United States Bankruptcy Court for the:

Northern District of lllinois

Case number Ur knownl

Official Form 101

Chapter you are filing under:

d Crrapter z

E Chapter 11

E chapterl2

D Chapier 13 fl Cnecf if this is an

amended filing

About Debtor 1:

Karen

First name

Anne

Middle name

Ley

Voluntary Petition for lndividuals Filing for Bankruptcy 12t15

The bankruptcy fornrs use you and Debtor I to refer to a debtor filing alone. A married couple may file a bankruptcy case togetheF-called a

joint cas*<nd 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 Debfor I and

Debtor 2 to distinguish betvyeen them. ln joint cases, one of the spouses must report information as Debtor I and the other as Debtor 2.The

same percon must be Debtor 7 in all of the forms.

Be as complete and accurate as possible. lf 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 eYery question.

!@ ,c"r,nrry vorr*",r 

-

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

t. Yourfull name

Write the name that is on youl

government-issued picture

identifi cation (for example,

your driver's license or

passport).

Bring your picture

identification to your meeting

with the trustee.

z. All other names you

have used in the last 8

years

lnclude your married or

maiden names.

s. Only the last 4 digits of

your Social Security

number or federal

lndividual Taxpayer

ldentification number

(rTrN)

Official Form 101

First name

Middle name

Last name Last name

Suffix (Sr., Jr., ll, lll) Sufiix (Sr., Jr., ll, lll)

First name First name

Middle name Middle name

Last name Last name

First name First name

Middle name Middle name

Last name

)ofi - xx- 6 2B

Last name

xxx -xxOR OR

9xx - xx -- 9xx - xx --

Voluntary Petition for lndividuals Filing for Bankruptcy page 1

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 1 of 31
Case number

Fid Name Middle Name Last Name

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

+. Any business names

and Employer E I have not used any business names or ElNs. E I have not used any business names or ElNs.

ldentification Num bers

(ElN) you have used in Earth Mama Esthetics

the Iast 8 years Business name Business name

lnclude trade names and Common Sense Skin, lnc

doing business as names Brsmess.ame Business name

2 6_2 7 3 I 3 1 I

EIN 

-

_B_J_3 7 2 1 2 I I

EIN

EIN

s. Where you live lf Debtor 2 lives at a different address:

1874 Westmore Grove Drive

Number Streel Number Street

Plainfield rL 60586

City

wilt

state ztp cooe city

County County

lf your mailing address is different from the one lf Debtor 2's mailing address is different from

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

any notices to you at this mailing address. any notices to this mailing address.

Number Street Number Street

P.O. Box P.O. Box

State ZIP Code CitY Slate ZIP Code

s. Why you are choosing Check one: Check one:

this districtto file for d ou", the tast 180 days before fiting this petition, B over the tast 180 days before filing this petition, bankruptcy I have lived in this district longer than in any I have lived in this district longer than in any

other district. other district'

E I have another reason. Explain. E I have another reason. Explain.

(See 28 U.S.C. S 1408.) (See 28 U.S'C. S 1408')

State ZIP Code

C'ty

Official Form 101 Voluntary Petition for lndividuals Filing for Bankruptcy page2

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 2 of 31
Debtor 1 Karen Anne Ley

Fi6t Name Middle Name Lasl Name

!@| Tell the Gourt About your Bankruptcy case

Case number (ir

z. The chapter of the Check one. (For a brief description of each, see Alofibe Required by 11 U.S.C. S 342(b) for lndividuals Filing

Bankruptcy Code you for Bankruptcy (Form 2010)). AIso, go to the top of page 'l and check the appropriate box.

are choosing to file Ut Cnapter Z

under

D Chapter 11

E Chapter 12

D Chapter 13

a" How you will pay the fee El t witt 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. lf your attorney is

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

with a pre-printed address.

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

Apptication for lndividuals to Pay The Filing Fee in lnstallmenfs (Official Form 103A).

E 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). lf you choose this option, you must fill out the Application ta Have the

Chapter 7 Filing Fee Waived (Official Form 1038) and file it with your petition.

e. Have you filed for El No

bankruptcy within the

last 8 years? D Yes- oi"tri"t

MM/ DD/YYYY

MM/ DDIYYYY

! ihen Case number

MMI DD/YYYY

ro. Are any bankruptcy U No

cases pending or being n . _

filed by a spouse who is u Yes' Debtor

Case number

Case number

Relaiionship to you

not filing this case with Case number, if knownyou, or by a business

partner, or by an

affiliate?

Relationship to you

District Case number. if known

MMIDDIYYYY

tt. Do you rent your El ruo, Go to line 12. residence? tl yes. Has your landlord obtained an eviction judgment against you and do you want to stay in your

residence?

fl uo. co to line 12.

E Yes. Fill out tnitial Statement About an Eviction Judgment Againsl You (Form 10'lA) and file it with

this bankruPtcY Petition.

