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

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 12/15

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

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

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

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

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

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

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

(if known). Answer every question.

Part 1: Identify Yourself

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

1. Your full name

Write the name that is on your 

government-issued picture 

identification (for example, 

your driver’s license or 

passport). 

Bring your picture 

identification to your meeting 

with the trustee.

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

___________________________

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

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

___________________________

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

2. All other names you 

have used in the last 8 

years

Include your married or 

maiden names.

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

3. Only the last 4 digits of 

your Social Security 

number or federal 

Individual Taxpayer 

Identification number

(ITIN)

xxx – xx – ____ ____ ____ ____

OR

9 xx – xx – ____ ____ ____ ____

xxx – xx – ____ ____ ____ ____

OR

9 xx – xx – ____ ____ ____ ____

United States Bankruptcy Court for the:

___________________________________________

Case number (If known): _________________________ Chapter you are filing under:

 Chapter 7 

 Chapter 11

 Chapter 12

 Chapter 13

 Fill in this information to identify your case:

 Check if this is an 

amended filing

X

Jill

Heftrig

M

8 2 7 8

Northern District Of Illinois

Jill

Heathy

M

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

4. Any business names 

and Employer 

Identification Numbers 

(EIN) you have used in 

the last 8 years

Include trade names and 

doing business as names

 I have not used any business names or EINs.

_________________________________________________

Business name

_________________________________________________

Business name

___ ___ – ___ ___ ___ ___ ___ ___ ___

EIN

___ ___ – ___ ___ ___ ___ ___ ___ ___

EIN

 I have not used any business names or EINs.

_________________________________________________

Business name

_________________________________________________

Business name

___ ___ – ___ ___ ___ ___ ___ ___ ___

EIN

___ ___ – ___ ___ ___ ___ ___ ___ ___

EIN

5. Where you live

_________________________________________________

Number Street

_________________________________________________

_________________________________________________

City State ZIP Code 

_________________________________________________

County

If your mailing address is different from the one 

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

any notices to you at this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________

City State ZIP Code 

If Debtor 2 lives at a different address:

_________________________________________________

Number Street

_________________________________________________

_________________________________________________

City State ZIP Code 

_________________________________________________

County

If Debtor 2’s mailing address is different from 

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

any notices to this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________

City State ZIP Code

6. Why you are choosing 

this district to file for 

bankruptcy 

Check one:

 Over the last 180 days before filing this petition, 

I have lived in this district longer than in any 

other district.

 I have another reason. Explain. 

(See 28 U.S.C. § 1408.)

________________________________________

________________________________________

________________________________________

________________________________________

Check one:

 Over the last 180 days before filing this petition, 

I have lived in this district longer than in any 

other district.

 I have another reason. Explain. 

(See 28 U.S.C. § 1408.)

________________________________________

________________________________________

________________________________________

________________________________________

X

X

Belvidere IL 61008

BOONE

Jill M Heftrig

1012 S Main St

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the 

Bankruptcy Code you 

are choosing to file 

under

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

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

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

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

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

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

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

with a pre-printed address.

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

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

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

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

less than 150% of the official poverty line that applies to your family size and you are unable to 

pay the fee in installments). If you choose this option, you must fill out the Application to Have the

Chapter 7 Filing Fee Waived (Official Form 103B) and file it with your petition.

9. Have you filed for 

bankruptcy within the 

last 8 years?

 No

 Yes. District __________________________ When _______________ Case number ___________________________

MM / DD / YYYY

District __________________________ When _______________ Case number ___________________________

MM / DD / YYYY

District __________________________ When _______________ Case number ___________________________

MM / DD / YYYY

10. Are any bankruptcy 

cases pending or being 

filed by a spouse who is 

not filing this case with

you, or by a business 

partner, or by an 

affiliate?

 No

 Yes. Debtor _________________________________________________ Relationship to you _____________________

District __________________________ When _______________ Case number, if known____________________

MM / DD / YYYY

Debtor _________________________________________________ Relationship to you _____________________

District __________________________ When _______________ Case number, if known____________________

MM / DD / YYYY

11. Do you rent your 

residence?

 No. Go to line 12.

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

residence?

 No. Go to line 12.

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

this bankruptcy petition.

X

X

X

X

X

X

Jill M Heftrig

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

12. Are you a sole proprietor

of any full- or part-time 

business?

A sole proprietorship is a 

business you operate as an 

individual, and is not a 

separate legal entity such as 

a corporation, partnership, or 

LLC.

If you have more than one 

sole proprietorship, use a 

separate sheet and attach it 

to this petition.

 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

13. Are you filing under 

Chapter 11 of the 

Bankruptcy Code and 

are you a small business 

debtor?

For a definition of small 

business debtor, see

11 U.S.C. § 101(51D).

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

can set appropriate deadlines. If you indicate that you are a small business debtor, you must attach your 

most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or if 

any of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B).

 No. I am not filing under Chapter 11.

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

the Bankruptcy Code.

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

Bankruptcy Code.

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

14. Do you own or have any 

property that poses or is 

alleged to pose a threat 

of imminent and 

identifiable hazard to 

public health or safety?

Or do you own any 

property that needs

immediate attention?

For example, do you own 

perishable goods, or livestock 

that must be fed, or a building 

that needs urgent repairs?

 No

 Yes. What is the hazard? ________________________________________________________________________

________________________________________________________________________

If immediate attention is needed, why is it needed? _______________________________________________

________________________________________________________________________

Where is the property? ________________________________________________________________________

Number Street

________________________________________________________________________

________________________________________ _______ ____________________

City State ZIP Code

X

X

X

Jill M Heftrig

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

15. Tell the court whether 

you have received

briefing about credit 

counseling.

The law requires that you 

receive a briefing about credit 

counseling before you file for 

bankruptcy. You must 

truthfully check one of the 

following choices. If you 

cannot do so, you are not 

eligible to file.

If you file anyway, the court 

can dismiss your case, you 

will lose whatever filing fee 

you paid, and your creditors 

can begin collection activities 

again.

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

You must check one:

 I received a briefing from an approved credit 

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a 

certificate of completion. 

Attach a copy of the certificate and the payment 

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

 I received a briefing from an approved credit 

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a 

certificate of completion. 

Within 14 days after you file this bankruptcy petition, 

you MUST file a copy of the certificate and payment 

plan, if any.

 I certify that I asked for credit counseling 

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver 

of the requirement. 

To ask for a 30-day temporary waiver of the 

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why 

you were unable to obtain it before you filed for 

bankruptcy, and what exigent circumstances 

required you to file this case.

Your case may be dismissed if the court is 

dissatisfied with your reasons for not receiving a 

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must 

still receive a briefing within 30 days after you file. 

You must file a certificate from the approved 

agency, along with a copy of the payment plan you 

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

may be dismissed.

Any extension of the 30-day deadline is granted 

only for cause and is limited to a maximum of 15 

days. 

 I am not required to receive a briefing about 

credit counseling because of:

 Incapacity. I have a mental illness or a mental 

deficiency that makes me

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I

reasonably tried to do so.

 Active duty. I am currently on active military 

duty in a military combat zone.

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

You must check one:

 I received a briefing from an approved credit 

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a 

certificate of completion. 

