yes.

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

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

15. Tell the court whether

you have received

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.

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.

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Debtor 1 Jack K. Johnson Case number: 

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

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

I certify that I asked for credit

counseling services from an approved

agency, but was unable to obtain those

services during the 7 days after I made my

request, and exigent circumstances merit

a 30-day temporary waiver of the

requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet

explaining what efforts you made to obtain the

briefing, why you were unable to obtain it

before you filed for bankruptcy, and what

exigent circumstances required you to file this

case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not

receiving a briefing before you filed for

bankruptcy. If the court is satisfied with your

reasons, you must still receive a briefing

within 30 days after you file. You must file a

certificate from the approved agency, along

with a copy of the payment plan you

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

case may be dismissed.

Any extension of the 30-day deadline is

granted only for cause and is limited to a

maximum of 15 days. 

I certify that I asked for credit

counseling services from an approved

agency, but was unable to obtain those

services during the 7 days after I made my

request, and exigent circumstances merit a

30-day temporary waiver of the

requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet

explaining what efforts you made to obtain the

briefing, why you were unable to obtain it

before you filed for bankruptcy, and what

exigent circumstances required you to file this

case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving

a briefing before you filed for bankruptcy. If

the court is satisfied with your reasons, you

must still receive a briefing within 30 days

after you file. You must file a certificate

from the approved agency, along with a copy

of the payment plan you developed, if any. If

you do not do so, your case may be dismissed.

Any extension of the 30-day deadline is

granted only for cause and is limited to a

maximum of 15 days. 

I am not required to receive a briefing

about credit counseling because of:

Incapacity. I have a mental illness

or a mental deficiency

that makes me incapable

of realizing or making

rational decisions about

finances.

Disability. My physical disability

causes me to be unable to

participate in a briefing

in person, by phone, or

through the internet, even

after I reasonably tried to

do so.

Active duty. I am currently on active

military duty in a

military combat zone.

If you believe you are not required to receive a

briefing about credit counseling, you must file

a motion for waiver of credit counseling with

the court.

I am not required to receive a briefing

about credit counseling because of:

Incapacity. I have a mental illness or

a mental deficiency that

makes me incapable of

realizing or making

rational decisions about

finances.

Disability. My physical disability

causes me to be unable to

participate in a briefing

in person, by phone, or

through the internet, even

after I reasonably tried to

do so.

Active duty. I am currently on active

military duty in a military

combat zone.

If you believe you are not required to receive a

briefing about credit counseling, you must file

a motion for waiver of credit counseling with

the court.

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Debtor 1 Jack K. Johnson Case number: 

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

Part 6: Answer These Questions for Reporting Purposes

16. What kind of debts do

you have?

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

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

No. Go to line 16b.

Yes. Go to line 17.

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

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

No. Go to line 16c.

Yes. Go to line 17.

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

17. Are you filing under

Chapter 7?

Do you estimate that

after any exempt

property is excluded and

administrative expenses

are paid that funds will

be available for

distribution to

unsecured creditors?

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

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

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

No.

Yes.

18. How many creditors do

you estimate that you

owe?

1-49

50-99

100-199

200-999

1,000 - 5,000

5,001 - 10,000

10,001 - 25,000

25,001 - 50,000

50,001 - 100,000

More than 100,000

19. How much do you

estimate your assets to

be worth?

$0 to $50,000

$50,001 to $100,000

$100,001 to $500,000

$500,001 to $1 million

$1,000,001 to $10 million

$10,000,001 to $50 million

$50,000,001, to $100 million

$100,000,001 to $500 million

$500,000,001 to $1 billion

$1,000,000,001 to $10 billion

$10,000,000,001 to $50 billion

More than $50 billion

20. How much do you

estimate your liabilities

to be?

$0 to $50,000

$50,001 to $100,000

$100,001 to $500,000

$500,001 to $1 million

$1,000,001 to $10 million

$10,000,001 to $50 million

$50,000,001, to $100 million

$100,000,001 to $500 million

$500,000,001 to $1 billion

$1,000,000,001 to $10 billion

$10,000,000,001 to $50 billion

More than $50 billion

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Debtor 1 Jack K. Johnson Case number: 

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

Part 7: Sign Below

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

correct.