MM/DD /YYYY

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

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 3 of 31
Case nurnber ri:r

flttr Report About Any Busines.ses You own as a $ole Proprietor I

fl. Are you a sole proprietor E ruo. co to Part 4.

of any full- or part'time

business? El Yes. Name and location of 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.

lf you have more than one

sole proprietorship, use a

separate sheet and attach it

to this petition.

Common Sense Skin, lnc.

Naperville

Karen Anne Lev

FiBt Neme l\4iddle Name Lasl Name

Name of business, if any

3340 Lacrosse Ln., Ste. 119

Number Street

ZIP Code

Check the appropriate box to describe your bustness:

E Heaftn Care Business (as defined in 11 U.S.C. S 101(27A))

D Singte Asset Real Estate (as defined in 1 1 U.S.C. S 101 (51 B))

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

E Commodity Broker (as defined in 1 1 U.S.C. S 1 01(6))

E[ None ofthe above

lf you are filing under Chapter 1 1, the couft must know whether you are a small business debtor so that it

cin set appropriate deadtines.lf 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 1 1 U.S.C. $ 1 1 16(1XB).

El No. t am notfiling under Chapter 11.

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

the Bankruptcy Code.

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

Bankruptcy Code.

El no

D Yes. \A/hat is the hazard?

lf immediate attention is needed, why is it needed?

Where is the property?

IL 60564

City

llt Report if you own or Have Any Hazardous Property or Any Property That Heeds lmmediate Attention

I

13. Are you filing under

Chapter 11 of the

Bankruptcy Code and

are you a small business

debtor'?

For a definition of small

busrness debtor, see

11 U.S.C. S 101(51D).

r+. 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?

City

Voluntary Petition for lndividuals Filing for Bankruptcy

ZIP Code

Page 4 Official Form 101

State

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 4 of 31
Case number

trlEtr E plai,, You, Effort" to R"""ire ",Bra"fing 

About cr"dit corttseling

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

You must check one:

E I received a briefing from an approved credit

counseling agency within the t80 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.

E 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.

E t certify that I asked for credit counseling

selvices 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.

lf the court is satisfied w,th 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. lf you do not do so, your case

may be dismissed.

Any extension of the 30day deadline is granted

only for cause and is limited to a maximum of 15

days.

E I am not required to receive a briefing about

credit counseling because of:

U hcapacity. I have a mental illness or a mental

deficiencY that makes me

incapable of realizing or making

rational decisions about finances.

E oisaOitity. My physical disability @uses 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.

B Active duty. I am currently on active military

duty in a military combat zone.

lf 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.

1s. Tell the court whether

you have received a

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. lf you

cannot do so, you are not

eligible to file.

lf 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:

You must check one:

E! 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 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.

E I certify that I asked for credit counseling

services from an approved agencyr 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.

lf 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 30day deadline is granted

only for cause and is limited to a maximum of 15

days.

fl I am not required to receive a briefing about

credit counseling because of:

I lncapacity. I have a mental illness or a mental

deficiencY that makes me

incapable of realizing or making

rational decisions about finances.

E Disability. My physical disability Guses 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.

E Active duty. I am currently on active military

duty in a military combat zone.

lf you believe you are not required to receive a

briefing about credit counseling, you must file a

motion for waiver of credit counseling with ihe court.

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

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 5 of 31
Case number

f,lft| Answer These Questions for Reporting Purposes

re. What kind of debts do

you have?

t7. 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?

ra. How many creditors do

you estimate that You

owe?

rs. How much do you

estimate your assets to

be worth?

eo. How much do you

estimate your liabilities

to be?

Q tas

E so-gs

D roo-rss

E zoo-ssg

El $o-$so,ooo

U $so,oot-$too,ooo

E $roo,oot-$soo,ooo

fl $soo,oot-$1 mitlion

El $o-$so,ooo

E $so,oot-$too,ooo

E $roo,oot-$5oo,ooo

E $soo,oot-$1 mitlion

B r,ooo-s,ooo

E s,oor-to,ooo

fl ro,oot-zs,ooo

E $r,ooo,oot-$10 milion

E $t o,ooo,oo1-$50 mitlion

D $so,ooo,oo1-g1oo mittion

D $roo,ooo,oo1 -$5oo million

E $t,ooo,oot-g1o million

E $ro,ooo,oo1-$50 mittion

D $so,ooo,oo1-g'too mittion

E stoo,ooo.ool -$5oo million

I zs,oot-so,ooo

B so,oor-roo,ooo

Ll More than 100,000

B $soo,ooo,oo1-91 bilion

[ $r,ooo,ooo,oo1-g1o bittion

[ $t o,ooo,ooo,oo1 -$50 bittion

E More than $50 billion

B $soo,ooo,oo1-$1 bittion

[ $t,ooo,ooo,oo1-$10 billion

D $r o,ooo,ooo,oo1 -$50 bitlion

D More than $50 billion

't6a. Are your debts primarily consumer debts? Consumer debfs are defined in 11 U.S.C. S 101(8)

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

I uo. Go to line 16b.

E Yes. Go to line 17.

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

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

E No. Go to line 16c.

El Yes. Go to line 17.