Attach a copy of the certificate and the payment 

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

 I received a briefing from an approved credit 

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a 

certificate of completion. 

Within 14 days after you file this bankruptcy petition, 

you MUST file a copy of the certificate and payment 

plan, if any.

 I certify that I asked for credit counseling 

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver 

of the requirement. 

To ask for a 30-day temporary waiver of the 

requirement, attach a separate sheet explaining 

what efforts you made to obtain the briefing, why 

you were unable to obtain it before you filed for 

bankruptcy, and what exigent circumstances 

required you to file this case.

Your case may be dismissed if the court is 

dissatisfied with your reasons for not receiving a 

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must 

still receive a briefing within 30 days after you file. 

You must file a certificate from the approved 

agency, along with a copy of the payment plan you 

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

may be dismissed.

Any extension of the 30-day deadline is granted 

only for cause and is limited to a maximum of 15 

days. 

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental 

deficiency that makes me

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I

reasonably tried to do so.

 Active duty. I am currently on active military 

duty in a military combat zone.

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

X

Jill M Heftrig

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 6: Answer These Questions for Reporting Purposes

16. What kind of debts do 

you have?

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

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

 No. Go to line 16b.

 Yes. Go to line 17.

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

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

 No. Go to line 16c.

 Yes. Go to line 17.

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

_______________________________________________________________

17. Are you filing under 

Chapter 7?

Do you estimate that after 

any exempt property is 

excluded and 

administrative expenses 

are paid that funds will be 

available for distribution 

to unsecured creditors?

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

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

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

 No

 Yes

18. How many creditors do 

you estimate that you 

owe?

 1-49

 50-99

 100-199

 200-999

 1,000-5,000

 5,001-10,000

 10,001-25,000

 25,001-50,000

 50,001-100,000

 More than 100,000

19. How much do you 

estimate your assets to 

be worth?

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million 

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

20. How much do you 

estimate your liabilities 

to be?

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion 

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

Part 7: Sign Below

For you

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

correct.

If I have chosen to file under Chapter 7, I am aware that I may proceed, if eligible, under Chapter 7, 11,12, or 13 

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

under Chapter 7.

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

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

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

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

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

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

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Executed on _________________ Executed on __________________

MM / DD / YYYY MM / DD / YYYY

X

s/Jill Hestrig

08/24/2016

X

X

X

X

X

Jill M Heftrig

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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. 

_________________________________ Date _________________

Signature of Attorney for Debtor MM / DD / YYYY

_________________________________________________________________________________________________

Printed name

_________________________________________________________________________________________________

Firm name

_________________________________________________________________________________________________

Number Street

_________________________________________________________________________________________________

______________________________________________________ ____________ ______________________________

City State ZIP Code 

Contact phone _____________________________________ Email address ______________________________

______________________________________________________ ____________

Bar number State

s/Laura L. McGarragan 08/24/2016

Laura L McGarragan

McGarragan Law Corp.

Rockford IL 61103

(815) 961-1111 Laura@McGarraganLaw.com

6199753 IL

Jill M Heftrig

1004 N. Main Street

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

Official Form 106A/B

Schedule A/B: Property 12/15

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

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

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

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

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

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

 No. Go to Part 2.

 Yes. Where is the property?

 

1.1. _________________________________________

Street address, if available, or other description

_________________________________________

_________________________________________

City State ZIP Code 

_________________________________________

County

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: _______________________________

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

1.2. ________________________________________

Street address, if available, or other description

________________________________________

________________________________________

City State ZIP Code 

________________________________________

County

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: _______________________________

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

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

 Check if this is an 

amended filing

Jill M Heftrig

X

Northern District of Illinois

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

1.3. ________________________________________

Street address, if available, or other description

________________________________________

________________________________________

City State ZIP Code 

________________________________________

County

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: _______________________________

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

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

$_________________

Part 2: Describe Your Vehicles

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

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

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

 No

 Yes

3.1. Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

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

3.2. Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

Jill M Heftrig

X

Kia

Sportage

2013

60000

16,135.00 16,135.00

X

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 Document Page 9 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

3.3. Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

3.4. Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

$________________

Current value of the 

portion you own?

$________________

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

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

 No

 Yes

4.1. Make: ____________________

Model: ____________________

Year: ____________

Other information:

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

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

4.2. Make: ____________________

Model: ____________________

Year: ____________

Other information:

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see 

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

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

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

$_________________

Jill M Heftrig

16,135.00

X

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 Document Page 10 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 3: Describe Your Personal and Household Items

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

portion you own?

Do not deduct secured claims 

or exemptions.

6. Household goods and furnishings

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

 No

 Yes. Describe......... $___________________

7. Electronics

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

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

 No

 Yes. Describe.......... $___________________

8. Collectibles of value

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

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

 No

 Yes. Describe.......... $___________________

9. Equipment for sports and hobbies

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

and kayaks; carpentry tools; musical instruments

 No

 Yes. Describe.......... $___________________

10.Firearms 

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

 No

 Yes. Describe........... $___________________

11. Clothes

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

 No

 Yes. Describe........... $___________________

12. Jewelry

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

gold, silver

 No

 Yes. Describe........... $___________________

13. Non-farm animals

Examples: Dogs, cats, birds, horses

 No

 Yes. Describe............. $___________________

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

 No 

 Yes. Give specific 

information..................

$___________________

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

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

$______________________

1,000.00

Jill M Heftrig

200.00

Clothing 2,000.00

3,200.00

X

X

X

X

X

X

X

X

X

Furniture

Electronics

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 11 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 4: Describe Your Financial Assets

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

portion you own?

Do not deduct secured claims 

or exemptions.

16. Cash

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

 No

 Yes..................................................................................................................................................................... Cash: ....................... $__________________

17. Deposits of money

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

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

 No

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

17.1. Checking account: _________________________________________________________

17.2. Checking account: _________________________________________________________

17.3. Savings account: _________________________________________________________

17.4. Savings account: _________________________________________________________

17.5. Certificates of deposit: _________________________________________________________

17.6. Other financial account: _________________________________________________________

17.7. Other financial account: _________________________________________________________

17.8. Other financial account: _________________________________________________________

17.9. Other financial account: _________________________________________________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

18. Bonds, mutual funds, or publicly traded stocks

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

 No

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

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

$__________________

$__________________

$__________________

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

an LLC, partnership, and joint venture

 No 

Yes. Give specific 

information about

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

Name of entity: % of ownership:

_____________________________________________________________________ ___________%

_____________________________________________________________________ ___________%

_____________________________________________________________________ ___________%

$__________________

$__________________

$__________________

Jill M Heftrig

700.00 X

X

X

X

Chase 100.00

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

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

 No 

Yes. Give specific 

information about

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

Issuer name: 

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

$__________________

$__________________

$__________________

21. Retirement or pension accounts

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

 No

 Yes. List each 

account separately.. Type of account: Institution name:

401(k) or similar plan: ___________________________________________________________________

Pension plan: ___________________________________________________________________

IRA: ___________________________________________________________________

Retirement account: ___________________________________________________________________

Keogh: ___________________________________________________________________

Additional account: ___________________________________________________________________

Additional account: ___________________________________________________________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

22.Security deposits and prepayments

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

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

companies, or others

 No

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

Electric: ______________________________________________________________________

Gas: ______________________________________________________________________

Heating oil: ______________________________________________________________________

Security deposit on rental unit: _____________________________________________________________

Prepaid rent: ______________________________________________________________________

Telephone: ______________________________________________________________________

Water: ______________________________________________________________________

Rented furniture: ______________________________________________________________________

Other: ______________________________________________________________________

$___________________

$___________________

$___________________

$___________________

$___________________

$___________________

$___________________

$___________________

$___________________

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

 No

 Yes........................... Issuer name and description:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

$__________________

$__________________

$__________________

Jill M Heftrig

X

X

X

X

Alpine Bank 26,482.07

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 Document Page 13 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

 No

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

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

$_________________

$_________________

$_________________

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

exercisable for your benefit

 No

 Yes. Give specific 

information about them. .. $__________________

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

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

 No

 Yes. Give specific 

information about them. .. $__________________

27. Licenses, franchises, and other general intangibles

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

 No

 Yes. Give specific 

information about them. .. $__________________

Money or property owed to you? Current value of the 

portion you own?