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

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

under Chapter 7.

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

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

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

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

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

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

/s/ Jack K. Johnson 08/12/2016

Debtor 1 MM/DD/YYYY

For your attorney, if you

are represented by one

Note that BkAssist is licensed for

use only by attorneys. If you are

not represented by an attorney, you

may not file this petition.

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.

/s/ Jeffrey Whitehead 08/12/2016

Attorney for Debtor(s) MM/DD/YYYY

Jeffrey Whitehead

Printed name

Whitehead & Associates, LLC

Firm name

105 W. Madison St., Ste 900

Number Street

Chicago IL 60602

City, State, ZIP Code

312-648-0473 jeffwhitehead_2000@yahoo.com

Contact phone Email address

6280034

Bar number

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

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 106Sum

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

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

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

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

Part 1: Summarize Your Assets

Your assets

Value of what

you own

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

1a. Copy line 55, Total real estate, from Schedule A/B ......................................................................................... $0.00

1b. Copy line 62, Total personal property, from Schedule A/B .............................................................................. $14,850.00

1c. Copy line 63, Total of all property on Schedule A/B......................................................................................... $14,850.00

Part 2: Summarize Your Liabilities

Your liabilities

Amount you owe

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

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

Schedule D............................................................................................................................................................. $11,654.61

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 ........................... $2,900.00

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F....................... $15,847.00

Your total liabilities $30,401.61

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 .......................................................................... $1,442.97

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

Copy your monthly expenses from line 22, Column A, of Schedule J. .................................................................. $1,046.00

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Debtor 1 Jack K. Johnson Case number: 

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 8-9 for statistical purposes. 28 U.S.C. § 159.

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

submit this form to the court with your other schedules.

8. From the Statement of Your Current Monthly Income (Official Form 122A-1, 122B, or 122C-1):

Copy your total current monthly income from line 11............................................................................................. $1,668.33

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: Total claim

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

9b. Taxes and certain other debts you owe the government. (Copy line 6b.)........................................................ $2,900.00

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

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

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

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

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

9g. Total. Add lines 9a through 9f.......................................................................................................................... $2,900.00

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

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 106A/B

Schedule A/B: Property 12/15

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

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

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

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

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

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

No. Go to Part 2.

Yes. Where is the property?

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

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: Mazda

Model: CX7

Year: 2011

Approximate mileage: 50,000

Other information: ; Automobile

Who has an interest in the property? Check

one

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property

(see instructions)

Do not deduct secured claims or exemptions.

Put the amount of any secured claims on 

Schedule D: Creditors Who Have Claims

Secured by Property.

Current value of

the entire property?

Current value of

the portion you

own?

$13,000.00 $13,000.00

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

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

No.

Yes.

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

entries for pages you have attached for Part 2. Write that number here ............................................

$13,000.00

Part 3: Describe Your Personal and Household Items

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Debtor 1 Jack K. Johnson Case number: 

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

Do you own or have any legal or equitable interest in any of the following items? (List the current value of the portion you own. Do not

deduct secured claims or exemptions)

6. Household goods and furnishings

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

No

Yes Household Furnishings; Basic Household Goods and Furnshings (D1, $750.00)............... $750.00

7. Electronics

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

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

No

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

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

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

9. Equipment for sports and hobbies

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

and kayaks; carpentry tools; musical instruments

No

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

10. Firearms

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

No

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

11. Clothes

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

No

Yes Clothes; Basic Wearing Apparel (D1, $750.00)........................................................................ $750.00

12. Jewelry

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

gold, silver

No

Yes Costume Jewelry; Costume Jewelry (D1, $50.00) ................................................................... $50.00

13. Non-farm animals

Examples: Dogs, cats, birds, horses

No

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

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

did not list

No

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

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

$1,550.00

Part 4: Describe Your Financial Assets

Do you own or have any legal or equitable interest in any of the following? (List the current value of the portion you own. Do not deduct

secured claims or exemptions)

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Debtor 1 Jack K. Johnson Case number: 

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

16. Cash

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

petition

No

Yes Cash on Hand; Cash on Hand (D1)........................................................................................... $100.00

17. Deposits of money

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

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

No

Yes Chase Checking; Bank Account (D1) ....................................................................................... $200.00

