Check if this is an

Fill in this information to identify your case:

United States Bankruptcy Court for the:

Case number (if known): Chapter you are filing under: Chapter 7

Chapter 11

Chapter 12

Chapter 13

amended filing

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 12/15

Part 1: Identify Yourself

1. Your full name About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case):

First Name

Middle Name

Last Name

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

First Name

Middle Name

Last Name

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

Toms

Ziemelis

NORTHERN DISTRICT OF ILLINOIS

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.

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.

2. All other names you

First Name Middle Name

Last Name

First Name Middle Name

Last Name

have used in the last 8

years

Include your married or maiden names.

3. xxx – xx –

9xx – xx –

OR

xxx – xx –

9xx – xx –

OR

4 7 5 0

Only the last 4 digits of

your Social Security number or federal

Individual Taxpayer

Identification number

(ITIN)

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 4. I have not used any business names or EINs.

Business name

Business name

I have not used any business names or EINs.

Business name

Business name

Business name Business name

Any business names

and Employer

Identification Numbers

(EIN) you have used in

the last 8 years

Include trade names and

doing business as names

–

–

–

–

EIN EIN

EIN EIN

5. Where you live

Number Street

City

County

If Debtor 2 lives at a different address:

State ZIP Code

Number

State ZIP Code

County

City

Street

If your mailing address is different from

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

court will send any notices to you at this mailing address.

If Debtor 2's mailing address is different

from yours, fill it in here. Note that the court will send any notices to you at this mailing

address.

Number Street

City State ZIP Code

P.O. Box

Number Street

City State ZIP Code

P.O. Box

4912 West Montrose Ave., apt 1

Chicago IL 60641

Cook

6. Why you are choosing Check one: Check one: this district to file for bankruptcy 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.)

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.)

Part 2: Tell the Court About Your Bankruptcy Case

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

for Bankruptcy (Form 2010)). Also, go to the top of page 1 and check the appropriate box. Chapter 7

Chapter 11

Chapter 12

Chapter 13

The chapter of the Bankruptcy Code you

are choosing to file under

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

8. How you will pay the fee I will pay the entire fee when I file my petition.

I need to pay the fee in installments.

I request that my fee be waived

Please check with the clerk's office in your local

If you choose this option, sign and attach the Application for

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

(You may request this option only if you are filing for Chapter 7.

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.

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. NoYes. District When Case number MM / DD / YYYY

District When Case number MM / DD / YYYY

District When Case number MM / DD / YYYY

Have you filed for bankruptcy within the

last 8 years?

10. NoYes. Debtor District

Relationship to you

MM / DD / YYYY

When Case number,

if known

Debtor DistrictRelationship to you

MM / DD / YYYY

When Case number,

if known

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?

11. No. Yes. Go to line 12.

No. Go to line 12.

Do you rent your

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

residence?

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

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

12. No. Go to Part 4. Yes. Name and location of business

Name of business, if any

Number Street

City State ZIP Code Check the appropriate box to describe your business: Health Care Business (as defined in 11 U.S.C. § 101(27A))

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

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

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

None of the above

Are you a sole proprietor of any full- or part-time business?

A sole proprietorship is a

business you operate as an

individual, and is not a

separate legal entity such as a corporation, partnership, or LLC.

If you have more than one

sole proprietorship, use a

separate sheet and attach it

to this petition.

13. If you are filing under Chapter 11, the court must know whether you are a small business debtor so that it can set appropriate deadlines. If you indicate that you are a small business debtor, you must attach your most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return

or if any of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B). No. No.

Yes.

I am not filing under Chapter 11.

I am filing under Chapter 11, but I am NOT a small business debtor according to the definition in

the Bankruptcy Code.

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

are you a small business debtor?

Are you filing under Chapter 11 of the Bankruptcy Code and

For a definition of small

business debtor, see

11 U.S.C. § 101(51D).

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

14. NoYes. What is the hazard?

If immediate attention is needed, why is it needed?

Where is the property?

Number Street

City State ZIP Code

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?

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

15. About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): You must check one:

Incapacity.

Disability.

Active duty.

Incapacity.

Disability.

Active duty.

You must check one: 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.

I received a briefing from an approved credit counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion. Attach a copy of the certificate and the payment

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

I received a briefing from an approved credit counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have

a certificate of completion. Within 14 days after you file this bankruptcy petition, you MUST file a copy of the certificate and payment

plan, if any.

I certify that I asked for credit counseling

services from an approved agency, but was unable to obtain those services during the 7

days after I made my request, and exigent circumstances merit a 30-day temporary waiver of the requirement. To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining what efforts you made to obtain the briefing, why you were unable to obtain it before you filed for bankruptcy, and what exigent circumstances

required you to file this case. Your case may be dismissed if the court is dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must still receive a briefing within 30 days after you file. You must file a certificate from the approved agency, along with a copy of the payment plan you

developed, if any. If you do not do so, your case may be dismissed. Any extension of the 30-day deadline is granted only

for cause and is limited to a maximum of 15 days.

I am not required to receive a briefing about credit counseling because of:

I have a mental illness or a mental

deficiency that makes me

incapable of realizing or making

rational decisions about finances. 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.

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 received a briefing from an approved credit counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion. Attach a copy of the certificate and the payment

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

I received a briefing from an approved credit counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have

a certificate of completion. Within 14 days after you file this bankruptcy petition, you MUST file a copy of the certificate and payment

plan, if any.