Do not deduct secured 

claims or exemptions.

28.Tax refunds owed to you

 No

 Yes. Give specific information 

about them, including whether 

you already filed the returns 

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

Federal: $_________________

State: $_________________

Local: $_________________

29. Family support

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

 No

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

Alimony: 

Maintenance:

Support: 

Divorce settlement:

Property settlement: 

$________________

$________________

$________________

$________________

$________________

30. Other amounts someone owes you

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

Social Security benefits; unpaid loans you made to someone else

 No

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

$______________________

Jill M Heftrig

X

X

X

X

X

X

X

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 Document Page 14 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

31. Interests in insurance policies 

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

 No

 Yes. Name the insurance company 

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

Company name: Beneficiary:

___________________________________________ ____________________________

___________________________________________ ____________________________

___________________________________________ ____________________________

Surrender or refund value:

$__________________

$__________________

$__________________

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

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

property because someone has died.

 No

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

$_____________________

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

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

 No

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

$______________________

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

to set off claims

 No

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

$_____________________

35. Any financial assets you did not already list

 No 

 Yes. Give specific information............ $_____________________

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

for Part 4. Write that number here ........................................................................................................................................................ $_____________________

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.

Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

38. Accounts receivable or commissions you already earned

 No

 Yes. Describe........

$_____________________

39. Office equipment, furnishings, and supplies

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

 No

 Yes. Describe........ $_____________________

Jill M Heftrig

27,282.07

X

X

X

X

X

X

X

X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 15 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

 No

 Yes. Describe........ $_____________________

41. Inventory

 No

 Yes. Describe........ $_____________________

42. Interests in partnerships or joint ventures 

 No

 Yes. Describe........ Name of entity: % of ownership:

______________________________________________________________________ ________%

______________________________________________________________________ ________%

______________________________________________________________________ ________%

$_____________________

$_____________________

$_____________________

43. Customer lists, mailing lists, or other compilations 

 No

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

 No

 Yes. Describe.........

$____________________

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

 No

 Yes. Give specific 

information .........

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

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

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

$____________________

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

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

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

 No. Go to Part 7.

 Yes. Go to line 47.

Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

47. Farm animals

Examples: Livestock, poultry, farm-raised fish

 No

 Yes...........................

$___________________

Jill M Heftrig

0.00

X

X

X

X

X

X

X

X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 16 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

48. Crops—either growing or harvested

 No 

 Yes. Give specific 

information. ............ $___________________

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

 No

 Yes...........................

$___________________

50.Farm and fishing supplies, chemicals, and feed

 No

 Yes...........................

$___________________

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

 No 

 Yes. 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 ........................................................................................................................................................

$___________________

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

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

Examples: Season tickets, country club membership

 No 

 Yes. Give specific 

information. ............

$________________

$________________

$________________

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

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. Add lines 56 through 61. ................... $________________ Copy personal property total  + $_________________

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

Jill M Heftrig

0.00

0.00

16,135.00

3,200.00

27,282.07

0.00

0.00

0.00

46,617.07 46,617.07

46,617.07

X

X

X

X

X

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 Document Page 17 of 66
Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __ 

Official Form 106C 

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

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

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

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

your name and case number (if known). 

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

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

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

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

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

would be limited to the applicable statutory amount. 

Part 1: Identify the Property You Claim as Exempt

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

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

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

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

Brief description of the property and line on 

Schedule A/B that lists this property 

Current value of the 

portion you own 

Copy the value from 

Schedule A/B

Amount of the exemption you claim 

Check only one box for each exemption. 

Specific laws that allow exemption

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: _________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ Line from 

Schedule A/B: ______ 

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

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

 No

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

 No

 Yes

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: __________ District of __________ 

Case number ___________________________________________ 

 (If known) 

  Fill in this information to identify your case: 

 Check if this is an

amended filing

_____________________________________________ Northern District of Illinois

X

Jill M Heftrig

Cash

16

700.00 X 700.00 735 ILCS 5/12-1001(b)

See Attachment 1

17.1

100.00 X 100.00 735 ILCS 5/12-1001(b)

Furniture

6

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

2

X

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 Document Page 18 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

Part 2: Additional Page

Brief description of the property and line 

on Schedule A/B that lists this property 

Current value of the 

portion you own 

Copy the value from 

Schedule A/B

Amount of the exemption you claim 

Check only one box for each exemption

Specific laws that allow exemption

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

______ ____________________________ 

Brief 

description: 

Line from 

Schedule A/B:

_________________________ $________________  $ ____________ 

 100% of fair market value, up to

any applicable statutory limit

____________________________ 

____________________________ 

____________________________ 

____________________________ ______ 

Electronics

7

200.00 X 200.00

735 ILCS 5/12-1001(b)

Clothing

11

2,000.00 X 2,000.00 735 ILCS 5/12-1001(a),(e)

See Attachment 2

21

26,482.07 X 26,482.07

735 ILCS 5/12-1006

Jill M Heftrig

2 2

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 19 of 66
Attachment

Debtor: Jill M Heftrig Case No:

Attachment 1

Checking Account with Chase

Attachment 2

401(k) or Similar Plan with Alpine Bank

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 Document Page 20 of 66
 Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___

Official Form 106D

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

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

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

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

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

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

 Yes. Fill in all of the information below.

Part 1: List All Secured Claims

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

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

As much as possible, list the claims in alphabetical order according to the creditor’s name.

Column A

Amount of claim

Do not deduct the 

value of collateral.

Column B

Value of collateral

that supports this 

claim

Column C

Unsecured 

portion

If any

2.1

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

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) ____________________

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 ____________ Last 4 digits of account number ___ ___ ___ ___

2.2

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

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) ____________________

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 ____________ Last 4 digits of account number ___ ___ ___ ___

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an 

amended filing

Jill M Heftrig

Northern District of Illinois

X

16,135.00

1

RBS Citizens NA

480 Jefferson Blvd

Warwick RI See

2013 Kia Sportage with 60000 miles.

X

* * * *

16,135.00 16,135.00

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Attachment

Debtor: Jill M Heftrig Case No:

Attachment 1

02886-1359

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

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

Official Form 106E/F

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

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

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

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

creditors with partially secured claims that are listed in Schedule D: Creditors Who Hold Claims Secured by Property. If more space is 

needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of 

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

Part 1: List All of Your PRIORITY Unsecured Claims

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

 No. Go to Part 2.