18. Bonds, mutual funds, or publicly traded stocks

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

No

Yes ...................................................................................................................................................... $0.00

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

including an interest in an LLC, partnership, and joint venture

No

Yes ...................................................................................................................................................... $0.00

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

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

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

No

Yes ...................................................................................................................................................... $0.00

21. Retirement or pension accounts

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

plans

No

Yes ...................................................................................................................................................... $0.00

22. Security deposits and prepayments

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

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

companies, or others

No

Yes ...................................................................................................................................................... $0.00

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

No

Yes ...................................................................................................................................................... $0.00

24. Interests in an education IRA as defined in 26 U.S.C. § 530(b)(1) or under a qualified state tuition

plan as defined in 26 U.S.C. § 529(b)(1).

No

Yes ...................................................................................................................................................... $0.00

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

or powers exercisable for your benefit

No

Yes ...................................................................................................................................................... $0.00

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

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

No

Yes ...................................................................................................................................................... $0.00

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Debtor 1 Jack K. Johnson Case number: 

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

27. Licenses, franchises, and other general intangibles

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

No

Yes ...................................................................................................................................................... $0.00

28. Tax refunds owed to you

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

No

Yes ...................................................................................................................................................... $0.00

29. Family support

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

settlement

No

Yes ...................................................................................................................................................... $0.00

30. Other amounts someone owes you

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

compensation, Social Security benefits; unpaid loans you made to someone else

No

Yes ...................................................................................................................................................... $0.00

31. Interests in insurance policies

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

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

No

Yes ...................................................................................................................................................... $0.00

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

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

receive property because someone has died.

No

Yes ...................................................................................................................................................... $0.00

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

payment

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

No

Yes ...................................................................................................................................................... $0.00

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

and rights to set off claims

No

Yes ...................................................................................................................................................... $0.00

35. Any financial assets you did not already list

No

Yes ...................................................................................................................................................... $0.00

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

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

$300.00

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.

Yes. Go to line 38.

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

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

Case 16-26014 Doc 1 Filed 08/12/16 Entered 08/12/16 19:47:59 Desc Main

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Debtor 1 Jack K. Johnson Case number: 

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

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

property?

No. Go to part 7.

Yes. Go to line 47.

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

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

Examples: Season tickets, country club membership

No

Yes ..................................................................................................................................................... $0.00

54. Add the dollar value of all of your entries from Part 7, including any entries for pages you have

attached for Part 7. Write that number here ...........................................................................................

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............................................................................. $13,000.00

57. Part 3: Total personal and household items, line 15 ..................................... $1,550.00

58. Part 4: Total financial assets, line 36 .............................................................. $300.00

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.................................................................................... $14,850.00

63. Total of all property on Schedule A/B. Add line 55 + line 62 .................................................................. $14,850.00

Case 16-26014 Doc 1 Filed 08/12/16 Entered 08/12/16 19:47:59 Desc Main

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

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 106C

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

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

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

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

and case number (if known).

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

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

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

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

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

to the applicable statutory amount.

Part 1: Identify the Property You Claim as Exempt

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

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

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

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

Brief description of the property

and line on Schedule A/B that lists

this property

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each

exemption

Specific laws that allow exemption

2011 Mazda CX7 (Line 3) $13,000.00 $1,345.39

100% of fair market value, up to

any applicable statutory limit

735 ILCS 5/12-1001(c)

Household Furnishings (Line 6) $750.00 $750.00

100% of fair market value, up to

any applicable statutory limit

735 ILCS 5/12-1001(b)

Clothes (Line 11) $750.00 $750.00

100% of fair market value, up to

any applicable statutory limit

735 ILCS 5/12-1001(a)

Costume Jewelry (Line 12) $50.00 $50.00

100% of fair market value, up to

any applicable statutory limit

735 ILCS 5/12-1001(b)

Cash on Hand (Line 16) $100.00 $100.00

100% of fair market value, up to

any applicable statutory limit

735 ILCS 5/12-1001(b)

Chase Checking (Line 17) $200.00 $200.00

100% of fair market value, up to

any applicable statutory limit

735 ILCS 5/12-1001(b)

Total $14,850.00 $3,195.39

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Debtor 1 Jack K. Johnson Case number: 

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

3. Are you claiming a homestead exemption of more than $155,675.00?

(Subject to adjustment on 04/01/2016 and every 3 years after that for cases filed on or after the date of adjustment.)