I certify that I asked for credit counseling

services from an approved agency, but was unable to obtain those services during the 7

days after I made my request, and exigent circumstances merit a 30-day temporary waiver of the requirement. To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining what efforts you made to obtain the briefing, why you were unable to obtain it before you filed for bankruptcy, and what exigent circumstances

required you to file this case. Your case may be dismissed if the court is dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must still receive a briefing within 30 days after you file. You must file a certificate from the approved agency, along with a copy of the payment plan you

developed, if any. If you do not do so, your case may be dismissed. Any extension of the 30-day deadline is granted only

for cause and is limited to a maximum of 15 days.

I am not required to receive a briefing about credit counseling because of:

I have a mental illness or a mental

deficiency that makes me

incapable of realizing or making

rational decisions about finances. 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.

I am currently on active military

duty in a military combat zone.

If you believe you are not required to receive a

briefing about credit counseling, you must file a motion for waiver of credit counseling with the court.

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

Part 6: Answer These Questions for Reporting Purposes

16. 16a.

16b.

16c.

Are your debts primarily consumer debts?

Are your debts primarily business debts?

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

Consumer debts

Business debts

are defined in 11 U.S.C. § 101(8) as "incurred by an individual primarily for a personal, family, or household purpose."

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 16b. Yes. Go to line 17.

No. Go to line 16c. Yes. Go to line 17.

What kind of debts do you

have?

17. No. Yes.

I am not filing under Chapter 7. Go to line 18.

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?

NoYes

Are you filing under Chapter 7?

Do you estimate that after any exempt property is

excluded and

administrative expenses

are paid that funds will be

available for distribution

to unsecured creditors?

18. 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

How many creditors do

you estimate that you

owe?

19. $0-$50,000

$50,001-$100,000

$100,001-$500,000

$500,001-$1 million

$1,000,001-$10 million

$10,000,001-$50 million

$50,000,001-$100 million

$500,000,001-$1 billion

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

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

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

How much do you

estimate your assets to

be worth?

20. $0-$50,000

$50,001-$100,000

$100,001-$500,000

$500,001-$1 million

$1,000,001-$10 million

$10,000,001-$50 million

$50,000,001-$100 million

$500,000,001-$1 billion

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

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

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

How much do you

estimate your liabilities to

be?

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

Part 7: Sign Below

X /s/ Toms Ziemelis X

Toms Ziemelis, Debtor 1 Signature of Debtor 2

Executed on MM / DD / YYYYExecuted on MM / DD / YYYY08/31/2016

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.

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

X /s/ Igor Gromov

Signature of Attorney for Debtor Date MM / DD / YYYY

Printed name

Firm Name

Number Street

City State ZIP Code

Contact phone Email address

Bar number State

08/31/2016

Igor Gromov

Gromov Law Offices

1020 N. Milwaukee Ave., Ste. 101

Deerfield IL 60015

(847) 845-1779 gromlaw@gmail.com

6282530

For your attorney, if you are

represented by one

If you are not represented by

an attorney, you do not need

to file this page.

I, the attorney for the debtor(s) named in this petition, declare that I have informed the debtor(s) about eligibility to proceed under Chapter 7, 11, 12, or 13 of title 11, United States Code, and have explained the

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

the debtor(s) the notice required by 11 U.S.C. § 342(b) and, in a case in which § 707(b)(4)(D) applies, certify that I have no knowledge after an inquiry that the information in the schedules filed with the petition

is incorrect.

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 8

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Official Form 106A/B

Schedule A/B: Property 12/15

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

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

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?

Check if this is an

amended filing

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

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.

What is the property?

Check all that apply. Single-family home Duplex or multi-unit building

Condominium or cooperative Manufactured or mobile home

Land

Investment property

Timeshare Other

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?

Describe the nature of your ownership

interest (such as fee simple, tenancy by the

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

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

property identification number:

1.1.

County $96,000.00

fee title

$192,000.00

Cook

361 Vita Drive, Wheeling

50% owner

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............................................................. $96,000.00

Part 2: Describe Your Vehicles

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

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

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

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

3.1. Who has an interest in the property?

Check one. Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this is community property

(see instructions)

Do not deduct secured claims or exemptions. Put the

amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property. Current value of the

entire property?

Current value of the portion you own?

Make: Model: Year: Approximate mileage: Other information: $10,000.00 $10,000.00Volkswagen

Gti

2012

85,000

2012 Volkswagen Gti (approx. 85000

miles)

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

NoYes

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

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

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

Part 3: Describe Your Personal and Household Items

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

Do not deduct secured

claims or exemptions. 6. Household goods and furnishings

NoYes. Describe............

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

ordinary furniture and electronics $1,000.00

7. Electronics

NoYes. Describe............

Examples: Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music collections; electronic devices including cell phones, cameras, media players, games

8. Collectibles of value

NoYes. Describe............

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

9. Equipment for sports and hobbies

NoYes. Describe............

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

10. Firearms

NoYes. Describe............

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

11. Clothes

NoYes. Describe............

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

necessary clothing $300.00

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

12. Jewelry

NoYes. Describe............

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

13. Non-farm animals

NoYes. Describe............

Examples: Dogs, cats, birds, horses

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

NoYes. Give specific

did not list

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 the number here....................................................................................................................... $1,300.00

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

NoYes.....................................................................................................................................................................................................

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

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

17. Deposits of money

Examples: Checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerage houses, and other similar institutions. If you have multiple accounts with the same

NoYes..............................

institution, list each.

Institution name:

17.1. Checking account: 2 Checking accounts Chase $2.00

18. Bonds, mutual funds, or publicly traded stocks Examples: Bond funds, investment accounts with brokerage firms, money market accounts NoYes.............................. 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 NoYes. Give specific Name of entity: % of ownership:

information about

them............................................... 20. Government and corporate bonds and other negotiable and non-negotiable instruments Negotiable instruments include personal checks, cashiers' checks, promissory notes, and money orders.

No

Issuer name:

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

Yes. Give specific

information about

them...............................................

