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Fill in this information to identify your case and this filing: Debtor 1 Kiersten D. Clemons

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

Case number  Check if this is an

amended filing

Official Form 106A/B

Schedule A/B: Property 12/15

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

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

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

Answer every question.

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

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

 No. Go to Part 2.

 Yes. Where is the property?

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

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 pagesyou have attached for Part 2. Write that number here.............................................................................=> $0.00

Part 3: Describe Your Personal and Household Items

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

Do not deduct secured

claims or exemptions.

6. Household goods and furnishings Examples: Major appliances, furniture, linens, china, kitchenware  No

Yes. Describe.....

furniture $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. Describe.....

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

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Debtor 1 Clemons, Kiersten D. Case number (if known)

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. Describe.....

9. Equipment for sports and hobbies Examples: Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes and kayaks; carpentry tools; musical

instruments

 No

Yes. Describe.....

10. Firearms Examples: Pistols, rifles, shotguns, ammunition, and related equipment

 No

Yes. Describe.....

11. Clothes Examples: Everyday clothes, furs, leather coats, designer wear, shoes, accessories  No

Yes. Describe..... wearing apparel $600.00

12. Jewelry

Examples: Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems, gold, silver  No

Yes. Describe.....

13. Non-farm animals Examples: Dogs, cats, birds, horses  No

Yes. Describe.....

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

 No

Yes. Give specific information.....

15. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached for Part 3. Write that number here .............................................................................. $1,350.00

Part 4: Describe Your Financial Assets

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

Do not deduct secured

claims or exemptions.

16. Cash

Examples: Money you have in your wallet, in your home, in a safe deposit box, and on hand when you file your petition  No

 Yes................................................................................................................

Cash on Hand $700.00

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

Institution name:

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

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Debtor 1 Clemons, Kiersten D. Case number (if known)

18. Bonds, mutual funds, or publicly traded stocks Examples: Bond funds, investment accounts with brokerage firms, money market accounts  No

Yes..................

Institution or issuer name:

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

joint venture  No

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

Name of entity: % of ownership:

20. Government and corporate bonds and other negotiable and non-negotiable instruments Negotiable instruments include personal checks, cashiers’checks, promissory notes, and money orders. Non-negotiable instruments are those you cannot transfer to someone by signing or delivering them.  No

Yes. Give specific information about them

Issuer name:

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

 No

Yes. List each account separately. Type of account: Institution name:

Pension Plan Post Office Pension unknown

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

Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications companies, or others  No

Yes. .....................

Institution name or individual:

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

 No

Yes.............

Issuer name and description.

24. Interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program. 26 U.S.C. §§ 530(b)(1), 529A(b), and 529(b)(1).  No

Yes.............

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

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

 No

 Yes. Give specific information about them...

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

Examples: Internet domain names, websites, proceeds from royalties and licensing agreements  No

 Yes. Give specific information about them...

27. Licenses, franchises, and other general intangibles Examples: Building permits, exclusive licenses, cooperative association holdings, liquor licenses, professional licenses  No

 Yes. Give specific information about them...

Money or property owed to you? Current value of the portion you own?

Do not deduct secured

claims or exemptions.

28. Tax refunds owed to you  No

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

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

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Debtor 1 Clemons, Kiersten D. Case number (if known)

29. Family support

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

 No

Yes. Give specific information......

30. Other amounts someone owes you Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compensation, Social Security benefits;

unpaid loans you made to someone else

 No

Yes. Give specific information..

31. Interests in insurance policies Examples: Health, disability, or life insurance; health savings account (HSA); credit, homeowner’s, or renter’s insurance  No

Yes. Name the insurance company of each policy and list its value. Company name: Beneficiary: Surrender or refund

value:

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

If you are the beneficiary of a living trust, expect proceeds from a life insurance policy, or are currently entitled to receive property because someone has died.

 No

Yes. Give specific information..