 Yes.

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

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

nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor’s name. If you have more than two priority 

unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.

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

Total claim Priority 

amount

Nonpriority 

amount

2.1

____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___ $_____________ $___________ $____________

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were 

intoxicated

 Other. Specify _________________________________

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another 

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

2.2

____________________________________________

Priority 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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were 

intoxicated

 Other. Specify _________________________________

$_____________ $___________ $____________

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an 

amended filing

Jill M Heftrig

Northern District of Illinois

13

X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: List All of Your NONPRIORITY Unsecured Claims

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

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

 Yes

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

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

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than four priority unsecured claims 

fill out the Continuation Page of Part 2. 

Total claim

4.1

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___

$__________________

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 

that you did not report as priority claims

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

 Other. Specify ______________________________________

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another 

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

4.2

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___ $__________________

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 

that you did not report as priority claims

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

 Other. Specify ______________________________________

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another 

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

4.3

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___

$_________________

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 

that you did not report as priority claims

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

 Other. Specify ______________________________________

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another 

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

2 13

Jill M Heftrig

X

Barclays Bank Delaware

125 W. State Street

Wilmington DE 19801

X X

* * * *

Credit Card Charges

806.00

Belvidere HIgh School

1500 East Ave

Belvidere IL 61008

X X

7 0 6 7

General Services

770.00

Capital One Bank (USA), N.A.

15000 Capital One Dr.

Richmond VA 23238

X

X

C 2 2 5

Civil Judgment

3,152.00

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Your NONPRIORITY Unsecured Claims ─Continuation Page

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

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

3 13

Jill M Heftrig

4.4

4.5

4.6

Chase/Bank One Card Service

PO Box 15298

Wilmington DE 19850

X

X

* * * *

Credit Card Charges

2,318.00

Comenity Bank/Victoria Secret

PO Box 182789

Columbus OH 43218

X

X

* * * *

Credit Card Charges

643.00

Convergent Healthcare Recoveries

121 NE Jefferson St. Suite 100

Peoria IL 61602

X

X

* * * *

Medical Services

863.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Your NONPRIORITY Unsecured Claims ─Continuation Page

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

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

4 13

Jill M Heftrig

4.7

4.8

4.9

Experian

Atten: Bankruptcy Dept. PO BOX 2002

Allen TX 75013

X

X Notice Only

0.00

Frontier Communications

Bankruptcy Dept. 19 John Street

Middletown NY 10940-4918

X

X

5 0 2 2

General Services

198.82

GI Pathology

PO Box 1000 Dept. 461

Memphis TN 38148-0001

X

X

2 9 6 2

Medical Services

31.15

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Your NONPRIORITY Unsecured Claims ─Continuation Page

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

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

5 13

Jill M Heftrig

4.10

4.11

4.12

Illinois Tollway Authority

Attention: Violation Administration Center 2700 Ogden Ave

Downers Grove IL 60515

X

X

2 2 4 6

Tolls

212.70

LTD Financial Services, L.P.

7322 Southwest Freeway Suite 1600

Houston TX 77074

X

X

0 1 7 2

Credit Card Charges

724.14

Merrick Bank

PO Box 1500

Draper UT 84020

X

X

* * * *

Credit Card Charges

4,212.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Your NONPRIORITY Unsecured Claims ─Continuation Page

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

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

6 13

Jill M Heftrig

4.13

4.14

4.15

Mutual Management Services

PO Box 8740

Rockford IL 61126-8740

X

X

* * * *

Medical Services

13.00

One Main Financial

6801 Colwell Blvd. C/S Care Dept.

Irving TX 75039

X

X

* * * *

Personal Loan

9,634.00

OSF HealthCare System

7978 Solution Center

Chicago IL 60677-7009

X

X

9 1 4 7

Medical Services

152.10

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Your NONPRIORITY Unsecured Claims ─Continuation Page

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

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

7 13

Jill M Heftrig

4.16

4.17

4.18

OSF Medical Group

PO BOX 91011

Chicago IL 60680-8807

X

X

0 0 4 6

Medical Services

139.48

Rockford Gastroenterology Associates, LTD.

401 Roxbury Road

Rockford IL 61107-5075

X

X

1 5 8 9

Medical Services

60.49

Rockford Mercantile Agency

P.O. Box 5847

Rockford IL 61125-0847

X

X

0 2 2 5

Medical Services

376.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 29 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Your NONPRIORITY Unsecured Claims ─Continuation Page

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

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

8 13

Jill M Heftrig

4.19

4.20

4.21

Swedish American Hospital

PO Box 310283

Des Moines IA 50331-0283

X

X

4 3 7 1

Medical Services

2,677.44

Synchrony Bank/Lowes

Attn: Bankruptcy Department PO Box 965061

Orlando FL 32896

X

X

* * * *

Credit Card Charges

651.00

Synchrony Bank/Sams

Attn: Bankruptcy Department PO Box 965061

Orlando FL 32896-5061

X

X

6 * * *

Credit Card Charges

2,838.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 30 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Your NONPRIORITY Unsecured Claims ─Continuation Page

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

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

_____________________________________________________________

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?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

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 that 

you did not report as priority claims

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

 Other. Specify________________________________

$____________

9 13

Jill M Heftrig

4.22

4.23

4.24

Synchrony Bank/Walmart

Attn: Bankruptcy Department PO Box 965061

Orlando FL 32896-5061

X

X

C 1 9 1

Civil Judgment

3,524.44

The Affiliated Group

7381 Airport View Dr. SW

Rochester MN 55902

X

X

* * * *

Medical Services

64.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 31 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

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

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

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

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

_____________________________________________________

Name

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

10 13

Jill M Heftrig

Belvidere Community Unit School District 100

919 E. 6th St.

Belvidere, Illinois 61008

4.2

X

7 0 6 7

Blatt, Hasenmiller, Leibsker & Moore, LLC

10 South La Salle Street

Suite 2200

Chicago, Illinois 60603-1069

4.3

X

C 2 2 5

Boone County Circuit Clerk

601 N. Main St.

Belvidere, Illinois 61008

4.3

X

C 2 2 5

MRS BPO, L.C.C.

1930 Olney Ave.

Cherry HIll , New Jersey 08003

4.4

X

* * * *

Professional Bureau of Collections of Maryland, Inc.

PO Box 628

Elk Grove, California 95759

4.5

X

* * * *

OSF HealthCare

Common Business Office

PO Box 1806

Peoria, Illinois 61656-1806

4.6

X

* * * *

OSF Saint Anthony Medical Center

5510 E. State Street

Rockford, Illinois 61108-2381

4.6

X

* * * *

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 32 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

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

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

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

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

_____________________________________________________

Name

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

11 13

Jill M Heftrig

Equifax

Attn: Bankruptcy Dept.

PO BOX 740241

Atlanta , Georgia 30374

4.7

X

Transunion

Attn: Bankruptcy Dept.

PO BOX 1000

Chester, Pennsylvania 19022

4.7

X

Arnold Scott Harris, P.C.