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

21. Retirement or pension accounts Examples: Interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sharing plans No

Type of account: Institution name: Yes. List eachaccount separately. 22. Security deposits and prepayments Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications

companies, or others NoYes.............................. Institution name or individual:

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

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

NoYes.............................. 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.

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

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

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

NoYes. Give specific

powers exercisable for your benefit

information about them

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

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

Yes. Give specific

information about them

27. Licenses, franchises, and other general intangibles

No Examples: Building permits, exclusive licenses, cooperative association holdings, liquor licenses, professional licenses

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 NoYes. Give specific information

about them, including whether you already filed the returns and the tax years.....................................

Federal: State: Local:$0.00

$0.00

$0.00

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

29. Family support

No Examples: Past due or lump sum alimony, spousal support, child support, maintenance, divorce settlement, property settlement

Yes. Give specific information Alimony: Maintenance: Support: Divorce settlement: Property settlement:$0.00

$0.00

$0.00

$0.00

$0.00

30. Other amounts someone owes you

No

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

Yes. Give specific information

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

31. Interests in insurance policies

NoYes. Name the insurance Company name: Beneficiary:

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

Surrender or refund value: company of each policy and list its value................ 32. Any interest in property that is due you from someone who has died

No

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

Yes. Give specific information

entitled to receive property because someone has died

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

No Examples: Accidents, employment disputes, insurance claims, or rights to sue

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

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

No

rights to set off claims

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

35. Any financial assets you did not already list

NoYes. 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....................................................................................................................... $2.00

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.

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

38. Accounts receivable or commissions you already earned

NoYes. Describe................

Current value of the portion you own?

Do not deduct secured

claims or exemptions.

39. Office equipment, furnishings, and supplies

NoYes. Describe................

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

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

41. Inventory

NoYes. Describe................

42. Interests in partnerships or joint ventures NoYes. Describe........N..a..m...e. of entity: % of ownership: 43. Customer lists, mailing lists, or other compilations NoYes. Do your lists include personally identifiable information (as defined in 11 U.S.C. § 101(41A))?

NoYes. Describe..............

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

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

attached for Part 5. Write that number here....................................................................................................................... $0.00

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

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.

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

47. Farm animals

NoYes............................

Examples: Livestock, poultry, farm-raised fish

Current value of the portion you own?

Do not deduct secured

claims or exemptions.

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

48. Crops--either growing or harvested

NoYes. Give specific

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

50. Farm and fishing supplies, chemicals, and feed

NoYes..............................

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

NoYes. Give specific

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

attached for Part 6. Write that number here....................................................................................................................... $0.00

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

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

NoYes. Give specific information.

Examples: Season tickets, country club membership

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

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

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

56. Part 2: Total vehicles, line 5

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

58. Part 4: Total financial assets, line 36

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

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

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

62. Total personal property.

63. Total of all property on Schedule A/B.

Add lines 56 through 61................................. Copy personal

property total

+

+

Add line 55 + line 62.......................................................................................................

$96,000.00

$10,000.00

$1,300.00

$2.00

$0.00

$0.00

$0.00

$11,302.00 $11,302.00

$107,302.00

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

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Official Form 106C

Schedule C: The Property You Claim as Exempt 04/16

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

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).

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)

Check if this is an

amended filing

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.

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

Copy the value from

Schedule A/B

Amount of the

exemption you claim

Check only one box for each exemption

Current value of Specific laws that allow exemption

the portion you

own

Brief description:

Line from Schedule A/B: 1.1

$96,000.00 $14,966.50

361 Vita Drive, Wheeling

50% owner

735 ILCS 5/12-901

100% of fair market value, up to any applicable statutory

limit

Brief description:

Line from Schedule A/B: 3.1

$10,000.00 $0.00

2012 Volkswagen Gti (approx. 85000

miles)

735 ILCS 5/12-1001(c)

100% of fair market value, up to any applicable statutory

limit

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

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

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

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

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Debtor 1

First Name Middle Name Last Name Case number (if known)

Part 2: Additional Page

Brief description of the property and line on Schedule A/B that lists this property

Copy the value from

Schedule A/B

Toms Ziemelis

Amount of the

exemption you claim

Check only one box for each exemption

Current value of Specific laws that allow exemption

the portion you

own

Brief description:

Line from Schedule A/B: 6

$1,000.00 $1,000.00

ordinary furniture and electronics

735 ILCS 5/12-1001(b)

100% of fair market value, up to any applicable statutory

limit

Brief description:

Line from Schedule A/B: 11

$300.00 $300.00

necessary clothing

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

100% of fair market value, up to any applicable statutory

limit

Brief description:

Line from Schedule A/B: 17.1

$2.00 $2.00

2 Checking accounts Chase

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 2

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Official Form 106D

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

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.

Check if this is an

amended filing

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

correct information. If more space is needed, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any additional pages, write your name and case number (if known).

Part 1: List All Secured Claims

2. List all secured claims. If a creditor has more than one secured

Column A Column B Column C

Amount of claim Value of collateral Unsecured

portion

If any

that supports this

claim

Do not deduct the

value of collateral

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.

2.1 Describe the property that secures the claim: Creditor's name Number Street

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

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

Bank of America

Attn: Bankruptcy Department

475 Cross Point Pkwy

Getzville NY 14068-9000

02/28/2015

$15,023.00 $10,000.00 $5,023.00

3 7 6 9

PO Box 9000

2012 Volkswagen Gti (approx. 85000 miles)

auto loan

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

$15,023.00

Add the dollar value of your entries in Column A on this page. Write

that number here:

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Part 1:

Additional Page Column A Column B Column C

Amount of claim Value of collateral Unsecured

portion

If any

that supports this

claim

Do not deduct the

value of collateral

Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

After listing any entries on this page, number them

sequentially from the previous page.