1 6c. State the type of debts you owe that are not consumer debts or business debts.

E ruo. t am not filing under Chapter 7. Go to line 18.

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

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

El ruo

E ves

EEEE sbn e"to,,

For you

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

correct.

lf 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 tiile 1 1, United States Code. I understand the relief available under each chapter, and I choose to proceed

under Chapter 7.

lf no attorney represents me and I did not pay or agree to pay someonewlo is,19t an attorney to help me fill out

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

I request relief in accordance with the chapter of title 1 1, United States Code, specified in this petiiion.

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

x

Signature of Debtor 2

Executed Execuied on on

Official Form 101 Voluntary Petition for lndividuals Fiting for Bankruptcy

MM / DD /YYYY

page 6

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 6 of 31
For your attorney, if you are

represented by one

lf you are not represented

by an attorney, you do not

need to file this page.

Case number

l, 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 'l 1, 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. S 342(b) and, in a case in which S 707(bX4XD) applies, certify that I have no

knowledge after an inquiry that the information in the schedules filed with the petition is incorrect.

X /s/ William M. Murakowski

Signature of Attorney for Debtor

Date ? / / t^^,'(

MMI DD /YYYY

William M. Murakowski

Printed name

Law Office of William M. Murakowski P.C

Firm name

15 N. Northwest Hiohwav

Number Street

Park Ridqe ILSta6- 60068

ZIP Code

Emait address caineg3@live.com

IL

City

Contact phone

6206280

(847\ 268-0201

Bar number

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

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 7 of 31
Debtor 1

Debtor 2

(Spous, if filing) Fi6t Name

United States Bankruptcy Court for the:

Case number

Middle Name Lasl Name

Northern District of tllinois

(lf knoM)

E CnecX if this is an

amended filing

Official Form 106Sum

Summary of Your Assets and Liabilities and Gertain Statistical lnformation 1z1s

Be as complete and accurate as possible. lf 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, lf 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.

l!l@ $ummarize Your Assets

1. Schedule NB: Property (Official Form 1064/8)

1a. Copy line 55, Total real estate, from Schedule NB

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

]!p| summarize Your Liabilities

Your assets

Value of what you own

s 125,000.00

$ 139,683.78

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

za.Copythetotal youlistedinColumn A,Amountof ctaim, atthebottomof thelastpageof Partl of ScheduleD.....'.....

s. Schedule E/F: Creditors Who Have Unsecured Clams (Official Form '106E/F)

sa. 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

Your liabilities

Amount you owe

s 6,054.00

$

+$

$ 52,511.50

0.00

46,457.50

IlEtI summarize Your lneome and Expenses

-

4. Schedule l: Your lncome (Official Form 1061)

Copy your combined monthly income from line 12 of Schedule / "....'...'............

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

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

9,u2.97

5,654.87

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical lnfonnation page 1 ot2

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 8 of 31
Case number (if krowr)

ffi Answer These euestions for Administrative and statistical Records

- 

,

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

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

U Y""

7 what kind of debt do you have?

E Yorr debts are primarily consumer debts. Consum er debts are those "incurred by an individual primarily for a personal,

family, or household purpose." 1 1 U.S.C. S 101 (8). Fill out lines 8-99 for statistical purposes. 28 U.S.C. S 159.

U Yoljr 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 Sfafement of Your Current Monthty lneome: Copy your total current monthly income from Official

Fotm 122A-1 Line 11; OR, Form 1228 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

Debtor l

FiEl Name Mrddle Nsme Lasl Name

From Part 4 on Schedu/e FJF, 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.)

0.00

0.00

0.00

* _----.----..-..- i 1,'/,?3.0o

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

0.00

priority claims. (Copy line 69.)

9f. Debts to pension or profit-sharing plans, and other similar debts. (Copy line 6h.) + $----------8-'08-

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

$

$

.0

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical lnformation page2 o'f 2

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 9 of 31
Debtor 1

Debtor 2

(Spous, if filing) FiEt Name Middle Name Last Name

United States Bankruptcy Court for the: Northern District of lllinois

Case number O Cnecf if this is an

amended filing

Official Form 106A/8

$chedule A/B: Property 12t15

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

category where-you think it fib best. Be as complete and accurate ae possibte. lf two married people are filing together, both ale equally

r""p6njiOn for iupplying correct information. lf more space is needed, aftach a separate sheet to this form. On the top of any additional pages'

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

Describe Each Residence, Building, Land, or Other Beal Estate You Own or Have an lnlerest ln

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

E tto. Go to Part 2.

il Y"r. Where is the property?

What is the property? Check all that apply

U Singte-family home

fl Duplex or multi-unit building

f,] Condominium or cooperative

E Manufactured or mobile home

Do not deduct secured claims or exemptions- Put

the amount ot any secured claims on Schedule D

Creditots Who Have Claims Secured by Property j.1. 1874 Westmore lroyg lnye

Sheet address, if available, or other description

Plainfield IL 60586

City

wiil

County

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

Street address. if available, or other description

County

Current value of the

entire propefi?