No

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

No

Yes

Case 16-26014 Doc 1 Filed 08/12/16 Entered 08/12/16 19:47:59 Desc Main

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

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 106D

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

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

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

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

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

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

Yes. Fill in all of the information below.

Part 1: List All Secured Claims

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

particular claim, list the other creditors in Part 2. As much as possible, list the claims in alphabetical order according to the creditor’s name.

Column A

Amount of claim

Do not deduct the value

of the collateral

Column B

Value of collateral

that supports this

claim

Column C

Unsecured portion

if any

2.1

Mazda Capital Services

Creditor's Name

c/o Chase

Number Street

PO Box 901076

Fort Worth TX 76101

City, State, ZIP Code

Who owes the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim relates to a community

debt

Date debt was incurred: UNKNOWN

Describe the property that secures the claim:

2011 Mazda CX7

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

Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply

An agreement you made (such as

mortgage or secured car loan)

Statutory lien (such as tax lien, mechanic’s

lien)

Judgment lien from a lawsuit

Other (including a right to offset) 

Last 4 digits of account number: 1410

$11,654.61 $13,000.00

Add the dollar value of your entries in Column A. Write that number here:............................................. $11,654.61

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

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

collection agency is trying to collect from you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection

agency here. Similarly, if you have more than one creditor for any of the debts that you listed in Part 1, list the additional creditors here.

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

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

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 106E/F

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

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

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

A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any

creditors with partially secured claims that are listed in Schedule D: Creditors Who 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?

No. Go to Part 2.

Yes.

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

2.1

IRS

Priority Creditor's Name

PO Box 7346

Number Street

Philadelphia PA 19101

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 0177

When was the debt incurred: 2006

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

Contingent

Unliquidated

Disputed

Type of PRIORITY unsecured claim:

Domestic support obligations

Taxes and certain other debts you owe

the government

Claims for death or personal injury while

you were intoxicated

Other. Specify 

$2,200.00 $2,200.00 $0.00

2.2

State of Illinois Dept of Revenue

Priority Creditor's Name

PO Box 19006

Number Street

Springfield IL 62794

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 0177

When was the debt incurred: UNKNOWN

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

Contingent

Unliquidated

Disputed

Type of PRIORITY unsecured claim:

Domestic support obligations

Taxes and certain other debts you owe

the government

Claims for death or personal injury while

you were intoxicated

Other. Specify 

$700.00 $700.00 $0.00

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Debtor 1 Jack K. Johnson Case number: 

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?

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

Yes.

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

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

Account Recovery Service

Nonriority Creditor's Name

3031 N. 114 Street

Number Street

Milwaukee WI 53222

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 5199

When was the debt incurred: 2007

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$945.00

4.2

ALLIANCE ONE

Nonriority Creditor's Name

4850 STREET RD

Number Street

SUITE 300

Feasterville Trevose PA 19053

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 8762

When was the debt incurred: 2011

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$2,267.00

4.3

Arrow Financial

Nonriority Creditor's Name

5996 W. Touhy Avenue

Number Street

Niles IL 60714

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 1563

When was the debt incurred: 2008

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$491.00

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Total claim

4.4

CAPITAL ONE

Nonriority Creditor's Name

c/o Freedman Anselmo & Lindberg

Number Street

PO Box 3107

Park Forest IL 60466

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 5463

When was the debt incurred: 2010

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$2,256.00

4.5

CHASE

Nonriority Creditor's Name

PO BOX 36520

Number Street

Louisville KY 40233

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 0177

When was the debt incurred: 2010

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$100.00

4.6

City of Chicago Parking Tickets

Nonriority Creditor's Name

333 S. State Street

Number Street

Room 540

Chicago IL 60604

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 5615

When was the debt incurred: 2009

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Parking Tickets

$4,662.00

4.7

Cook County Health & Hospital System

Nonriority Creditor's Name

19 Mollison Way

Number Street

Lewiston ME 04240

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 5888

When was the debt incurred: UNKNOWN

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Medical

$440.00

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

Total claim

4.8

Illinois Department of Employment Sec

Nonriority Creditor's Name

Benefits Repayment

Number Street

PO Box 6996

Chicago IL 60680

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 0177

When was the debt incurred: 2010

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$2,200.00

4.9

KCA Financial

Nonriority Creditor's Name

628 North Street

Number Street

Geneva IL 60134

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 1512

When was the debt incurred: 2005

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$160.00

4.10

NCO Financial Systems, Inc.