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

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

 No

 Yes. Describe each claim.........

34. Other contingent and unliquidated claims of every nature, including counterclaims of the debtor and rights to set off claims  No

 Yes. Describe each claim.........

Back child support $1,800.00

35. Any financial assets you did not already list

 No

Yes. Give specific information..

36. Add the dollar value of all of your entries from Part 4, including any entries for pages you have attached for Part 4. Write that number here..................................................................................................................... $2,500.00

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.

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

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

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Debtor 1 Clemons, Kiersten D. Case number (if known)

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

Examples: Season tickets, country club membership

 No

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

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

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

55. Part 1: Total real estate, line 2 ...................................................................................................................... $0.00

56. Part 2: Total vehicles, line 5 $0.00

57. Part 3: Total personal and household items, line 15 $1,350.00

58. Part 4: Total financial assets, line 36 $2,500.00

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

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

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

62. Total personal property. Add lines 56 through 61... $3,850.00 Copy personal property total $3,850.00

63. Total of all property on Schedule A/B. Add line 55 + line 62 $3,850.00

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

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Fill in this information to identify your case: Debtor 1 Kiersten D. Clemons

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106C

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

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

property you listed on Schedule A/B: Property (Official Form 106A/B) as your source, list the property that you claim as exempt. If more space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On the top of any additional pages, write your name and case number (if

known).

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

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

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

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

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

applicable statutory amount. Part 1: Identify the Property You Claim as Exempt

1. Which set of exemptions are you claiming? Check one only, even if your spouse is filing with you. You are claiming state and federal nonbankruptcy exemptions. 11 U.S.C. § 522(b)(3)

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

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

Schedule A/B that lists this property

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption.

Specific laws that allow exemption

furniture

Line from Schedule A/B: 6.1

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

 100% of fair market value, up to

any applicable statutory limit

wearing apparel

Line from Schedule A/B: 11.1

$600.00  $600.00 735 ILCS 5/12-1001(a)

 100% of fair market value, up to

any applicable statutory limit

Cash on Hand

Line from Schedule A/B: 16.1

$700.00  $700.00 735 ILCS 5/12-1001(b)

 100% of fair market value, up to

any applicable statutory limit

Post Office Pension

Line from Schedule A/B: 21.1

Unknown  735 ILCS 5/12-1006

 100% of fair market value, up to

any applicable statutory limit

Back child support

Line from Schedule A/B: 34.1

$1,800.00  $1,800.00 735 ILCS 5/12-1001(b)

 100% of fair market value, up to

any applicable statutory limit

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

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

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

 No

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

 No

 Yes

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

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Fill in this information to identify your case: Debtor 1 Kiersten D. Clemons

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

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.

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

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Fill in this information to identify your case: Debtor 1 Kiersten D. Clemons

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106E/F

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

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

any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule A/B: Property (Official Form 106A/B) and on

Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any creditors with partially secured claims that are listed in Schedule

D: Creditors Who Have Claims Secured by Property. If more space is needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach

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

case number (if known).

Part 1: List All of Your PRIORITY Unsecured Claims

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

 No. Go to Part 2.

Yes. Part 2: List All of Your NONPRIORITY Unsecured Claims

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

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

Yes.

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

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

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

2.

Total claim

4.1 Acl Laboratories Last 4 digits of account number 7648 $214.00

Nonpriority Creditor's Name

111 N Wabash Ave Ste 1600

Chicago, IL 60602-3051

When was the debt incurred? Unknown

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 1 of 7

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Debtor 1 Clemons, Kiersten D. Case number (if know)

4.2 Bonnie Brook Apartments Last 4 digits of account number M501 $3,280.00

Nonpriority Creditor's Name

1919 N Lewis Ave

Waukegan, IL 60087-4739

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.3 CAPITAL ONE BANK Last 4 digits of account number unknown