2.2 Describe the property that secures the claim: Creditor's name Number Street

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

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

Pennymac Loan Services

3043 Townsgate Rd, Suite 200

Westlake Village CA 91361

04/30/2015

$162,067.00 $96,000.00 $66,067.00

0 3 6 1

361 Vita Drive, Wheeling

first mortgage

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

$162,067.00

$177,090.00

Add the dollar value of your entries in Column A on this page. Write

that number here:

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

all pages. Write that number here:

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Official Form 106E/F

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

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

No. Go to Part 2. Yes.

Check if this is an

amended filing

on Schedule A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases 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).

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

Part 1: List All of Your PRIORITY Unsecured Claims

(Official Form 106G).

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

Total claim Priority

amount

Nonpriority

amount

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

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 more space is needed for 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.

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

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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

Part 2: List All of Your NONPRIORITY Unsecured Claims

Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim.

Total 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 more space is needed for nonpriority unsecured claims, fill out the Continuation Page of Part 2.

4.1

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

American Express

PO Box 981535

El Paso TX 79998-1535

$3,360.00

5 0 2 0

12/2010

Credit Card

4.2

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Bank of America

Attn: Bankruptcy Department

475 Cross Point Pkwy

Getzville NY 14068-9000

$1,964.00

x x x 1

02/2014

PO Box 9000

Credit Card

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

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Debtor 1

First Name Middle Name Last Name Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the previous page.

Toms Ziemelis

4.3

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Capital One Bank

PO Box 26074

Richmond VA 23260-0000

$1,750.00

0 5 9 2

05/2010

Credit Card

4.4

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

CBNA

PO Box 6497

Sioux Falls SD 57117-6497

$700.00

7 1 2 3

07/2012

Credit Card

4.5

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Chase

800 Brooksedge Boulevard

Westerville OH 43081-0000

$5,000.00

8 4 1 4

12/2014

Credit Card

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

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Debtor 1

First Name Middle Name Last Name Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the previous page.

Toms Ziemelis

4.6

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Citibank

PO Box 6241

Sioux Falls SD 57117-6241

$5,282.00

0 0 3 8

11/2012

Credit Card

4.7

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

City of Chicago EMS

33589 Treasury Center

Chicago IL 60694

$180.00

9 2 4 5

01/24/2016

medical

4.8

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Direct TV

PO Box 9001069

Louisville KY 40290-1069

$521.00

6 2 5 0

year 2016

cable television

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

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Debtor 1

First Name Middle Name Last Name Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the previous page.

Toms Ziemelis

4.9

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Discover Financial Services

PO Box 15316

Wilmington DE 19850-5316

$6,156.00

0 0 2 7

06/2011

Credit Card

4.10

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Macy's Bankruptcy Processing

PO Box 8053

Mason OH 45040-0000

$800.00

7 1 3 6

05/2011

Credit Card

4.11

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Syncb/Sam's Club

PO Box 965005

Orlando FL 32896

$2,543.00

n o w n

year 2016

Credit Card

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

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Debtor 1

First Name Middle Name Last Name Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim

After listing any entries on this page, number them sequentially from the previous page.

Toms Ziemelis

4.12

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Synchrony Bank

PO Box 965007

Orlando FL 32896-5007

$2,000.00

9 9 2 2

10/2010

Credit Card

4.13

Last 4 digits of account number Nonpriority Creditor's Name Number Street

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?

NoYes

When was the debt incurred?

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

that you did not report as priority claims

Synchrony Bank

PO Box 965007

Orlando FL 32896-5007

$1,500.00

6 2 0 1

03/2016

Credit Card

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

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

5.

Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

Name Number Street

City State ZIP Code

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

Line of (Check one): Part 1: Creditors with Priority Unsecured Claims Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

CBNA

PO Box 6497

Sioux Falls SD 57117-6497

4.6

Name Number Street

City State ZIP Code

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

Line of (Check one): Part 1: Creditors with Priority Unsecured Claims Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

DSNB

PO Box 8218

Mason OH 45040

4.10

Name Number Street

City State ZIP Code

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

Line of (Check one): Part 1: Creditors with Priority Unsecured Claims Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number

Nationwide Credit, Inc. 2015 Vaughn Rd., NW, Ste 400

Kennesaw GA 30144-7802

4.1

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

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

6.

6a. Domestic support obligations

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

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

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

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

6a.

Total claim

6b.

6c.

6d.

6d.

+

6f. Student loans

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

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

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

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

6f.

Total claim

6g.

6h.

6i.

6j.

+

that you did not report as priority claims

debts

Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$31,756.00

$31,756.00

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

Total claims

from Part 1

Total claims

from Part 2

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 8

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Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

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

Check if this is an

amended filing

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

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).

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

is for (for example, rent, vehicle lease, cell phone). See the instructions for this form in the instruction booklet for more examples of executory contracts and unexpired leases. Person or company with whom you have the contract or lease State what the contract or lease is for

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

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Official Form 106H

Schedule H: Your Codebtors 12/15

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

1. Do you have any codebtors?

NoYes

Check if this is an

amended filing

(If you are filing a joint case, do not list either spouse as a codebtor.)

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.

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?

NoYes 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:

Name Number Street

City State ZIP Code

3.1 Schedule D, line Schedule E/F, line Schedule G, line

Nelli Zavalova

361 Vita Drive

Wheeling IL 60090 Pennymac Loan Services

2.2

Official Form 106H Schedule H: Your Codebtors page 1

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Official Form 106I

Schedule I: Your Income 12/15

Part 1: Describe Employment

1.

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

An amended filing

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

Fill in your employment

Check if this is:

A supplement showing postpetition

chapter 13 income as of the following date: MM / DD / YYYY

information. Employment status

Occupation

Employer's name

Employer's address

How long employed there?