Nonriority Creditor's Name

PO Box 15630

Number Street

Dept 15

Wilmington DE 19850

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 8133

When was the debt incurred: 2008

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$1,371.00

4.11

Professional Recovery System

Nonriority Creditor's Name

600 17 Street

Number Street

Suite 2600

Denver CO 80202

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 1565

When was the debt incurred: 2006

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Other

$630.00

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Total claim

4.12

Provident Hospital

Nonriority Creditor's Name

500 E. 51st Street

Number Street

Chicago IL 60637

City, State, ZIP Code

Who incurred the debt? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

No

Yes

Last 4 digits of account number: 6148

When was the debt incurred: 2011

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Medical

$325.00

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

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

example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or 2,

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

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

this page.

1

Arnold Scott Harris, P.C.

Creditor's Name

111 W. Jackson Blvd.

Number Street

Suite 600

Chicago IL 60604

City, State, ZIP Code

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

Line 4.6 of (Check one): Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number: 

2

Linebarger Goggan Blair Sampson

Creditor's Name

PO Box 06152

Number Street

Chicago IL 60606

City, State, ZIP Code

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

Line 4.6 of (Check one): Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number: 

3

Nationwide Credit & Collection, Inc.

Creditor's Name

815 Commerce Drive 

Number Street

Suite 270

Oak Brook IL 60523

City, State, ZIP Code

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

Line 4.7 of (Check one): Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number: 

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

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

Add the amounts for each type of unsecured claim.

Total claim

Total

claims from

Part 1 6a. Domestic support obligations ................................................................................................. 6a. $0.00

6b. Taxes and certain other debts you owe the government ..................................................... 6b. $2,900.00

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Debtor 1 Jack K. Johnson Case number: 

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

Total claim

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

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

6e. Total Add lines 6a through 6d. ................................................................................................... 6e. $2,900.00

Total

claims from

Part 2 6f. Student loans............................................................................................................................. 6f. $0.00

6g. Obligations arising out of a separation agreement or divorce that you did not report as

priority claims ................................................................................................................................. 6g. $0.00

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

6i. Other. Add all other nonpriority unsecured claims. Write that amount here................................ 6i. $15,847.00

6j. Total. Add lines 6f through 6i. ..................................................................................................... 6j. $15,847.00

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

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

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

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

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

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

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

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Official Form 106H Schedule H: Your Codebtors Page 1

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 106H

Schedule H: Your Codebtors 12/15

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

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

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

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

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

No

Yes

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

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

No. Go to line 3.

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

No

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

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

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Official Form 106I Schedule I: Your Income Page 1

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is:

An amended filing

A supplement showing

post-petition chapter 13

income as of 

Official Form 106I

Schedule I: Your Income 12/15

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

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

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

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

Part 1: Describe Employment

1. Fill in your employment

information

If you have more than one job,

attach a separate page with

information about additional

employers.

Include part-time, seasonal, or

self-employed work.

Occupation may include student or

homemaker, if it applies.

Employment status

Occupation

Employer's name

Employer's address

How long employed there?

Debtor 1

 Employed

 Not employed

Janitor 

St. Elizabeth Parrish 

3 months

Debtor 2 or non-filing spouse

 Employed

 Not employed

N/A 

N/A

N/A

Part 2: Give Details About Monthly Income

For Debtor 1

For Debtor 2

or

non-filing

spouse

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

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

2. $1,668.33

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

4. Calculate gross income. Add line 2 + line 3. 4. $1,668.33

5. List All payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a. $225.36

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

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

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

5e. Insurance 5e. $0.00

5f. Domestic support obligations 5f. $0.00

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Debtor 1 Jack K. Johnson Case number: 

Official Form 106I Schedule I: Your Income Page 2

For Debtor 1

For Debtor 2

or non-filing

spouse

5g. Union dues 5g. $0.00

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

6. Add the payroll deductions. Add lines 5a through 5h 6. $225.36

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $1,442.97

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-8h. 9. $0.00

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

Add the entries in line 9 for Debtor 1 and Debtor 2 or non-filing spouse.