Current value of the

portion you own?

ZIP Code

E r-ano

fl lnvestment property

E Timeshare

fl other

llYho has an interest in the property? Check one

E Debtor t only

E Debtor 2 onty

fl Debtor 1 and Debtor 2 only

E[ At least one of the debtors and another

Other information you wish to add about this

property identification number:

What is the property? Check all that apply

E Single-family home

B Duplex or multi-unit building

E Condominium or cooperative

I Manufactured or mobile home

E lano

E lnvestment property

E Timeshare

il otter

Who has an interest in the property? check one.

E Debtor'l only

f,J Debtor 2 only

B D"btor 1 and Debtor 2 onlY

E At leastone ofthe debtors and another

$ 2s 4qq.09 $ 125,000.00

Describe the nature of your ownership

interest (such as fee simple, tenancy by

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

Tenancy by the Entireties

f,] Cfrecx if this is community property

(see instructions)

item, such as local

Do not deduct secured claims or exemplions. Put

the amount of any secured claims on Schedule D:

Credirors Who Have Claims Secured by Property.

Current value of the Current value of the

entire property? Portion You own?

$-

Describe the nature of your ownership

interest (such as fee simple, tenancy by

the entiretiGs, or a life estate), if known'

E cnecf if this is community property

(see instructions)

City

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

property identifi cation number:

Official Form 1064/8

ZIP Code

Schedule A/B: Property page 1

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 10 of 31
Karen Anne LeY

FlEl Name Middle Name Lasl Name

Case number

What is the property? check all that apply.

E Single-family home

E Duptex or multi-unit building

D Condominium or cooperative

B Manufactured or mobile home

E Lano

E Investment propefi

I Timeshare

E otnet

Who has an interest in the property? Check one

E Debtor 1 only

I Debtor 2 only

E Deutor 1 and Debtor 2 only

E At least one of the debtors and another

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D

Creditots Who Have Claims Secured by Propefiy

Street address, if available, or other description

ZIP Code

County

Current value of the

entire property?

Current value of the

portion you own?

$

City Describe the nature of your ownership

interest {such as fee simple, tenancy by

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

E Cnect if this is community property

(see instructions)

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

property identification number:

Add the dollar value of the poftion 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. ....'....... """"""""'+

125,000.00

EA Describe Your vehicles E

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

you own that someone else drives. lf you lease a vehicle, also report it on Schedu/e G: Executory Contracts and Unexpired Leases.

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

Euo

El v".

3.1. Make:

Model:

Year:

Approximate mileage:

Other information:

Dodge

Grand Cara

2011

70000

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

32. Make:

Model:

Year:

Approximate mileage:

Other information:

Who has an interest in the property? Check one

E Debtor'1 only

E Debtor 2 only

E Debtor 1 and Debtor 2 only

[l At least one of ihe debtors and another

E Check if this is community property (see

instructions)

Who has an interest in the property? Check one

U Debtor 1 only

E Debtor z only

E D"bto, 1 and Debior 2 only

E At leastone ofthe debtors and another

fl CtrecX 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 Clains Secured by Propefty.

Current value of the Current value of the

entire property? Portion You own?

6.500.00 $_____!,250.0q

Do notdeductsecured claims orexemptions Put

the amount of any secured claims on Schedule D:

Creditots Who Have Claims Secured by Propefty.

Current value of the Current value of the

entire property? Portion You own?

$--

Official Form 106A/8 Schedule A/B: Property page 2

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 11 of 31
Make:

Model:

Year:

Approximate mileage:

Other information:

3.4. Make:

Model:

Year:

Approximate mileage

Other information:

4.1. Make:

Model:

Year:

Other information:

lf you own or have more than one, list here

4.2. Make:

Model

Year:

Other information:

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

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

lJ tto

D Yes

Karen Anne LeY Case number fi

Who has an interest in the property? Check one

E Debtor'1 only

fl Debtor 2 only

E oebto,'l and Debtor 2 only

E At least one of the debtors and another

D Check if this is community property (see

instructions)

Who has an interest in the property? Check one

E Debtor 1 onty

I Debtor 2 only

B Debtor 1 and Debtor 2 only

D At leastone ofthe debtors and another

E Cnecf if this is community proprty (see

instructions)

Who has an interest in the property? Check one.

E Debtor t only

E Debtor 2 only

E oebtor 1 and Debtor 2 only

E At least one of the debtors and another

E Ctrect if this is community propefi (see

instructions)

Who has an interest in the property? Check one

E Debtor 1 only

fJ Debtor 2 only

B Debtor 1 and Debtor 2 onlY

B At least one of the debtors and another

fl Cnecf if this is community property (see

instructions)

Do not deduct secured claims or exempiions. Put

the amount of any secured claims on Schedule D:

Creditors who Have Clains Secured by Propetty.

Current value of the Current value of the

entire property? portion you own?

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 Current value of the

entire property? Portion You own?

Do not deduct secured claims or exemptions. Put

the amount of any secured ciaims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

Current value of the

portion you own?