Debtor 1 Debtor 2 or non-filing spouse Employed

Not employed

Employed

Not employed

Number Street Number Street

City State Zip Code City State Zip Code

unemployed

1 year

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.

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.

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.

2. List monthly gross wages, salary, and commissions

For Debtor 1 For Debtor 2 or non-filing spouse

(before all

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

2. $0.00 would be.

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.

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

4. Calculate gross income. Add line 2 + line 3. 4. $0.00

Official Form 106I Schedule I: Your Income page 1

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

For Debtor 1 For Debtor 2 or non-filing spouse

4. $0.00

5. List all payroll deductions: 5a. Tax, Medicare, and Social Security deductions 5a. 5b. Mandatory contributions for retirement plans 5b. 5c. Voluntary contributions for retirement plans 5c. 5d. Required repayments of retirement fund loans 5d. 5e. Insurance 5e. 5f. Domestic support obligations 5f. 5g. Union dues 5g.

5h. 5h. Other deductions. Specify: +

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e + 5f + 6. $0.00

5g + 5h. 7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $0.00

8. List all other income regularly received: 8a. 8a.

8b. Interest and dividends 8b. 8c. 8c.

8d. Unemployment compensation 8d.

8f.

8f. 8e. Social Security 8e. Other government assistance that you regularly receive

Specify:

8h. 8h. 8g. Pension or retirement income 8g. Other monthly income. Specify: +

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

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.

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.

Include cash assistance and the value (if known) or any non- cash assistance that you receive, such as food stamps

(benefits under the Supplemental Nutrition Assistance Program) or housing subsidies.

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

10. Calculate monthly income. Add line 7 + line 9. 10. Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse. $0.00 + = $0.00

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

Specify: 11. + $0.00

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.

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

income. Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, Combined monthly income

$0.00

if it applies.

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

No. Yes. Explain: none at this point, debtor is unemployed and is fully supported by his mother.

Official Form 106I Schedule I: Your Income page 2

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Official Form 106J

Schedule J: Your Expenses 12/15

Part 1: Describe Your Household

1.

An amended filing

Is this a joint case?

Check if this is:

A supplement showing postpetition

chapter 13 expenses as of the

following date: MM / DD / YYYY

No. Go to line 2. Yes. NoYes. Debtor 2 must file Official Form 106J-2, Expenses for Separate Household of Debtor 2.

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

Does Debtor 2 live in a separate household?

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.

2. Do you have dependents? NoYes. Fill out this information

for each dependent................................... Dependent's relationship to Debtor 1 or Debtor 2

Dependent's

age Does dependentlive with you?

NoYes NoYes NoYes NoYes NoYes

Do not list Debtor 1 and

Debtor 2. Do not state the dependents' names.

3. NoYes Do your expenses include

expenses of people other than

yourself and your dependents?

Part 2: Estimate Your Ongoing Monthly Expenses

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.

If not included in line 4: 4a. Real estate taxes 4b. Property, homeowner's, or renter's insurance

4c. Home maintenance, repair, and upkeep expenses 4d. Homeowner's association or condominium dues

4a. 4b. 4c. 4d.

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.)

Official Form 106J Schedule J: Your Expenses page 1

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

Your expenses

5. Additional mortgage payments for your residence, such as home equity loans 5. 6. Utilities: 6a. Electricity, heat, natural gas 6b. Water, sewer, garbage collection

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

6d. Other. Specify:

6a. 6b. 6c.

6d.

cable services

7. Food and housekeeping supplies 7. 8. Childcare and children's education costs 8. 9. Clothing, laundry, and dry cleaning 9. 10. Personal care products and services 10. 11. Medical and dental expenses 11. 12. Transportation. Include gas, maintenance, bus or train 12.

fare. Do not include car payments. 13. Entertainment, clubs, recreation, newspapers, 13. magazines, and books

14. Charitable contributions and religious donations 14. 15. Insurance.

15a. Life insurance

15b. Health insurance

15c. Vehicle insurance

15d. Other insurance. Specify:

15a. 15b. 15c. 15d.

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

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

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

17b. Car payments for Vehicle 2

17c. Other. Specify: 17d. Other. Specify:

17a. 17b. 17c. 17d. 18. Your payments of alimony, maintenance, and support that you did not report as 18. deducted from your pay on line 5, Schedule I, Your Income (Official Form 106I).

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

Official Form 106J Schedule J: Your Expenses page 2

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

20a. Mortgages on other property

20b. Real estate taxes 20c. Property, homeowner's, or renter's insurance

20d. Maintenance, repair, and upkeep expenses

20a. 20b. 20c. 20d.

Schedule I: Your Income.

20e. Homeowner's association or condominium dues 20e. 21. Other. Specify: 21. +

22. Calculate your monthly expenses. 22a. Add lines 4 through 21. 22b. Copy line 22 (monthly expenses for Debtor 2), if any, from Official Form 106J-2. 22c. Add line 22a and 22b. The result is your monthly expenses. 22c.

$0.00

$0.00

22a. 22b.

23. Calculate your monthly net income. 23a. Copy line 12 (your combined monthly income) from Schedule I. 23b. Copy your monthly expenses from line 22c above. 23c. Subtract your monthly expenses from your monthly income.

23a. 23b.

The result is your monthly net income. 23c.

–

$0.00

$0.00

$0.00

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

No. Yes. Explain here:

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?

none at this point, debtor is unemployed and is fully supported by his mother.

Official Form 106J Schedule J: Your Expenses page 3

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Official Form 106Sum

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

Part 1: Summarize Your Assets

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

1a.

1b.

1c.