10. $1,442.97

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

(Official Form 106J).

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 (Official Form 106J).

Specify: 

11. $0.00

12. Add the amounts on lines 10 and 11. The result is the combined monthly income. Also

write that amount on the Summary of Your Assets and Liabilities and Certain Statistical

Information (Official Form 106Sum) if it applies.

12.

$1,442.97

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

No

Yes.

Explain.....

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Official Form 106J Schedule J: Your Expenses Page 1

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is:

An amended filing

A supplement showing

post-petition chapter 13

expenses as of 

Official Form 106J

Schedule J: Your Expenses 12/15

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

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

number (if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case?

No. Go to line 2.

Yes. Does Debtor 2 live in a separate household?

No.

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

2. Do you have dependents?

Do not list Debtor 1 or Debtor 2.

Do not state the dependents'

names.

No

Yes. Fill out this

information for

each dependent

Dependent's

relationship to Debtor

1 or Debtor 2

Dependent's age Does dependent live

with you?

3. Do your expenses include expenses of people other than yourself and your

dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

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

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

the applicable date

Include expenses paid for with non-cash governmental assistance if you know the value of such assistance and have included it on 

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

Note: Expenses for property other than the debtor(s)' primary residence(s), if any, are reported in the Summary of Business/Real-Estate Income &

Expense annexed to Schedule I.

Note: Monthly payments that are being made through the Chapter 13 Plan, if any, are not included in the expenses listed on this schedule.

Your

expenses

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

mortgage payments and any rent for the ground or lot.

4. $400.00

If not included in line 4:

4a. Real estate taxes 4a.

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

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Debtor 1 Jack K. Johnson Case number: 

Official Form 106J Schedule J: Your Expenses Page 2

Your

expenses

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

4d. Homeowner's association or condominium dues 4d.

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

6. Utilities:

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

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

6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $52.00

6d. Other. Specify: N/A 6d.

7. Food and housekeeping supplies 7. $300.00

8. Childcare and children’s education costs 8.

9. Clothing, laundry, and dry cleaning 9. $40.00

10. Personal care products and services 10. $45.00

11. Medical and dental expenses 11. $45.00

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

Do not include car payments.

12. $60.00

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

14. Charitable contributions and religious donations 14.

15. Insurance.

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

15a. Life insurance 15a.

15b. Health insurance 15b.

15c. Vehicle insurance 15c. $104.00

15d. Other insurance. Specify: N/A 15d.

16. Taxes. Do not include taxes deducted from your pay or included in lines 4 or 20. Specify: N/A 16.

17. Installment or lease payments

(None) 17. $0.00

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

deducted from your pay on line 5, Schedule I (Official Form 106I)

18.

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

Specify: N/A

19.

20. Other real property expenses not included in lines 4 or 5 of this form or on

Schedule I (Official Form 106I)

20a. Mortgages on other property 20a.

20b. Real estate taxes 20b.

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

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

20e. Homeowner's association or condominium dues 20e.

20f. Other. Specify: 20f.

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Debtor 1 Jack K. Johnson Case number: 

Official Form 106J Schedule J: Your Expenses Page 3

Your

expenses

21. Other. Specify: N/A 21.

22. Calculate your monthly expenses.

22a. Add lines 4 through 21. 22a. $1,046.00

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

22c. Add line 22a and 22b. The result is your monthly expenses. 22c. $1,046.00

23. Calculate your monthly net income

23a. Copy line 12 (your combined monthly income) from Schedule I 23a. $1,442.97

23b. Copy your monthly expenses from line 22 above. 23b. $1,046.00

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

The result is your monthly net income

23c. $396.97

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.....

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Official Form 106Dec Declaration About an Individual Debtor’s Schedules Page 1

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 106Dec

Declaration About an Individual Debtor’s Schedules 12/15

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

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

obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20

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

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

No

Yes. Name of person N/A. Attach Bankruptcy Petition Preparer's Notice, Declaration, and Signature (Official Form 119).

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

are true and correct.