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 ......

Do not deduct secured claams or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Propefiy.

Current value of the Current value of the

entire property? Portion You own?

3,250.00

Official Form 106A'/8 Schedule A/Bl Property

t

page 3

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 12 of 31
n^h+^r, Karen Anne LeY

Fid Name Middlo Name Last Name

f,fi! Describe Your Personal and Household ltems

Case number (iruoo@)

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

6. Household goods and furnishings

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

fl tto

E ves. Describe......... Used Furniture and Appliances

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

E tto

E Yes. Describe.......... used lpad; used cell phone

e. Collectibles of value

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

. 

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

E tto

fl Yes. Describe .........

s. Equipmentforsports and hobbies

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

and kayaks; carpentry tools; musical instruments

El no

E Yes. Describe..........

10. Firearms

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

Ouo

D Yes. Describe..........

rt. Clothes

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

E tto

Z Yes. Describe"........ Used personal Clothes and Shoes

12.Jewelry

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

gold, silver

E tto

E Yes. Describe.......... Wedding ring

13. Non-farm animals

Examples: Dogs, cats, birds, horses

El tlo

E Yes. Describe...........

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

Ul tto

fl Yes. Give sPecific

information.

1s. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached

Curent value of the

portion you ourn?

Do not deduct secured claims

or exemptions.

s 800.00

$ 200-.0!

s 600.00

s 300.00

s 1.900.00

Official Form 1064/8 Schedule A'/B: Property page 4

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 13 of 31
Karen Anne Ley Case number (it

Micldle Name

Describe Your Financial Assets

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

to. Cash

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

Current value of the

portion you own?

Do not dduct secured claims

or exemptions.

50.00 E

s

48.00

Cash:

17. Deposits of money

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

and other simitai institutions. lf you have muttiple accounts with the same institution, list each'

ENo

Zl Yes................... Institution name:

Bank of America - Joint Account 17.1. Checking account:

17.2. Checking account:

t z.a. Savings account:

tz.a. Savings account:

17.5. Certificates of deposit:

17 6 Other financial account:

17-7. Other financial account:

I 7.8. Other financial account:

17 9. Other financial account:

Bank of America - lndividual

Northstar - lndividual

ta. Bonds, mutual funds, or publicly traded stocks

Examples: Bond funds, investment acrounts with brokerage firms, mOney market accounts

El No

E Yes...... .....

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

an LLC, partnership, and joint venture

E trto Name of entity: % of ownershiP:

100Yo ,t

100% o/o

O ves. Givespecific Earth Mama Esthetics, lnc. - lnvol' Dissolved 0712416

Common Sense Skin, lnc.

48.00

Bank of America - lndividual

Northstar - Business Checkinq

Harris Business Checking

$"

$.

$.

$.

$.

$.

s

8.00

300.00

0.00

lnstitution or issuer name:

0.00

information about

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

$.

$.

u

100.00

fficial Form 106fu8 Schedule A/B: Property

0o/o

page 5

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 14 of 31
rlehror 1 Karen Anne LeY

FiBt Nsme Middle Name Lasl Name

Case number

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

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

f,lo-n-negatiabte instruments are those you cannot transfer to someone by signing or delivering them.

Oruo

E Yes. Give specific

information about

them............,..,.......

lssuer name:

21. Retirement or pension accounts

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

ENo

E Yes. Listeach

account separately. Type of account:

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 @mpany

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

companies, or others

Eruo

E Yes...... .... .. ...

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)

O r.ro

I Yes

lnstitution name:

$.

$

lnstitution name or individual:

Official Form 106A/8

lssuer name and descriPtion:

Schedule A/B: ProFrtY page 6

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 15 of 31
Debtoill Case

lnterests in an education lR.A, in an account in a qualified ABLE program, or under a qualified state tuition program.

26 U.S.c. SS 530(bX1), 529A(b), and 529(b)(1).

El ruo

E Yes lnstitution name and description. Separately file the records of any interests.l l U.S.C. $ 521{c):

2s. Trusts, equitable or future interests in property (other than anything listed in line 1), and rights or powets

exercisable for your benefit

UNo

E Yes. Give specific

information about them....

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

Examptes'.lnternet domain names, websites, proceeds from royalties and licensing agreements

Eruo

D Yes. Give specific

information about them....

27. Licenses, franchises, and othergeneral intangibles

Examples'. Building permits, exclusive licenses, cooperative associaiion holdings, liquor licenses, professional licenses

El ruo

D Yes. Give specific

information about them....

Money or property owed to You?

Karen Anne LeY

Fid Name Middle Name Last Name

ea. Tax refunds owed to you

El ruo

E Yes. Give specific information

about them, including whether

you already filed the returns

and the tax years.

Federal

State:

Local:

$

$

Current value of the

portion you own?

Do not deduct secured

clalms or exemptions.

$

$

Family support

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

El uo

E Yes. Give specific information

Alimony:

Maintenance:

Support:

Divorce settlement:

Property settlement:

workers' compensation,

E

$

$

$

e

30. Other amounts someone owes You

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

Social Security benefits; unpaid loans you made to someone else

Euo

E yes. Give specific information...............