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

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

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

Check if this is an

amended filing

$96,000.00

$11,302.00

$107,302.00

Your assets Value of what you own

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 2: Summarize Your Liabilities

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

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

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

3a.

3b.

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

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

Your total liabilities

2a. $177,090.00

$0.00

$31,756.00

$208,846.00

Your liabilities Amount you owe

Part 3: Summarize Your Income and Expenses

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

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

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

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

$0.00

$0.00

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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.

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. $0.00

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

Total claim

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

9a.

9b.

Domestic support obligations. (Copy line 6a.)

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

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

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

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

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

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

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

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

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Official Form 106Dec

Declaration About an Individual Debtor's Schedules 12/15

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

Check if this is an

amended filing

Sign Below

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

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

X /s/ Toms Ziemelis X

Toms Ziemelis, Debtor 1 Signature of Debtor 2

Date MM / DD / YYYYDate MM / DD / YYYY

08/31/2016

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.

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.

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

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Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy 04/16

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

1. What is your current marital status?

Married

Not married

Check if this is an

amended filing

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

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.

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

NoYes. 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?

NoYes. Make sure you fill out

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

Schedule H: Your Codebtors (Official Form 106H).

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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?

NoYes. Fill in the details.

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.

Operating a business

For the last calendar year:

(January 1 to December 31, YYYY) Operating a business

Operating a business

For the calendar year before that:

(January 1 to December 31, YYYY)

Operating a business

Operating a business

Operating a business

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

2015

2014

$9,109.00

$24,195.00

Wages, commissions, bonuses, tips From January 1 of the current year until

the date you filed for bankruptcy:

Wages, commissions, bonuses, tips

Wages, commissions, bonuses, tips

Wages, commissions, bonuses, tips

Wages, commissions, bonuses, tips

Wages, commissions, bonuses, tips

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

NoYes. Fill in the details.

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 in 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.

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

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

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

"incurred by an individual primarily for a personal, family, or household purpose." During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,425* or more?

No. Go to line 7. Yes.

* Subject to adjustment on 4/01/19 and every 3 years after that for cases filed on or after the date of adjustment. Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts. During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more?

No. Go to line 7. Yes.

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

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

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

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;

NoYes. List all payments to an insider.

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.

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?

NoYes. List all payments that benefited an insider.

Include payments on debts guaranteed or cosigned by 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?

NoYes. Fill in the details.

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

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

No. Go to line 11. Yes. Fill in the information below.

seized, or levied?

Check all that apply and fill in the details below.

11.

NoYes. Fill in the details.

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?

12.

NoYes

Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of creditors, a court-appointed receiver, a custodian, or another official?

Part 5: List Certain Gifts and Contributions

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

NoYes. Fill in the details for each gift. 14.

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

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?

Part 6: List Certain Losses

15.

NoYes. Fill in the details.

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?

Part 7: List Certain Payments or Transfers

16.

NoYes. Fill in the details.

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

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?

Description and value of any property transferred Date payment or transfer was Amount of

Person Who Was Paid

Number Street

City State ZIP Code

Email or website address

Person Who Made the Payment, if Not You

payment Gromov Law Offices

May 2016 $600.00

August 2016

debtor's mother

made

$935.00

legal and filing fee

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

Description and value of any property transferred Date payment or transfer was Amount of

Person Who Was Paid

Number Street

City State ZIP Code

Email or website address

Person Who Made the Payment, if Not You

payment Summit Financial

$10.00 made counseling

17.

NoYes. Fill in the details.

Do not include any payment or transfer that you listed on line 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 who promised to help you deal with your creditors or to make payments to your creditors?

18.

NoYes. Fill in the details.

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 granting of a security interest or mortgage on your property). Do not include gifts and transfers that you have already listed on this statement.

Description and value of any Date transfer was made Person Who Received Transfer

Number Street

City State ZIP Code

property transferred

Describe any property or payments

received or debts paid in exchange Pawn Shop

May 20, 2016

Person's relationship to you

gold chain, received $1,200

19.

NoYes. Fill in the details.

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.)

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

20.

NoYes. Fill in the details.

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.

21.

NoYes. Fill in the details.

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?

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

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

23.

NoYes. Fill in the details.

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.

Part 10: Give Details About Environmental Information

For the purpose of Part 10, the following definitions apply: means any federal, state, or local statute or regulation concerning pollution, contamination, releases of

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

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

Environmental law

Site

Hazardous material

hazardous or toxic substance, 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.

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

substance, hazardous material, pollutant, contaminant, or similar item. Report all notices, releases, and proceedings that you know about, regardless of when they occurred.

24.

NoYes. Fill in the details.

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

law?

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

25. NoYes. Fill in the details.Have you notified any governmental unit of any release of hazardous material?

26.

NoYes. Fill in the details.

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

orders.

27.

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)

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

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.

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

business?

Business Name

Number Street

City State ZIP Code

Describe the nature of the business Employer Identification number

Name of accountant or bookkeeper

Do not include Social Security number or ITIN. EIN: – Dates business existed

From To

T & T Transit, Inc.

04/26/2010 june 2015

trucking

28.

NoYes. Fill in the details below.

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.

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

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

X /s/ Toms Ziemelis X

Toms Ziemelis, Debtor 1 Signature of Debtor 2

Date Date

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

NoYes

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

NoYes. Name of person Attach the Bankruptcy Petition Preparer's Notice, Declaration, and Signature (Official Form 119).

08/31/2016

that 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.

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

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Official Form 108

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name United States Bankruptcy Court for the: Case number

(if known)

Toms Ziemelis

NORTHERN DISTRICT OF ILLINOIS

Part 1: List Your Creditors Who Hold Secured Claims

1. For any creditors that you listed in Part 1 of Schedule D: Creditors Who Hold Claims Secured by Property

If you are an individual filing under chapter 7, you must fill out this form if: creditors have claims secured by your property, or you have leased personal property and the lease has not expired.