/s/ Jack K. Johnson 08/12/2016

Signature of Debtor 1 Date

08/12/2016

Signature of Debtor 2 Date

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

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is an amended

filing

Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy 12/15

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

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

number (if known). Answer every question.

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

1. What is your current marital status?

Married

Not married

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

No

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

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

(Community property states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico,

Texas, Washington, and Wisconsin.)

No

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

Part 2: Explain the Sources of Your Income

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

years?

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

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

No

Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income

Check all that apply

Gross income

(before deductions and

exclusions)

Sources of income

Check all that apply

Gross income

(before deductions and

exclusions)

From January 1 of current

year until the date you

filed for bankruptcy:

Wages, commissions,

bonuses, tips

Operating a business $8,690.00

Wages, commissions,

bonuses, tips

Operating a business

For last calendar year:

(January 1 to December 31, 2015)

Wages, commissions,

bonuses, tips

Operating a business $13,834.05

Wages, commissions,

bonuses, tips

Operating a business

For the calendar year

before that:

(January 1 to December 31, 2014)

Wages, commissions,

bonuses, tips

Operating a business $16,570.00

Wages, commissions,

bonuses, tips

Operating a business

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Debtor 1 Jack K. Johnson Case number: 

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

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

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

Security, unemployment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from

lawsuits; royalties; and gambling and lottery winnings. If you are filing a joint case and you have income that you received

together, list it only once under Debtor 1.

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

No

Yes. Fill in the details.

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

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

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

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

During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,225.00* or more?

No. Go to line 7.

Yes. List below each creditor to whom you paid a total of $6,225.00* or more in one or more payments and the total

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

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

* Subject to adjustment on 04/01/2016 and every 3 years after that for cases filed on or after the date of adjustment.

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

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

No. Go to line 7.

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

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

include payments to an attorney for this bankruptcy case.

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

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

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

securities; and any managing agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include

payments for domestic support obligations, such as child support and alimony.

No

Yes. List all payments to an insider

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

that benefited an insider?

Include payments on debts guaranteed or cosigned by an insider.

No

Yes. List all payments that benefited an insider.

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

proceeding?

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

or custody modifications, and contract disputes.

No

Yes. Fill in the details

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Debtor 1 Jack K. Johnson Case number: 

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

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

seized, or levied?

Check all that apply and fill in the details below.

No. Go to line 11.

Yes. Fill in the information below.

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

any amounts from your accounts or refuse to make a payment because you owed a debt?

No

Yes. Fill in the details

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

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

No

Yes

Part 5: List Certain Gifts and Contributions

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

No

Yes. Fill in the details for each gift.

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

$600 to any charity?

No

Yes. Fill in the details of each gift or contribution

Part 6: List Certain Losses

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

fire, other disaster, or gambling?

No

Yes. Fill in the details

Part 7: List Certain Payments or Transfers

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

property to anyone you consulted about seeking bankruptcy or preparing a bankruptcy petition?

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

No

Yes. Fill in the details

Person who was paid Description and value of any property

transferred

Date payment

or transfer

was made

Amount of payment

Access Counseling

633 West 5th Street

Suite 26001

Los Angeles, CA 90081

Email or website address: 

Person Who Made the Payment if Not

You: 

Fee for § 109(h)(1) briefing by approved

nonprofit budget and credit counseling

agency

02/02/2016 $25.00

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Debtor 1 Jack K. Johnson Case number: 

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

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

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

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

No

Yes. Fill in the details.

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

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

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

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

No

Yes. Fill in the details

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

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

No

Yes. Fill in the details

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.

No

Yes. Fill in the details

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

for securities, cash, or other valuables?

No

Yes. Fill in the details.

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

No

Yes. Fill in the details.

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

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

hold in trust for someone.

No

Yes. Fill in the details.

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.

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BkAssist® Software Copyright© 2010-2015 by Walter Oney. All rights reserved.

Debtor 1 Jack K. Johnson Case number: 

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

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

environmental law?

No

Yes. Fill in the details

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

No

Yes. Fill in the details

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

and orders.

No

Yes. Fill in the details

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

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

business?

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

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

A partner in a partnership

An officer, director, or managing executive of a corporation

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

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

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

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

Include all financial institutions, creditors, or other parties.

No

Yes. Fill in the details below.

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.