Nonpriority Creditor's Name

11013 W. Broad St.

Glen Allen, VA 23060

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.4 CITY OF CHICAGO Last 4 digits of account number 5140 $350.00

Nonpriority Creditor's Name

Department of Revenue

PO Box 88292

Chicago, IL 60680-1292

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 2 of 7

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Debtor 1 Clemons, Kiersten D. Case number (if know)

4.5 Elmhurst Radiologists Last 4 digits of account number 8611 $25.00

Nonpriority Creditor's Name

44000 Garfield Rd

Clinton Township, MI 48038-1125

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.6 Fed Loan Serv Last 4 digits of account number 0002 $7,734.00

Nonpriority Creditor's Name

PO Box 60610

Harrisburg, PA 17106-0610

When was the debt incurred? 2011-12

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.7 Fed Loan Serv Last 4 digits of account number 0001 $3,864.00

Nonpriority Creditor's Name

PO Box 60610

Harrisburg, PA 17106-0610

When was the debt incurred? 2011-12

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 3 of 7

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Debtor 1 Clemons, Kiersten D. Case number (if know)

4.8 Loyola University Health Syste Last 4 digits of account number 1301 $360.00

Nonpriority Creditor's Name

2160 S 1st Ave

Maywood, IL 60153-3328

When was the debt incurred? 2016-03

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.9 Loyola University Health Systems Last 4 digits of account number 3857 $197.55

Nonpriority Creditor's Name

2160 S 1st Ave

Maywood, IL 60153-3328

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.10 Loyola University Medical Center Last 4 digits of account number 1858 $210.62

Nonpriority Creditor's Name

PO Box 3021

Milwaukee, WI 53201-3021

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 4 of 7

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Debtor 1 Clemons, Kiersten D. Case number (if know)

4.11 MID AMERICA BANK Last 4 digits of account number unknown

Nonpriority Creditor's Name

1830 W Fullerton Ave # 21

Chicago, IL 60614-2034

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.12 SPRINT Last 4 digits of account number unknown

Nonpriority Creditor's Name

Bankruptcy Department 6200

Sprint Parkwa

Overland Park, KS 66251

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.13 T-Mobile Last 4 digits of account number unknown

Nonpriority Creditor's Name

T Mobile Bankruptcy

PO Box 37380

Albuquerque, NM 87176-7380

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 5 of 7

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Debtor 1 Clemons, Kiersten D. Case number (if know)

4.14 TCF BANK HEADQUARTERS Last 4 digits of account number unknown

Nonpriority Creditor's Name

800 BURR RIDGE PARKWAY

BURR RIDGE, IL 60521

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

4.15 VICTORIA'S SECRET Last 4 digits of account number unknown

Nonpriority Creditor's Name

P.O. BOX 182510

COLUMBUS, OH 43218-2510

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that you did not

report as priority claims

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

Yes Other. Specify

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

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

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

have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the additional creditors here. If you do not have additional persons to be

notified for any debts in Parts 1 or 2, do not fill out or submit this page.

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

Fedloan Servicing

PO Box 69184

Harrisburg, PA 17106-9184

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 0002

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

Fedloan Servicing

PO Box 69184

Harrisburg, PA 17106-9184

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 0001

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

LAKE LAW MAGISTRATE COURT Line 4.2 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number M501

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

Nationwide Credit & Co

815 Commerce Dr Ste 270

Oak Brook, IL 60523-8852

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

 Part 2: Creditors with Nonpriority Unsecured Claims

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 6 of 7

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Debtor 1 Clemons, Kiersten D. Case number (if know)

Last 4 digits of account number 1301

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

Nationwide Credit & Coll

Attn Collections/Bankruptcy

815 Commerce Dr Ste 270

Oak Brook, IL 60523-8852

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

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 1301

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

Nationwide Credit & Collection INC

C/O Evergreen Bank Group

PO Box 3219

Oak Brook, IL 60522-3219

Line 4.9 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 3857

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

State Collection Service

PO Box 6250

Madison, WI 53716-0250

Line 4.1 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 7648

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

State Colls

2509 S Stoughton Rd

Madison, WI 53716-3314

Line 4.1 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 7648

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

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

type of unsecured claim.