(Official Form 106D), fill in the information below.

Identify the creditor and the property that is collateral What do you intend to do with the property that secures a debt?Did you claim the property

as exempt on Schedule C?

Check if this is an

amended filing

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

of creditors, whichever is earlier, unless the court extends the time for cause. You must also send copies to the creditors

and lessors you list on the form.

If two married people are filing together in a joint case, both are equally responsible for supplying correct information. Both debtors must sign and date the form. Be as complete and accurate as possible. If more space is needed, attach a separate sheet to this form. On the top of any

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

Creditor's name: Description of

property

securing debt:

Surrender the property. Retain the property and redeem it. Retain the property and enter into a Reaffirmation Agreement. Retain the property and [explain]:NoYes Bank of America

2012 Volkswagen Gti (approx. 85000

miles)

Debtor will continue making payments to creditor without

reaffirming.

Creditor's name: Description of

property

securing debt:

Surrender the property. Retain the property and redeem it. Retain the property and enter into a Reaffirmation Agreement. Retain the property and [explain]:NoYes Pennymac Loan Services

361 Vita Drive, Wheeling

debtor does not reside in, and does not pay for this

property.

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

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Debtor 1

First Name Middle Name Last Name Toms Ziemelis Case number (if known)

Part 2: List Your Unexpired Personal Property Leases

For any unexpired personal property lease that you listed in Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G), fill in the information below. Do not list real estate leases. Unexpired leases are leases that are still in effect; the lease period has not

yet ended. You may assume an unexpired personal property lease if the trustee does not assume it. 11 U.S.C. § 365(p)(2). Describe your unexpired personal property leases Will this lease be assumed?

None.

Part 3: Sign Below

X /s/ Toms Ziemelis X

Toms Ziemelis, Debtor 1 Signature of Debtor 2

Date MM / DD / YYYYDate MM / DD / YYYY

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

personal property that is subject to an unexpired lease.

08/31/2016

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

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

Individuals Filing for Bankruptcy (Form 2010)

This notice is for you if:

You are an individual filing for bankruptcy, and

Your debts are primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8)

as "incurred by an individual primarily for a

personal, family, or household purpose."

Chapter 7 -- Liqudation

Chapter 11 -- Reorganization

Chapter 12 --

Chapter 13 --

Chapter 7: Liquidation

+

most taxes;

most student loans;

domestic support and property settlement obligations;

The types of bankruptcy that are available

to individuals

Individuals who meet the qualifications may file under one

of four different chapters of the Bankruptcy Code:

Voluntary repayment plan for family

farmers or fishermen

Voluntary repayment plan for

individuals with regular income

You should have an attorney review your

decision to file for bankruptcy and the choice

of chapter.

$245

$75

$15

filing fee

administrative fee

trustee surcharge

Chapter 7 is for individuals who have financial difficulty

preventing them from paying their debts and who are

willing to allow their non-exempt property to be used to

pay their creditors. The primary purpose of filing under

chapter 7 is to have your debts discharged. The

bankruptcy discharge relieves you after bankruptcy from

having to pay many of your pre-bankruptcy debts. Exceptions exist for particular debts, and liens on

property may still be enforced after discharge. For

example, a creditor may have the right to foreclose a

home mortgage or repossess an automobile. However, if the court finds that you have committed

certain kinds of improper conduct described in the

Bankruptcy Code, the court may deny your discharge. You should know that the even if you file chapter 7 and

you receive a discharge, some debts are not discharged

under the law. Therefore, you may still be responsible to

pay:

$335 total fee

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 1

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Chapter 11: Reorganization

+

fraud or theft;

intentional injuries that you inflicted; and

Chapter 7 Statement of Your Current Monthly

Chapter 7 Means Test Calculation (Official Form

Chapter 7 Means Test Calculation

If your income is above the median for your state, you must

file a second form--the

(Official Form 122A-2). The calculations on the form-- sometimes called the Means Test-- deduct from your

income living expenses and payments on certain debts to

determine any amount available to pay unsecured

Means Test, the U.S. trustee,

called exempt property.

must list it on Schedule C: The Property You Claim as

must file

Income (Official Form 122A-1) if you are an individual filing

the

122A-2).

creditors. If your income is more than the median income

for your state of residence and family size, depending

on the results of the

Exemptions may enable you to

Exempt (Official Form 106C). If you do not list the

most fines, penalties, forfeitures, and criminal

restitution obligations; and

certain debts that are not listed in your bankruptcy

papers.

$1,167

$550

filing fee

administrative fee

If your debts are primarily consumer debts, the court can

dismiss your chapter 7 case if it finds that you have

enough income to repay creditors a certain amount. You

You may also be required to pay debts arising from:

fraud or defalcation while acting in breach of fiduciary

capacity;

death or personal injury caused by operating a motor

vehicle, vessel, or aircraft while intoxicated from

alcohol or drugs.

for bankruptcy under chapter 7. This form will determine

your current monthly income and compare whether your

income is more than the median income that applies in

your state.

If your income is not above the median for your state, you will not have to complete the other chapter 7 form,

bankruptcy administrator, or creditors can file a motion to

dismiss your case under § 707(b) of the Bankruptcy

Code. If a motion is filed, the court will decide if your

case should be dismissed. To avoid dismissal, you may

choose to proceed under another chapter of the

Bankruptcy Code.

If you are an individual filing for chapter 7 bankruptcy, the

trustee may sell your property to pay your debts, subject

to your right to exempt the property or a portion of the

proceeds from the sale of the property. The property, and the proceeds from property that your bankruptcy

trustee sells or liquidates that you are entitled to, is

keep your home, a car, clothing, and household items or

to receive some of the proceeds if the property is sold. Exemptions are not automatic. To exempt property, you

property, the trustee may sell it and pay all of the

proceeds to your creditors.