111 West Jackson Blvd.

Suite 600

Chicago, Illinois 60604

4.10

X

2 2 4 6

Office of the Secretary of State

Safety & Financial Responsibility Section

2701 S. Dirksen Parkway

Springfield, Illinois 62723

4.10

X

2 2 4 6

CitiBank, N.A./The Home Depot

701 East 60th St. North

Sioux Falls, South Dakota 57104

4.11

X

0 1 7 2

Midland Funding, LLC

2365 Northside Dr.

Suite 300

San Diego, California 92108

4.14

X

* * * *

OSF Saint Anthony Medical Center

5510 E. State Street

Rockford, Illinois 61108-2381

4.18

X

0 2 2 5

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 33 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

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

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

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

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

_____________________________________________________

Name

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

_____________________________________________________

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 ___ ___ ___ ___

12 13

Jill M Heftrig

Dennis A. Brebner & Associates

Attorneys at Law

860 Northpoint Blvd.

Waukegan, Illinois 60085-8211

4.19

X

4 3 7 1

Blitt and Gaines, PC.

661 Glenn Ave.

Wheeling, Illinois 60090

4.20

X

* * * *

Portfolio Recovery Associates, LLC.

Riverside Commerce Center

120 Corporate Blvd, Suite 100

Norfolk, Virginia 23502-4962

4.20

X

* * * *

Enhanced Recovery Collections LLC

8014 Bayberry Rd.

Jacksonville, Florida 32256

4.21

X

6 * * *

Blitt and Gaines, PC.

661 Glenn Ave.

Wheeling, Illinois 60090

4.22

X

C 1 9 1

Portfolio Recovery Associates, LLC.

Riverside Commerce Center

120 Corporate Blvd, Suite 100

Norfolk, Virginia 23502-4962

4.22

X

C 1 9 1

Physicians Immediate Care

9701 W. Higgens Rd.

Suite 270

Rosemont, Illinois 60018

4.23

X

* * * *

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 34 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

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

Add the amounts for each type of unsecured claim. 

Total claim

Total claims 

from Part 1

6a. Domestic support obligations 6a. $_________________________

6b. Taxes and certain other debts you owe the 

government 6b.

$_________________________

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

intoxicated 6c.

$_________________________

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

Write that amount here. 6d. +$_________________________

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

$_________________________

Total claim

Total claims 

from Part 2

6f. Student loans 6f.

$_________________________

6g. Obligations arising out of a separation agreement 

or divorce that you did not report as priority 

claims 6g. $_________________________

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

similar debts 6h. $_________________________

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

Write that amount here. 6i. + $_________________________

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

$_________________________

Jill M Heftrig

0.00

0.00

0.00

34,060.76

34,060.76

13 13

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 35 of 66
Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

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

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

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

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

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

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

2.1

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.2

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.3

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.4

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.5

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

Debtor __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse If filing) First Name Middle Name Last Name

United States Bankruptcy Court for the:______________________________________

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an 

amended filing

Jill M Heftrig

Northern District of Illinois

X

1

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 36 of 66
Official Form 106H Schedule H: Your Codebtors page 1 of ___

Official Form 106H

Schedule H: Your Codebtors 12/15

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

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

and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and 

case number (if known). Answer every question.

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

 No 

 Yes

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

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

 No. Go to line 3.

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

 No

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

______________________________________________________________________

Name of your spouse, former spouse, or legal equivalent

______________________________________________________________________

Number Street

______________________________________________________________________

City State ZIP Code

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

shown in line 2 again as a codebtor only if that person is a guarantor or cosigner. Make sure you have listed the creditor on 

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

Schedule E/F, or Schedule G to fill out Column 2.

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

Check all schedules that apply:

3.1

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

3.2

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

3.3

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the:_______________________________________

Case number ____________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an 

amended filing

1

Jill M Heftrig

Northern District of Illinois

X

X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 37 of 66
Official Form 106I Schedule I: Your Income page 1

Official Form 106I

Schedule I: Your Income 12/15

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

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

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

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

Part 1: Describe Employment

1. Fill in your employment 

information.

If you have more than one job, 

attach a separate page with 

information about additional 

employers.

Include part-time, seasonal, or 

self-employed work. 

Occupation may Include student 

or homemaker, if it applies.

Debtor 1 Debtor 2 or non-filing spouse

Employment status  Employed

 Not employed Fill out this information:

 Employed

 Not employed 

Occupation __________________________________ __________________________________

Employer’s name __________________________________ __________________________________

Employer’s address ________________________________________

Number Street

________________________________________

________________________________________

________________________________________

City State ZIP Code

________________________________________

Number Street

________________________________________

________________________________________

________________________________________

City State ZIP Code

How long employed there? _______ _______

Part 2: Give Details About Monthly Income

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

spouse unless you are separated.

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

below. If you need more space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or 

non-filing spouse

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

deductions). If not paid monthly, calculate what the monthly wage would be. 2. $___________ $____________

3. Estimate and list monthly overtime pay. 3. +$___________ + $____________

4. Calculate gross income. Add line 2 + line 3. 4. $__________ $____________

Debtor 1 ____________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ____________________________________________________________________

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

United States Bankruptcy Court for the: ___________________________________________

 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is:

 An amended filing

 A supplement showing post-petition 

chapter 13 income as of the following date: 

________________ 

MM / DD / YYYY

Jill M Heftrig

Northern District of Illinois

2,999.36

0.00

2,999.36 0.00

0.00

0.00

Every Ready Pin & Manufacturing, Inc,

Rockford, Illinois 61109

5560 International Dr.

X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 38 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106I Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or 

non-filing spouse

Copy line 4 here ............................................................................................ 4. $___________ $_____________

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. Other deductions. Specify: __________________________________ 5h. +$____________ + $_____________

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h. 6. $____________ $_____________

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $____________ $_____________

8. List all other income regularly received:

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

profession, or farm

Attach a statement for each property and business showing gross 

receipts, ordinary and necessary business expenses, and the total 

monthly net income. 8a.

$____________ $_____________

8b. Interest and dividends 8b. $____________ $_____________

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

regularly receive

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

settlement, and property settlement. 8c.

$____________ $_____________

8d. Unemployment compensation 8d. $____________ $_____________

8e. Social Security 8e. $____________ $_____________

8f. Other government assistance that you regularly receive

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

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

Nutrition Assistance Program) or housing subsidies.

Specify: ___________________________________________________ 8f.

$____________ $_____________

8g. Pension or retirement income 8g. $____________ $_____________

8h. Other monthly income. Specify: _______________________________ 8h. +$____________ +$_____________

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

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

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

$___________ + $_____________ = $_____________

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

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

friends or relatives.

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

Specify: _______________________________________________________________________________ 11. + $_____________

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

Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies 12. $_____________

Combined 

monthly income

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

 No. 

 Yes. Explain:

2,999.36 0.00

Jill M Heftrig

466.53

0.00

0.00

0.00

0.00

0.00

849.81 0.00

2,149.55 0.00

0.00 0.00

0.00 0.00

0.00 0.00

0.00 0.00

865.00 0.00

3,014.55 0.00 3,014.55

209.95

0.00

0.00

0.00

0.00

0.00

0.00 0.00

173.33 0.00

0.00 0.00

865.00 0.00

0.00 0.00

 	 0.00

125 Caf Plan

3,014.55

0.00

Will not receive SS after 11/1/2016; Daughter will turn 18 years old. X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 39 of 66
 Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J

Schedule J: Your Expenses 12/15

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

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

(if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

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

 No

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

2. Do you have dependents?

Do not list Debtor 1 and 

Debtor 2. 