Total Claim

6a. Domestic support obligations 6a. $ 0.00

Total claims

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

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

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

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

Total Claim

6f. Student loans 6f. $ 0.00

Total claims

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

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

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

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

here.

6i.

$ 16,235.17

6j. Total Nonpriority. Add lines 6f through 6i. 6j. $ 16,235.17

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

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Fill in this information to identify your case: Debtor 1 Kiersten D. Clemons

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

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

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

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

No. Check this box and file this form with the court with your other schedules. You have nothing else to report on this form. Yes. Fill in all of the information below even if the contacts of leases are listed on Schedule A/B:Property (Official Form 106 A/B).

2. List separately each person or company with whom you have the contract or lease. Then state what each contract or lease is for (for example, rent, vehicle lease, cell phone). See the instructions for this form in the instruction booklet for more examples of executory contracts and

unexpired leases.

Person or company with whom you have the contract or lease

Name, Number, Street, City, State and ZIP Code State what the contract or lease is for

2.1

Name

Number Street

City State ZIP Code

2.2

Name

Number Street

City State ZIP Code

2.3

Name

Number Street

City State ZIP Code

2.4

Name

Number Street

City State ZIP Code

2.5

Name

Number Street

City State ZIP Code

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

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Fill in this information to identify your case: Debtor 1 Kiersten D. Clemons

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106H

Schedule H: Your Codebtors 12/15

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

are filing together, both are equally responsible for supplying correct information. If more space is needed, copy the Additional Page, fill it out, and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and

case number (if known). Answer every question.

1. Do you have any codebtors? (If you are filing a joint case, do not list either spouse as a codebtor.  No

Yes

2. Within the last 8 years, have you lived in a community property state or territory? (Community property states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)

 No. Go to line 3.

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

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

line 2 again as a codebtor only if that person is a guarantor or cosigner. Make sure you have listed the creditor on Schedule D (Official Form

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

Column 2.

Column 1: Your codebtor Name, Number, Street, City, State and ZIP Code Column 2: The creditor to whom you owe the debt

Check all schedules that apply:

3.1  Schedule D, line

Name  Schedule E/F, line

 Schedule G, line

Number Street

City State ZIP Code

3.2  Schedule D, line

Name  Schedule E/F, line

 Schedule G, line

Number Street

City State ZIP Code

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

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Fill in this information to identify your case:

Debtor 1 Kiersten D. Clemons

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN

DIVISION

Case number Check if this is:

(If known)  An amended filing

 A supplement showing postpetition chapter 13

income as of the following date: Official Form 106I MM / DD/ YYYY

Schedule I: Your Income 12/15

Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your spouse. If you are separated and your spouse is not filing with you, do not include information about your spouse. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Describe Employment

1. Fill in your employment

information. Debtor 1 Debtor 2 or non-filing spouse

If you have more than one job, attach a separate page with

information about additional employers.

Include part-time, seasonal, or self-employed work. Occupation may include student or

homemaker, if it applies.

Employment status  Employed

 Not employed

 Employed

 Not employed

Occupation clerk

Employer's name United States Postal Service

Employer's address 47 W North Ave

Northlake, IL 60164-3800

How long employed there? 3 years

Part 2: Give Details About Monthly Income

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

unless you are separated.

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

space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or non-filing spouse

2.