Official Form 106A/8 Schedule AIB: Property page 7

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 16 of 31
Case number

31. lnterests in insurance policies

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

Debtor l

FiEt Name Middle Name L6t Name

DNo

O Yes. Name the insurance company Comoanv name:

of each policy and list its value.

State Farm - Whole

Beneficiary:

Hubert Ley

Surrender or refund value:

s 3,804.78

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

lf 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.

Eruo

E Yes. Give specifi c information..............

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

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

Ul ruo

E Yes. Describe each claim.

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

to set off claims

Ul tto

D Yes. Describe each claim.

35. Any financial assets you did not already list

Eruo

E 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 ....... + $

4,258.78

I!![| Describe Any Business-Related property You own or Have an tnterest ln. List any realestate in Part'!.

-

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

E No. Go to Part 6.

E Yes. Go to line 38.

Current value of the

portion You own?

3l*:'#fJs *cured cra i ms

34. Accounts receivable or commissions you already earned

ZNo

E Yes. Describe....... s

sg. Office eguipment, furnishings, and supplies

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, elec{ronicdevices

Eruo

@ ves Describe 

Used laptop and printers; Used office fumiture; Used facial rnachines E

475.04

Official Form 106tu8 Schedule A/B: Property page 8

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 17 of 31
Debtor l

FiBl Name Mddle Name La$ Name

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

B tto

EI Y"". Describe.......

Used Massage Table

41. lnventory

Eruo

E[ ves Describe" opened/Used dispensary products

42. lnterests in partnerships or joint ventures

E[ ruo

E yes. Describe....... Name oI entity:

Case number

200.00

4,600.00

% of ownership:

o/"

43. Customer lists, mailing lists, or other compilations

UNo

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

E tto

E Yes. Describe........

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

EI tto

E Yes. Give specific

information ....."...

4s. 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 ...........................

$

s

t

Describe Any Farm- and Gornmercial Fishing'Related Propertyr You Own or Have an lnterest ln,

lf 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?

E[ uo. co to Part 7.

D Yes. Go to line 47.

47. Farm animals

Examples'. Livestock, poultry, farm-raised fish

EI tto

I Yes ......... ........

Current value of the

portion you own?

Do not deduct secured claims

or exemptions.

Official Form 1064/8 Schedule AIB: Property page I

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 18 of 31
Case number tir

Fi6t Name Middle Nane L61 Name

48. Crops+ither growing or harvested

[l ruo

E Yes. Give specific

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

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

El ruo

E Yes........ ...... ...

50. Farm and fishing supplies, chemicals, and feed

EI ruo

D Yes.. ....

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

El ruo

E Yes. Give specific

information .. ......

s2. Add the dollar value of all of your entries from Part 6, including any entries for pages you have attached

]l@ Describe All Property You Own or Have an lnterest in That You Did ilot List Above

Debtor 1 Karen Anne Ley

a 0,00

s3. Do you have other property of any kind you did not already list?

Examples: Season tickets, muntry club membership

Ul ruo

E Yes. Give specific $-

information. ...........,

54.Addthedollarvalueof allof yourentriesfromPart7.Writethatnumberhere................ ... . ....'.....+ $

0.00

Etr tirt tr" rot"tr ot Er"t prrt of tt i" ro.-

56. Part 2: Total vehicles, line 5

57.Paft 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

$ 3,250 00

$ 1,900.00

s__il!9'ftl

$ 5,275.00

60. Part 6: Total farm- and fishing-related property, line 52 $----9!g

61. Part 7: Total other property not listed, line 54 + s,_______! j9

62. Totat personat property. Add lines 56 through 61. ............ ... $----]j€8379 Copy personal property total ) + S----i1'693'78

63.Total of all property on Schedule AiB. Add line 55 + line 62............. $

139,683.78

Official Form 106A18 Schedule A/B: Property page 10

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 19 of 31
Debtor'l

Debtor 2

(Spouse, if liling) FiEl Name Middle Name Last Name

United States Bankruptcy Court for the Northern District of lllinois

Case number

(lf knos)

Official Form 106C

E Cnecf if this is an

amended filing

Schedule G: The Property You Glaim as Exempt 04116

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

Using the property you listed on Schedule AB: Proprty (Otricial Form 106418) as your source, list the property that you claim as exempt. lf more

space is needed, fill out and attach to this page as many copies of Part 2: Additionat 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 speci{y 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 rnarket 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. Hovyever, 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 limiled to the applicable statutory amountEl@ E"rrtry fir" P.op.rty Yo, cl"i- rt Er"-pt

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

d yo, are claiming state and federal nonbankruptcy exemptions' 11 U-S.C' S 522(bX3)

f,l you are claiming federal exemptions. 11 U.S.C. S 522(b)(2)