Do not state the dependents’ 

names.

 No

 Yes. Fill out this information for 

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

Dependent’s relationship to 

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent live 

with you?

_________________________ ________

 No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

3. Do your expenses include 

expenses of people other than 

yourself and your dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

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

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

applicable date.

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

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

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

any rent for the ground or lot. 4. $_____________________

If not included in line 4:

4a. Real estate taxes 4a. $_____________________

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

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

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is:

 An amended filing

 A supplement showing post-petition chapter 13 

expenses as of the following date: 

________________ 

MM / DD / YYYY

Jill M Heftrig

Northern District of Illinois

X

X

X

X

675.00

0.00

0.00

0.00

0.00

Daughter 17 X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 40 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106J Schedule J: Your Expenses page 2

Your expenses

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

$_____________________

6. Utilities: 

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

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

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

6d. Other. Specify: _______________________________________________ 6d. $_____________________

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 fare.

Do not include car payments. 12.

$_____________________

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

14. Charitable contributions and religious donations 14. $_____________________

15. Insurance.

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

16.

15a. Life insurance 15a. $_____________________

15b. Health insurance 15b. $_____________________

15c. Vehicle insurance 15c. $_____________________

15d. Other insurance. Specify:_______________________________________ 15d. $_____________________

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

Specify: ________________________________________________________ 16.

$_____________________

17. Installment or lease payments:

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

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

17c. Other. Specify:_______________________________________________ 17c. $_____________________

17d. Other. Specify:_______________________________________________ 17d. $_____________________

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

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

$_____________________

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

Specify:_______________________________________________________ 19. $_____________________

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

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

20b. Real estate taxes 20b. $_____________________

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

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

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

Jill M Heftrig

200.00

33.00

300.00

700.00

50.00

0.00

200.00

100.00

0.00

0.00

0.00

112.00

375.00

0.00

0.00

0.00

0.00

0.00

0.00

25.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 41 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

 Official Form 106J Schedule J: Your Expenses page 3

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. 22.

$_____________________

$_____________________

$_____________________

23. Calculate your monthly net income. 

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

$_____________________

23b. Copy your monthly expenses from line 22 above. 23b. – $_____________________

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

The result is your monthly net income. 23c.

$_____________________

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

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

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

 No. 

 Yes. Explain here:

Jill M Heftrig

3,014.55

244.55

0.00

X

2,770.00

2,770.00

2,770.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 42 of 66
Official Form 106Dec Declaration About an Individual Debtor’s Schedules page 1 

Official Form 106Dec

Declaration About an Individual Debtor’s Schedules 12/15

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

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

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

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

Sign Below

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

 No

 Yes. Name of person__________________________________________________. Attach Bankruptcy Petition Preparer’s Notice, Declaration, and 

Signature (Official Form 119).

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

that they are true and correct.

______________________________________________  _____________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: _______________________________________

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an 

amended filing

s/Jill Hestrig

08/24/2016

X

Northern District Of Illinois

Jill M Heftrig

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 43 of 66
Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2

Official Form 106Sum

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

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

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

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

Part 1: Summarize Your Assets

Your assets

Value of what you own

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

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

$ ________________

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

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

Part 2: Summarize Your Liabilities

Your liabilities

Amount you owe

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

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

$ ________________

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

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

$ ________________

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

+ $ ________________

Your total liabilities $ ________________

Part 3: Summarize Your Income and Expenses

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

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

$ ________________

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

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________________________

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an 

amended filing

Jill M Heftrig

Northern District of Illinois

0.00

46,617.07

46,617.07

16,135.00

0.00

34,060.76

50,195.76

3,014.55

2,770.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 44 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 4: Answer These Questions for Administrative and Statistical Records

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

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

 Yes

7. What kind of debt do you have?

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

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

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

this form to the court with your other schedules.

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

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

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

Total claim

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

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

$_____________________

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

$_____________________

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

$_____________________

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

$_____________________

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

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

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

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

2,999.36

0.00

0.00

0.00

0.00

0.00

0.00

Jill M Heftrig

0.00

X

X

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 Document Page 45 of 66
 Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

Official Form 107

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

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

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

number (if known). Answer every question.

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

1. What is your current marital status?

 Married 

 Not married 

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

 No 

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

Debtor 1: Dates Debtor 1 

lived there 

Debtor 2: Dates Debtor 2 

lived there 

__________________________________________

Number Street

__________________________________________

__________________________________________

City State ZIP Code

From ________

To ________

 Same as Debtor 1

___________________________________________

Number Street

___________________________________________

___________________________________________

City State ZIP Code

 Same as Debtor 1

From ________

To ________

__________________________________________

Number Street

__________________________________________

__________________________________________

City State ZIP Code

From ________

To ________

 Same as Debtor 1

___________________________________________

Number Street

___________________________________________

___________________________________________

City State ZIP Code

 Same as Debtor 1

From ________

To ________

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

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

 No

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ____________________________________________

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an 

amended filing

Jill M Heftrig

X

X

Northern District of Illinois

X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 46 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 2: Explain the Sources of Your Income

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

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

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

 No 

 Yes. Fill in the details.

Debtor 1 Debtor 2 

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy:

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

For last calendar year:

(January 1 to December 31, _________)

YYYY

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

For the calendar year before that: 

(January 1 to December 31, _________)

YYYY

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

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

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

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

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

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

 No 

 Yes. Fill in the details.

Debtor 1 Debtor 2 

Sources of income

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

Sources of income 

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy:

__________________ 

__________________

__________________

$_________________

$_________________

$_________________

_____________________ 

_____________________

_____________________

$_________________

$_________________

$_________________

For last calendar year:

(January 1 to December 31, ______)

YYYY

__________________ 

__________________

__________________

$_________________

$_________________

$_________________

_____________________ 

_____________________

_____________________

$_________________

$_________________

$_________________

For the calendar year before that: 

(January 1 to December 31, ______)

YYYY

__________________ 

__________________

__________________

$_________________

$_________________

$_________________

_____________________ 

_____________________

_____________________

$_________________

$_________________

$_________________

X

X

2015

2014

Jill M Heftrig

2015

2014

23,300.63

33,362.00

35,872.00

X

X

X

Social Security 6,920.00

Social Security 10,380.00

Social Security 10,380.00

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 47 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

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

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

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

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

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

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

 No. Go to line 7.

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

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

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

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

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

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

 No. Go to line 7.

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

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

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

____________________________________ 

Creditor’s Name 

____________________________________ 

Number Street 

____________________________________ 

____________________________________ 

City State ZIP Code

Dates of 

payment

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

_________ 

_________ 

_________ 

$_________________ $__________________  Mortgage

 Car

 Credit card

 Loan repayment

 Suppliers or vendors

 Other ____________

____________________________________ 

Creditor’s Name 

____________________________________ 

Number Street 

____________________________________ 

____________________________________ 

City State ZIP Code

_________ 

_________ 

_________ 

$_________________ $__________________  Mortgage

 Car

 Credit card

 Loan repayment

 Suppliers or vendors

 Other ____________

____________________________________ 

Creditor’s Name 

____________________________________ 

Number Street 

____________________________________ 

____________________________________ 

City State ZIP Code

_________ 

_________ 

_________ 

$_________________ $__________________  Mortgage

 Car

 Credit card

 Loan repayment

 Suppliers or vendors

 Other ____________

X

X

Jill M Heftrig

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 48 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

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

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

such as child support and alimony. 