/s/ Jack K. Johnson 08/12/2016

Signature of Debtor 1 Date

08/12/2016

Signature of Debtor 2 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

Yes. Name of person N/A -- the BkAssist software used to prepare this petition is licensed for use only by

attorneys.

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Form BKA-2030 Disclosure of Compensation of Attorney for Debtor Page 1

Fill in this information to identify your case:

Debtor 1 Jack K. Johnson

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the Northern District of Illinois

Case number

(If known)

Check if this is:

An amended filing

A supplement disclosing

additional payments or

agreements as of 

Form BKA-2030

Disclosure of Compensation of Attorney for Debtor 12/15

Use this procedural form, if desired, to disclose the matters enumerated in 11 U.S.C. § 329 and Fed. R. Bankr. P. 2016(b).

Disclosure is required within 14 days after the order for relief or another time as the court may direct. A supplemental disclosure is

required within 14 days after any payment or agreement not previously disclosed.

Attach a copy of the retainer agreement, if any.

Part 1: Compensation

For legal services, I have agreed to accept.......................... $4,000.00

Prior to the filing of this statement I have received

Retainer for legal services.............................................. $0.00

Retainer for expenses, including the court filing fee ......

Balance Due......................................................................... $4,000.00

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

 Debtor Other (specify) 

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

 Debtor Other (specify) N/A

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

associates of my law firm.

I have agreed to share the above-disclosed compensation with another 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.

Part 2: Services

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

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

bankruptcy.

b. Preparation and filing of any petition, schedules, statement of affairs and plan that may be required.

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

d. Representation of the debtor in adversary proceedings and other contested bankruptcy matters.

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Debtor 1 Jack K. Johnson Case number: 

Form BKA-2030 Disclosure of Compensation of Attorney for Debtor Page 2

e.

f.

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

(None)

7. A copy of my retainer agreement is is not attached.

Part 3: 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 case.

/s/ Jeffrey Whitehead 08/12/2016

Jeffrey Whitehead (Whitehead & Associates, LLC) Date

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BkAssist® Software Copyright© 2010-2015 by Walter Oney. All rights reserved.

United States Bankruptcy Court

Northern District of Illinois

Chicago Division

In re: Johnson, Jack Case No. 

VERIFICATION OF CREDITOR MATRIX

I(we) verify that the attached list of creditors and the matrix file to be uploaded in this case

are true and complete to the best of my(our) knowledge.

/s/ Jack K. Johnson 08/12/2016

Debtor Date

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Account Recovery Service

3031 N. 114 Street

Milwaukee, WI 53222

ALLIANCE ONE

4850 STREET RD

SUITE 300

Feasterville Trevose, PA 19053

Arnold Scott Harris, P.C.

111 W. Jackson Blvd.

Suite 600

Chicago, IL 60604

Arrow Financial

5996 W. Touhy Avenue

Niles, IL 60714

CAPITAL ONE

c/o Freedman Anselmo & Lindberg

PO Box 3107

Park Forest, IL 60466

CHASE

PO BOX 36520

Louisville, KY 40233

Chris Jewula Contracting

5200 West Roscoe Street

Chicago, IL 60641

City of Chicago Parking Tickets

333 S. State Street

Room 540

Chicago, IL 60604

Cook County Health & Hospital System

19 Mollison Way

Lewiston, ME 04240

Illinois Department of Employment Sec

Benefits Repayment

PO Box 6996

Chicago, IL 60680

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IRS

PO Box 7346

Philadelphia, PA 19101

KCA Financial

628 North Street

Geneva, IL 60134

Linebarger Goggan Blair Sampson

PO Box 06152

Chicago, IL 60606

Lowe's

P.O. box 530914

Atlanta, GA 30353

Mazda Capital Services

c/o Chase

PO Box 901076

Fort Worth, TX 76101

Nationwide Credit & Collection, Inc.

815 Commerce Drive 

Suite 270

Oak Brook, IL 60523

NCO Financial Systems, Inc.

PO Box 15630

Dept 15

Wilmington, DE 19850

Professional Recovery System

600 17 Street

Suite 2600

Denver, CO 80202

Provident Hospital

500 E. 51st Street

Chicago, IL 60637

State of Illinois Dept of Revenue

PO Box 19006

Springfield, IL 62794

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