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

deductions). If not paid monthly, calculate what the monthly wage would be. 2. $ 3,856.34 $ N/A

3. Estimate and list monthly overtime pay. 3. +$ 0.00 +$ N/A

4. Calculate gross Income. Add line 2 + line 3. 4. $ 3,856.34 $ N/A

Official Form 106I Schedule I: Your Income page 1

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Debtor 1 Clemons, Kiersten D. Case number (if known)

For Debtor 1 For Debtor 2 or non-filing spouse Copy line 4 here 4. $ 3,856.34 $ N/A

5. List all payroll deductions: 5a. Tax, Medicare, and Social Security deductions 5a. $ 821.32 $ N/A

5b. Mandatory contributions for retirement plans 5b. $ 0.00 $ N/A

5c. Voluntary contributions for retirement plans 5c. $ 249.43 $ N/A

5d. Required repayments of retirement fund loans 5d. $ 0.00 $ N/A

5e. Insurance 5e. $ 228.67 $ N/A

5f. Domestic support obligations 5f. $ 0.00 $ N/A

5g. Union dues 5g. $ 57.96 $ N/A

5h. Other deductions. Specify: Allotment 5h.+ $ 1,191.67 + $ N/A

6. Add the payroll deductions. Add lines 5a+5b+5c+5d+5e+5f+5g+5h. 6. $ 2,549.05 $ N/A

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $ 1,307.29 $ N/A

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 $ N/A

8b. Interest and dividends 8b. $ 0.00 $ N/A

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 $ N/A

8d. Unemployment compensation 8d. $ 0.00 $ N/A

8e. Social Security 8e. $ 0.00 $ N/A

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 $ N/A

8g. Pension or retirement income 8g. $ 0.00 $ N/A

8h. Other monthly income. Specify: 8h.+ $ 0.00 + $ N/A

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

10. Calculate monthly income. Add line 7 + line 9. 10. $ 1,307.29 + $ N/A = $ 1,307.29

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

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

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

other friends or relatives. Do not include any amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J. Specify: 11. +$ 0.00

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

Write that amount on the Summary of Schedules and Statistical Summary of Certain Liabilities and Related Data, if it applies 12. $ 1,307.29

Combined monthly income

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

 No.

 Yes. Explain:

Official Form 106I Schedule I: Your Income page 2

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Fill in this information to identify your case:

Debtor 1 Kiersten D. Clemons Check if this is:

 An amended filing

Debtor 2  A supplement showing postpetition chapter 13

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISIONMM / DD / YYYY

Case number

(If known)

Official Form 106J

Schedule J: Your Expenses 12/15

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

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

(if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

Yes. Does Debtor 2 live in a separate household?

 No

 Yes. Debtor 2 must file Official Form 106J-2, Expenses for Separate Householdof Debtor 2.

2. Do you have dependents?  No

Do not list Debtor 1 and

Debtor 2.

Yes. Fill out this information for

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

Dependent’s relationship to

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent

live with you?

Do not state the

dependents names. Daughter 7

 No

Yes  No

Yes  No

Yes  No

Yes 3. Do your expenses include

expenses of people other than

yourself and your dependents?

 No

Yes

Part 2: Estimate Your Ongoing Monthly Expenses Estimate your expenses as of your bankruptcy filing date unless you are using this form as a supplement in a Chapter 13 case to report expenses as of a date after the bankruptcy is filed. If this is a supplemental Schedule J, check the box at the top of the form and fill in the

applicable date.

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

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

(Official Form 106I.) Your expenses

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

payments and any rent for the ground or lot. 4. $ 0.00

If not included in line 4:

4a. Real estate taxes 4a. $ 0.00

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

4c. Home maintenance, repair, and upkeep expenses 4c. $ 0.00

4d. Homeowner’s association or condominium dues 4d. $ 0.00

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

Official Form 106J Schedule J: Your Expenses page 1

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Debtor 1 Clemons, Kiersten D. Case number (if known)