 No 

 Yes. List all payments to an insider. 

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

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

an insider? 

Include payments on debts guaranteed or cosigned by an insider.

 No 

 Yes. List all payments that benefited an insider. 

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

Include creditor’s name

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

X

X

Jill M Heftrig

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 Document Page 49 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

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

and contract disputes. 

 No 

 Yes. Fill in the details.

Case title_____________________________

____________________________________

Case number ________________________

Nature of the case Court or agency Status of the case

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

 Pending 

 On appeal 

 Concluded

Case title_____________________________

____________________________________

Case number ________________________

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

 Pending 

 On appeal 

 Concluded

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

Check all that apply and fill in the details below.

 No. Go to line 11.

 Yes. Fill in the information below.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

 Property was repossessed. 

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized, or levied.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

 Property was repossessed. 

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized, or levied.

Jill M Heftrig

X

X

Portfolio Recovery Associates,

LLC vs. Jill Hertrig

2016SC191

Civil Suit

Boone County, Illinois 17th Judicial Circuit

601 N. Main St.

Belvidere IL 61008

X

Capital One Bank USA, NA

vs. Jill Heftrig

2016SC225

Civil Suit

Boone County, Illinois 17th Judicial Circuit

601 N. Main St.

Belvidere IL 61008

X

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 Document Page 50 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

 No 

 Yes. Fill in the details.

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the action the creditor took Date action 

was taken

Amount

____________ $________________

Last 4 digits of account number: XXXX–___ ___ ___ ___

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

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

 No 

 Yes

Part 5: List Certain Gifts and Contributions

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

 No 

 Yes. Fill in the details for each gift. 

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

X

Jill M Heftrig

X

X

Number Street

Number Street

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 Document Page 51 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

 No 

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

Gifts or contributions to charities 

that total more than $600

Describe what you contributed Date you 

contributed

Value 

_____________________________________

Charity’s Name

_____________________________________

_____________________________________

_____________________________________

City State ZIP Code

_________

_________

$_____________

$_____________

Part 6: List Certain Losses

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

or gambling? 

 No 

 Yes. Fill in the details.

Describe the property you lost and how 

the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending insurance 

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

Date of your loss Value of property 

lost

_________ $_____________

Part 7: List Certain Payments or Transfers

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

consulted about seeking bankruptcy or preparing a bankruptcy petition?

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

 No 

 Yes. Fill in the details.

___________________________________

Person Who Was Paid 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

____________________________________________

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

Jill M Heftrig

X

X

X

Number Street

McGarragan Law Corp.

1004 N. Main Street

Rockford IL 61103

Laura@McGarraganLaw.com

06/23/16 600.00

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 Document Page 52 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

____________________________________

Person Who Was Paid 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

________________________________________________

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of 

payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

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

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

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

 No 

 Yes. Fill in the details.

____________________________________

Person Who Was Paid 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code 

Description and value of any property transferred Date payment or 

transfer was made

Amount of payment

_________

_________

$____________

$____________

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

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

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

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

 No 

 Yes. Fill in the details.

___________________________________

Person Who Received Transfer 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Description and value of property 

transferred

Describe any property or payments received 

or debts paid in exchange

Date transfer 

was made

_________

Person’s relationship to you _____________

___________________________________

Person Who Received Transfer 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

_________

Person’s relationship to you _____________

Jill M Heftrig

X

X

Access

633 W. 5th St.

Suite 260001

Los Angeles CA 90071

07/17/16 14.95

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 Document Page 53 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

 No 

 Yes. Fill in the details.

Name of trust __________________________

______________________________________

Description and value of the property transferred Date transfer 

was made

_________

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

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

closed, sold, moved, or transferred? 

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

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

 No 

 Yes. Fill in the details.

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code 

Last 4 digits of account number Type of account or 

instrument

Date account was 

closed, sold, moved, 

or transferred

Last balance before 

closing or transfer

XXXX–___ ___ ___ ___ Checking

 Savings

 Money market

 Brokerage 

 Other__________

_________ $___________

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

XXXX–___ ___ ___ ___ Checking

 Savings

 Money market

 Brokerage 

 Other__________

_________ $___________

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

securities, cash, or other valuables?

 No 

 Yes. Fill in the details.

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

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

have it?

_______________________________________

Name 

_______________________________________

Number Street

_______________________________________

City State ZIP Code

 No 

 Yes



Jill M Heftrig

X

X

X

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 Document Page 54 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

 No 

 Yes. Fill in the details.

___________________________________

Name of Storage Facility

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

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

have it?

_______________________________________

Name 

_______________________________________

Number Street

_______________________________________

CityState ZIP Code

 No 

 Yes



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

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

or hold in trust for someone.

 No 

 Yes. Fill in the details.

___________________________________

Owner’s Name

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Where is the property? Describe the property Value

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

$__________

Part 10: Give Details About Environmental Information

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

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

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

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

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

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

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

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

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

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

 No 

 Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

Jill M Heftrig

X

X

X

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 Document Page 55 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

 No 

 Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

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

 No 

 Yes. Fill in the details.

Case title______________________________

______________________________________

______________________________________

Case number

Court or agency Nature of the case Status of the 

case

________________________________

Court Name

________________________________

Number Street

________________________________

City State ZIP Code

 Pending 

 On appeal 

Concluded



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

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

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

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

 A partner in a partnership 

 An officer, director, or managing executive of a corporation

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

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

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

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

Jill M Heftrig

X

X

X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

 Document Page 56 of 66
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

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

institutions, creditors, or other parties. 

 No 

 Yes. Fill in the details below.

____________________________________

Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Date issued

____________ 

MM / DD / YYYY

Part 12: Sign Below

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

answers are true and correct. I understand that making a false statement, concealing property, or obtaining money or property by fraud 

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

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

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Date ________________ Date _________________

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

 No

 Yes

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

 No

 Yes. Name of person_____________________________________________________________. Attach the Bankruptcy Petition Preparer’s Notice, 

Declaration, and Signature (Official Form 119).

Jill M Heftrig

X

s/Jill Hestrig

24 August 2016

X

X

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

Official Form 108

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

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.

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

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

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

Both debtors must sign and date the form. 

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

write your name and case number (if known).

Part 1: List Your Creditors Who Hold Secured Claims

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

information below.

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

secures a debt?

Did you claim the property 

as exempt on Schedule C?

Creditor’s 

name:

 Surrender the property.

 Retain the property and redeem it.

 Retain the property and enter into a 

Reaffirmation Agreement.

 Retain the property and [explain]: __________

______________________________________

 No

 Yes

Description of 

property 

securing debt:

Creditor’s 

name:

 Surrender the property.

 Retain the property and redeem it.

 Retain the property and enter into a 

Reaffirmation Agreement.