2. For any property you list on Schedute NB that you claim as exempt, fill in the information below.

Brief description of the property and line on

Schedule NB that lists this property

Current value of the

portion you own

Copy the value from

Schedule NB

$12!pqq.0q_

Amount of the exemption you claim Specific laws that allow exemption

Check only one box for each exemption3l'!'lption, Real Estate

Line from

Schedule NB: l' I

U s 15,000.00

I t OOY" of fair market value, uP to

any applicable statutory limit

$-Q299.09-- d s 2,a00.00

E t OO"Z" of fair market value, uP to

any applicable statutory limit

s800.00 ds 800.00

fl tooY" of fair market value, uP to

any applicable statutory limit

735 rLCS 5112-901

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

\/ehicle

?1

Furniture/Appliance

6

735|LCS 5112-1001(c)

735 |LCS 5/12-1001(b)

Are you claiming a homestead exemption of more than $160'375?

(Subject to adjustment on 4tO1t1g and every 3 years after that for cases filed on or after the date of adjustment')

d r.ro

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

dNo

B Yes

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

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 20 of 31
Karen Anne Ley

@! Additionat Pase

Case number

Brief description ot the property and line

on Schedule NB that lists thls property

Electronics

7

Clothes

11

Jewelry

12

Checking Account

17.1

Checking Account

17.2

Savings Account

17.3

Savinqs Account

Current value of the

portion you own

Copy the value from

Schedule A/B

$________?9!pq

$ 600.00

$_____ r99.0q

50.00

48.00 ds

Amount of the exemption you claim Specitic hws that allow exemption

Check only one box for each exemption

[f s 200.00

E lOoX of fair market value, up to

any applicable staiutory limit

Bsp tOOZ" of fair market value, up to

any applicable statutory limit

d $ 300.00

El t ooY" of fair market value, up to

any applicable statutory limit

735 rLCS 5/12-1001(b)

735ILCS 5112-1001(a)

735ILCS 5/12-1001(b)

ds 50.00 735 ILCS s/12-1001(b)

f,l t ooY, of fair market value, up to

any applicable statutory limit

735 ILCS 5t12-1001(b)

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule N*

Brief

description:

Line from

Schedule A/B:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Sehedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule A/B:

Official Form 't05C

48.00

D toO'2" of hir market value, up to

any applicable statutory limit

48.00 ds 48.00

I t oo% of fair market value, up to

any applicable statutory limit

8.00 ds 8.00

300.00

E t OOY" of fair market value, up to

any applicable statutory limit

d $ 300.00

fl t oo"a of fair market value, up to

any applicable statutory limit

d $ 475.00

E 1OOY" of fair market value, up to

any applicable statutory limit

T3s rLCS 5t12-1001(b)

735 rLCS 5t12-1001(b)

17.4

Checkinq Account

17.6

Office Equipment

39

Trade Tools

735 ILCS 5112-1041(b)

$*_____lzq.0q 735 rLCS 5/12-1001(b)

735 iLCS 5/12-1001(d) 200.00 tr$

40

lnventory 4,600.00

d rcox of fair market value, up to

any applicable statutory limit

il $ 921.00

E 1OOY" of fair market value, up to

any applicable statutory limit

d $ 850.00

E t oO"Z" of fair market value, up to

any applicable statutory limit

735 ILCS 5112-1001(b)

41

Vehicle 850.00 735 rLCS 5/12-1001(b)

3.1

$chedule C: The Property You Claim as Exempt page2 ot&

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 21 of 31
Karen Anne Ley Case number

@| Additionat Pase

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Brief

descriPtion:

Line from

Schedule A/B:

Brief

description:

Line from

Schedule NB:

Brief

description:

Line from

Schedule NB:

Official Form 106C

Brief description of the property and line

on Schedule NB that lists this property

Current value of the Amount of the exemption you claim

portion you own

Copy the value from Check only one boxfor each exemption

Schedule NB

$-----i,Bq4Jg- tr s 

-

V IOO':,, of fair market value, up to

any applicable statutory limit

trsE t OO"Z" of fair market value, up to

any applicable statutory limit

$- B$

E t oOm of fair market value, up to

any applicable statutory limit

$- fl$

E t ooY" of fair market value, up to

any applicable statutory limit

tr$

I t oOY, of fair market value, up to

any applicable statutory limit

fl t oox of fair market value, up to

any applicable statutory limit

tr$

E too"z of fair market value, up to

any applicable statutory limit

$- tls

B t OOY" of fair market value, up to

any applicable statutory limit

us_.--

fl t oo"Z, of fair market value, up to

any applicable statutory limit

fl$

fl too'z of fair markei value, up to

any applicable statutory Iimit

trs

E t OOY" of fuir market value, up to

any applicable statutory limit

tr$

D t oO"Z, of fair market value, uP to

any applicable statutory limit

Schedule C: The Propefi You Claim as Exempt

Specific lai rs that allow exemption

735 ILCS snz-1jx$) Life lnsurance

31

pagei of 3

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 22 of 31
Debtor 1

Debtor 2

Karen Anne Ley

ks Name

(Spouse, if filing) FiEt Name

United States Bankruptcy Court for the:

Case number

Middle Name Lasl Name

Northern District of lllinois

(tf known) fl Cnecf if this is an

amended filing

Official Form 106D

Schedule D: Greditors Who Have Glaims Secured by Property 1A15

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

information. lf more space is needed, copy the Additional Page, fill lt 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).