6. Utilities: 6a. Electricity, heat, natural gas 6a. $ 0.00

6b. Water, sewer, garbage collection 6b. $ 0.00

6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $ 0.00

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

7. Food and housekeeping supplies 7. $ 0.00

8. Childcare and children’s education costs 8. $ 0.00

9. Clothing, laundry, and dry cleaning 9. $ 0.00

10. Personal care products and services 10. $ 0.00

11. Medical and dental expenses 11. $ 0.00

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

Do not include car payments. 12. $ 0.00

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $ 0.00

14. Charitable contributions and religious donations 14. $ 0.00

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

15a. Life insurance 15a. $ 0.00

15b. Health insurance 15b. $ 0.00

15c. Vehicle insurance 15c. $ 0.00

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

16. Taxes. Do not include taxes deducted from your pay or included in lines 4 or 20. Specify: 16. $ 0.00

17. Installment or lease payments: 17a. Car payments for Vehicle 1 17a. $ 0.00

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

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

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

18. Your payments of alimony, maintenance, and support that you did not report as deducted from your pay on line 5, Schedule I, Your Income (Official Form 106I). 18. $ 0.00

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

Specify: 19.

20. Other real property expenses not included in lines 4 or 5 of this form or on Schedule I: Your Income. 20a. Mortgages on other property 20a. $ 0.00

20b. Real estate taxes 20b. $ 0.00

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

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

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

21. Other: Specify: 21. +$ 0.00

22. Calculate your monthly expenses

22a. Add lines 4 through 21. $ 0.00

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

22c. Add line 22a and 22b. The result is your monthly expenses. $ 0.00

23. Calculate your monthly net income. 23a. Copy line 12(your combined monthly income) from Schedule I. 23a. $ 1,307.29

23b. Copy your monthly expenses from line 22c above. 23b. -$ 0.00

23c. Subtract your monthly expenses from your monthly income. The result is your monthly net income. 23c. $ 1,307.29

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

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

modification to the terms of your mortgage?

 No.

Yes. Explain here:

Official Form 106J Schedule J: Your Expenses page 2

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Fill in this information to identify your case: Debtor 1 Kiersten D. Clemons

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the: NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

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..................................................................................... $ 3,850.00

1c. Copy line 63, Total of all property on Schedule A/B............................................................................................... $ 3,850.00

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... $ 0.00

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

3a. Copy the total claims from Part 1 (priority unsecured claims) from line 6e of Schedule E/F................................. $ 0.00

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F............................ $ 16,235.17

Your total liabilities $ 16,235.17

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................................................................................ $ 1,307.29

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

Copy your monthly expenses from line 22c of Schedule J.......................................................................... $ 0.00

Part 4: Answer These Questions for Administrative and Statistical Records

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

 No. You have nothing to report on this part of the form. Check this box and submit this form to the court with your other schedules.  Yes 7. What kind of debt do you have?

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

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

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

court with your other schedules. Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2

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Debtor 1 Clemons, Kiersten D. Case number (if known)

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

122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14. $ 3,103.08

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

Total claim

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

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

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

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

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

9e. Obligations arising out of a separation agreement or divorce that you did not report as priority claims. (Copy line 6g.) $ 0.00

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

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

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

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Acl Laboratories

111 N Wabash Ave Ste 1600

Chicago, IL 60602-3051

Bonnie Brook Apartments

1919 N Lewis Ave

Waukegan, IL 60087-4739

CAPITAL ONE BANK

11013 W. Broad St.

Glen Allen, VA 23060

CITY OF CHICAGO

Department of Revenue

PO Box 88292

Chicago, IL 60680-1292

Elmhurst Radiologists

44000 Garfield Rd

Clinton Township, MI 48038-1125

Fed Loan Serv

PO Box 60610

Harrisburg, PA 17106-0610

Fedloan Servicing

PO Box 69184

Harrisburg, PA 17106-9184

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Loyola University Health Syste