 Retain the property and [explain]: __________

______________________________________

 No

 Yes

Description of 

property 

securing debt:

Creditor’s 

name:

 Surrender the property.

 Retain the property and redeem it.

 Retain the property and enter into a 

Reaffirmation Agreement.

 Retain the property and [explain]: __________

______________________________________

 No

 Yes

Description of 

property 

securing debt:

Creditor’s 

name:

 Surrender the property.

 Retain the property and redeem it.

 Retain the property and enter into a 

Reaffirmation Agreement.

 Retain the property and [explain]: __________

______________________________________

 No

 Yes

Description of 

property 

securing debt:

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: _______________________________________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

 Check if this is an 

amended filing

Jill M Heftrig

Northern District Of Illinois

RBS Citizens NA

2013 Kia Sportage with 60000 miles.

X

X

Case 16-82015 Doc 1 Filed 08/24/16 Entered 08/24/16 11:31:44 Desc Main

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Your name ______________________________________________________ Case number (If known)_____________________________________

First Name Middle Name Last Name

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

Part 2: List Your Unexpired Personal Property Leases

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

fill in the information below. Do not list real estate leases. Unexpired leases are leases that are still in effect; the lease period has not yet 

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

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

Lessor’s name:  No

 Yes Description of leased 

property:

Lessor’s name:  No

 Yes Description of leased 

property:

Lessor’s name:  No

Description of leased  Yes

property:

Lessor’s name:  No

 Yes

Description of leased 

property:

Lessor’s name:  No

 Yes

Description of leased 

property:

Lessor’s name:  No

 Yes

Description of leased 

property:

Lessor’s name:  No

 Yes

Description of leased 

property:

Part 3: Sign Below

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

personal property that is subject to an unexpired lease.

___________________________________________ ___________________________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

s/Jill Hestrig

08/24/2016

Jill M Heftrig

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Arnold Scott Harris, P.C.

111 West Jackson Blvd.

Suite 600

Chicago, IL 60604

Barclays Bank Delaware

125 W. State Street

Wilmington, DE 19801

Belvidere Community Unit School District

919 E. 6th St.

Belvidere, IL 61008

Belvidere HIgh School

1500 East Ave

Belvidere, IL 61008

Blatt, Hasenmiller, Leibsker & Moore, LL

10 South La Salle Street

Suite 2200

Chicago, IL 60603-1069

Blitt and Gaines, PC.

661 Glenn Ave.

Wheeling, IL 60090

Boone County Circuit Clerk

601 N. Main St.

Belvidere, IL 61008

Capital One Bank (USA), N.A.

15000 Capital One Dr.

Richmond, VA 23238

Chase/Bank One Card Service

PO Box 15298

Wilmington, DE 19850

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CitiBank, N.A./The Home Depot

701 East 60th St. North

Sioux Falls, SD 57104

Comenity Bank/Victoria Secret

PO Box 182789

Columbus, OH 43218

Convergent Healthcare Recoveries

121 NE Jefferson St.

Suite 100

Peoria, IL 61602

Dennis A. Brebner & Associates

Attorneys at Law

860 Northpoint Blvd.

Waukegan, IL 60085-8211

Enhanced Recovery Collections LLC

8014 Bayberry Rd.

Jacksonville, FL 32256

Equifax

Attn: Bankruptcy Dept.

PO BOX 740241

Atlanta, GA 30374

Experian

Atten: Bankruptcy Dept.

PO BOX 2002

Allen, TX 75013

Frontier Communications

Bankruptcy Dept.

19 John Street

Middletown, NY 10940-4918

GI Pathology

PO Box 1000

Dept. 461

Memphis, TN 38148-0001

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Illinois Tollway Authority

Attention: Violation Administration Cent

2700 Ogden Ave

Downers Grove, IL 60515

LTD Financial Services, L.P.

7322 Southwest Freeway

Suite 1600

Houston, TX 77074

Merrick Bank

PO Box 1500

Draper, UT 84020

Midland Funding, LLC

2365 Northside Dr.

Suite 300

San Diego, CA 92108

MRS BPO, L.C.C.

1930 Olney Ave.

Cherry HIll, NJ 08003

Mutual Management Services

PO Box 8740

Rockford, IL 61126-8740

Office of the Secretary of State

Safety & Financial Responsibility Sectio

2701 S. Dirksen Parkway

Springfield, IL 62723

One Main Financial

6801 Colwell Blvd.

C/S Care Dept.

Irving, TX 75039

OSF HealthCare 

Common Business Office

PO Box 1806

Peoria, IL 61656-1806

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OSF HealthCare System

7978 Solution Center

Chicago, IL 60677-7009

OSF Medical Group

PO BOX 91011

Chicago, IL 60680-8807

OSF Saint Anthony Medical Center

5510 E. State Street

Rockford, IL 61108-2381

Physicians Immediate Care

9701 W. Higgens Rd.

Suite 270

Rosemont, IL 60018

Portfolio Recovery Associates, LLC.

Riverside Commerce Center

120 Corporate Blvd, Suite 100

Norfolk, VA 23502-4962

Professional Bureau of Collections of Ma

PO Box 628

Elk Grove, CA 95759

RBS Citizens NA

480 Jefferson Blvd

Warwick, RI 02886-1359

Rockford Gastroenterology Associates, LT

401 Roxbury Road

Rockford, IL 61107-5075

Rockford Mercantile Agency

P.O. Box 5847

Rockford, IL 61125-0847

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Swedish American Hospital

PO Box 310283

Des Moines, IA 50331-0283

Synchrony Bank/Lowes

Attn: Bankruptcy Department

PO Box 965061

Orlando, FL 32896

Synchrony Bank/Sams

Attn: Bankruptcy Department

PO Box 965061

Orlando, FL 32896-5061

Synchrony Bank/Walmart

Attn: Bankruptcy Department

PO Box 965061

Orlando, FL 32896-5061

The Affiliated Group

7381 Airport View Dr. SW

Rochester, MN 55902

Transunion

Attn: Bankruptcy Dept.

PO BOX 1000

Chester, PA 19022

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B2030 (Form 2030) (12/15)

United States Bankruptcy Court

In re

Case No. ___________________

Debtor Chapter ____________________

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

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

named debtor(s) and that compensation paid to me within one year before the filing of the petition in

bankruptcy, or agreed to be paid to me, for services rendered or to be rendered on behalf of the debtor(s) in

contemplation of or in connection with the bankruptcy case is as follows:

For legal services, I have agreed to accept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________

Prior to the filing of this statement I have received . . . . . . . . . . . . . . . . . . . . . . . . $______________

Balance Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________

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

Debtor Other (specify)

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

Debtor Other (specify)

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

members and associates of my law firm.

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

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

people sharing in the compensation, is attached.

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;

1,100.00

600.00

500.00

7

Jill M Heftrig

X

NORTHERN DISTRICT OF ILLINOIS

X

X

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B2030 (Form 2030) (12/15)

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

e. [Other provisions as needed]

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

CERTIFICATION

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

me for representation of the debtor(s) in this bankruptcy proceeding.

______________________

Date Signature of Attorney

Name of law firm

McGarragan Law Corp.

August 24, 2016 s/Laura L. McGarragan

-------------------------------------------------------------------------------------------------------------------

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

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