Chapter 11 is often used for reorganizing a business, but

is also available to individuals. The provisions of chapter

11 are too complicated to summarize briefly.

$1,717 total fee

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 2

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Read These Important Warnings

Chapter 12: Repayment plan for family farmers

+

or fishermen

Chapter 13: Repayment plan for individuals with

+

regular income

domestic support obligations, most student loans, certain taxes, debts for fraud or theft,

most criminal fines and restitution obligations,

certain long-term secured debts.

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

your property, you should hire an attorney and carefully consider all of your options before you file. Only an attorney can give you legal advice about what can happen as a result of filing for bankruptcy

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

properly and protect you, your family, your home, and your possessions. Although the law allows you to represent yourself in bankruptcy court, you should understand that

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

mistake or inaction may harm you. If you file without an attorney, you are still responsible for

knowing and following all of the legal requirements. You should not file for bankruptcy if you are not eligible to file or if you do not intend to file the

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

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

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

to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

$200

$75

filing fee

administrative fee

Similar to chapter 13, chapter 12 permits family farmers

and fishermen to repay their debts over a period of time

using future earnings and to discharge some debts that

are not paid.

$235

$75

filing fee

administrative fee

Chapter 13 is for individuals who have regular income

and would like to pay all or part of their debts in

installments over a period of time and to discharge

some debts that are not paid. You are eligible for

chapter 13 only if your debts are not more than certain

dollar amounts set forth in 11 U.S.C. § 109.

Under chapter 13, you must file with the court a plan to

repay your creditors all or part of the money that you owe

them, usually using your future earnings. If the court

approves your plan, the court will allow you to repay your

debts, as adjusted by the plan, within 3 years or 5 years, depending on your income and other factors. After you make all the payments under your plan, many

of your debts are discharged. The debts that are not

discharged and that you may still be responsible to pay

include:

debts for fraud or defalcation while acting in a

fiduciary capacity,

certain debts that are not listed in your bankruptcy

papers,

certain debts for acts that caused death or personal

injury, and

$275

$310

total fee

total fee

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 3

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The bankruptcy court sends notices to the mailing address

Warning: File Your Forms on Time

you list onVoluntary Petition for Individuals Filing for

Bankruptcy (Official Form 101). To ensure you receive

A married couple may file a bankruptcy case together--

joint case. If you file a joint case and each

before you file your bankruptcy petition. This

In Alabama and North Carolina, go to:

called a

days

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

that you promptly file detailed information about

your creditors, assets, liabilities, income, expenses

and general financial condition. The court may

dismiss your bankruptcy case if you do not file this

information within the deadlines set by the

Bankruptcy Code, the Bankruptcy Rules, and local

rules of the court. For more information about the documents and

their deadlines, go to:

spouse lists the same mailing address on the

bankruptcy petition, the bankruptcy court generally will

mail you and your spouse one copy of each notice, unless you file a statement with the court asking that

each spouse receive separate copies.

If you knowingly and fraudulently conceal assets or

make a false oath or statement under penalty of

perjury--either orally or in writing--in connection with

a bankruptcy case, you may be fined, imprisoned, or

both.

All information you supply in connection with a

bankruptcy case is subject to examination by the

Attorney General acting through the Office of the

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

other offices and employees of the U.S. Department

of Justice.

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

.html#procedure.

Bankruptcy crimes have serious

consequences

Make sure the court has your mailing

address

information about your case, Bankruptcy Rule 4002

requires that you notify the court of any changes in your

address.

Understand which services you could

receive from credit counseling agencies

The law generally requires that you receive a credit

counseling briefing from an approved credit counseling

agency. 11 U.S.C. § 109(h). If you are filing a joint

case, both spouses must receive the briefing. With

limited exceptions, you must receive it within the 180

briefing is usually conducted by telephone or on the

Internet.

In addition, after filing a bankruptcy case, you generally

must complete a financial management instructional

course before you can receive a discharge. If you are

filing a joint case, both spouses must complete the

course. You can obtain the list of agencies approved to provide

both the briefing and the instructional course from:

http://justice.gov/ust/eo/hapcpa/ccde/cc_approved.html.

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

ptcyResources/ApprovedCreditAndDebtCounselors.aspx.

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

bankruptcy court may be able to help you obtain the list.

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 4

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS

EASTERN DIVISION (CHICAGO)

In re Case No. Chapter 7

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

B2030 (Form 2030) (12/15)

Toms Ziemelis

1.

For legal services, I have agreed to accept......................................................................................................... Prior to the filing of this statement I have received............................................................................................. Balance Due..............................................................................................................................................................$1,200.00

$0.00

$1,200.00

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:

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

Debtor Other (specify)

mother

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 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.

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

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

bankruptcy;

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

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

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B2030 (Form 2030) (12/15)

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

CERTIFICATION

Date

08/31/2016 /s/ Igor Gromov

Igor Gromov

/s/ Toms Ziemelis Toms Ziemelis

Bar No. 6282530

Gromov Law Offices

1020 N. Milwaukee Ave., Ste. 101

Deerfield, IL 60015

Phone: (847) 845-1779 / Fax: (888) 415-7687

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.

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS

EASTERN DIVISION (CHICAGO)

IN RE: CASE NO

CHAPTER 7

VERIFICATION OF CREDITOR MATRIX

Toms Ziemelis

The above named Debtor hereby verifies that the attached list of creditors is true and correct to the best of his/her

knowledge.

Date

Date

Signature

Signature

8/31/2016 /s/ Toms Ziemelis Toms Ziemelis

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