2160 S 1st Ave

Maywood, IL 60153-3328

Loyola University Health Systems

2160 S 1st Ave

Maywood, IL 60153-3328

Loyola University Medical Center

PO Box 3021

Milwaukee, WI 53201-3021

MID AMERICA BANK

1830 W Fullerton Ave # 21

Chicago, IL 60614-2034

Nationwide Credit & Co

815 Commerce Dr Ste 270

Oak Brook, IL 60523-8852

Nationwide Credit & Coll

Attn Collections/Bankruptcy

815 Commerce Dr Ste 270

Oak Brook, IL 60523-8852

Nationwide Credit & Collection INC

C/O Evergreen Bank Group

PO Box 3219

Oak Brook, IL 60522-3219

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SPRINT

Bankruptcy Department 6200 Sprint Parkwa

Overland Park, KS 66251

State Collection Service

PO Box 6250

Madison, WI 53716-0250

State Colls

2509 S Stoughton Rd

Madison, WI 53716-3314

T-Mobile

T Mobile Bankruptcy

PO Box 37380

Albuquerque, NM 87176-7380

TCF BANK HEADQUARTERS

800 BURR RIDGE PARKWAY

BURR RIDGE, IL 60521

VICTORIA'S SECRET

P.O. BOX 182510

COLUMBUS, OH 43218-2510

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© 2016 CINgroup 1.866.218.1003 – CINcompass (www.cincompass.com)

B201B (Form 201B) (12/09)

IN RE: Case No. 

Debtor(s)

Chapter 

UNDER § 342(b) OF THE BANKRUPTCY CODE

Certificate of [Non-Attorney] Bankruptcy Petition Preparer

I, the [non-attorney] bankruptcy petition preparer signing the debtor’s petition, hereby certify that I delivered to the debtor the attached

notice, as required by § 342(b) of the Bankruptcy Code.

Printed Name and title, if any, of Bankruptcy Petition Preparer

Address:

X

Signature of Bankruptcy Petition Preparer of officer, principal, responsible person, or

partner whose Social Security number is provided above.

Social Security number (If the bankruptcy

petition preparer is not an individual, state

the Social Security number of the officer,

principal, responsible person, or partner of

the bankruptcy petition preparer.)

(Required by 11 U.S.C. § 110.)

Certificate of the Debtor

I (We), the debtor(s), affirm that I (we) have received and read the attached notice, as required by § 342(b) of the Bankruptcy Code.

Printed Name(s) of Debtor(s)

X

Signature of Debtor Date

Case No. (if known) X

Signature of Joint Debtor (if any) Date

Instructions: Attach a copy of Form B 201A, Notice to Consumer Debtor(s) Under § 342(b) of the Bankruptcy Code.

Use this form to certify that the debtor has received the notice required by 11 U.S.C. § 342(b) only if the certification has

NOT been made on the Voluntary Petition, Official Form B1. Exhibit B on page 2 of Form B1 contains a certification by the debtor’s

attorney that the attorney has given the notice to the debtor. The Declarations made by debtors and bankruptcy petition preparers on

page 3 of Form B1 also include this certification.

United States Bankruptcy Court

Northern District of Illinois, Eastern Division

CERTIFICATION OF NOTICE TO CONSUMER DEBTOR(S)

Clemons, Kiersten D. 7

Clemons, Kiersten D. /s/ Kiersten D. Clemons 8/02/2016

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B2030 (Form 2030) (12/15)

United States Bankruptcy Court

Northern District of Illinois, Eastern Division

In re Clemons, Kiersten D. Case No.

Debtor(s) Chapter 7

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

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

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

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

For legal services, I have agreed to accept $ 650.00

Prior to the filing of this statement I have received $ 650.00

Balance Due $ 0.00

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):

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

firm.

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

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

d. [Other provisions as needed]

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

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 proceeding.

August 2, 2016 /s/ Michael R. Richmond

Date Michael R. Richmond

Signature of Attorney

Heller & Richmond, Ltd.

33 N Dearborn St Ste 1907

Chicago, IL 60602-3828

(312) 781-6700 Fax: (312) 781-6732

mrichmond@hellerrichmond.com

Name of law firm

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