{. Do any crcditors have claims securcd by your property?

f] ruo. Cnecf this box and submit this form to the court with your other schedules. You have nothing else to report on this form.

d V"". Fill in all of the information below.

m List All secured Gtaims

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

for each claim. lf 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.

Creditods Nare

200 Renaissance Ctr.

Describe the property that secures the claim:

2011 Dodge Grand Caravan

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

E Contingent

I Unliquidated

E oisputeo

Nature of lien. Check all that apply.

( An agre"rent you made (such as mortgage or secured

car loan)

Statutory lien (such as tax lien, mechanic's lien)

Judgment lien from a lawsuit

Other (including a right to offset)

Last 4 digits of account number

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

B Contingent

ff Untiquidated

f,l oispuieo

Nature of lien. Check all that apply.

B 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)

Column B Column C

Valueofcollateral Unsecured

that supports this portion

claim lf any

6,054.00 $ 6,500.00 $

0.00

$_$

Column A

Amount of claim

Do not deduct the

value of collateral.

E nty Financiat

Number Streei

Detroit

City State ZIP Code

Who owes the debt? Check one.

E Debtor 1 only

I Debtor 2 only

fl Debtor 1 and Debtor 2 only

E ,qt least one of the debtors and another

fl Cnecf if this claim relates to a

community debt

Date debtwas incurred

L}A Describe the property that secures the claim:

Creditor's Name

City State ZIP Code

Who owes the debt? Check one.

U Debtor 1 only

f,J oebtor z onty

fl D.btor 1 and Debtor 2 only

L] At least one of the debtors and another

E Check if this claim relates to a

community debt

Date debt was incurred Last il digits of account number

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

Mt 48243

u

u

tr

2098

tr

o

tr

Official Form 106D Schedule D: Creditors Who Have Claims Secured bv Propertv paqe 1 of i

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 23 of 31
Debtor 1

Debtor 2

(Spouse, if filing) FiEt Name

United States Bankruptcy Court for the:

Case number

Middle Name Last Name

Northem District of lllinois

(tf knM)

I CnecX if this is an

amended filing

Official Form 106E/F

Schedule E/F: Greditors llllho Have Unsecured Glaims 12t15

Be as complete and accurate as possible. Use Part 1 for creditorc with PRIORITY claims and Part2tor 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

NB: Praperty (Official Form 106A/8) and on Schedule G: fuecutory Contracts and Unexpired Leases (Official Form 106G). Do not include any

creditors with partially secured claims that are listed in Schedule D: Creditors Who Have C,aims Secured by Property. 1l morc 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).

t@ List Att of Your pRtoRtry Unsecured Glaims

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

EI ruo. co to Part 2.

E ves.

List all of your priority unsecured claims. lf 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. lf 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. lf you have more than two priority

unsecured claims, fill out the Continuation Page of Part '1. lf 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 instructjons for this form in the instruction booklet.)

Total claim Priority Nonpriority

amount amount

$_ $_ $-

d

Priority Creditois Name

City State ZIP Code

Who incurred the debt? Check one.

E Debtor 1 only

E Debtor 2 only

E Debtor 1 and Debtor 2 only

E At least one of the debtors and another

E Checf if ttris claim is for a community debt

ls the claim subject to offset?

ENo

E ves

Priority Creditois Name

City State ZIP Code

Who incurred the debt? Check one.

E Debtolt only

E Debtor z only

E Debtor 1 and Debtor 2 only

E At least one of the debtors and anothel

E check if this claim is for a community debt

ls the claim subject to offset?

f,l No

E yes

Last 4 digits of account number

When was th€ debt incurred?

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

I Contingent

I Unliquidated

fJ oisputec

Type of PRIORITY unsecured claim:

D Domestic support obligations

E Tar"s and certain other debts you owe the government

B Ctaims for death or personal injury ri/hile you were

intoxicated

E otner. speciry

Last 4 digits of aceount number 

-

9_$-$

When was the debt incurred?

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

fl contingent

Ll Unliquidated

E Disputed

Type of PRlORlfi unsecured claim:

f,l Domestic support obligations

B Taxes and certain other debts you owe the government

f,l Cbims for death orpersonal injury while you were

intoxicaied

E Otner. Speciry

Official Form 1O6F/F Schedrlle EIF: Creditorc Who l.lavc Unseclrred Claims naoe 1 of f

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 24 of 31
Debtor 1 Karen Anne Ley

FiEt Name MlJdle Name usl Name

E#]tr List At! of Your NoNPRtoRlrY unsecured claims

- 

,

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

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

U v"t

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

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

included in Part 1. lf more than one creditor holds a particular claim, list the other creditors in Part 3.lf you have more than three nonpriority unsecured

claims fill out the Continuation Page of Part 2.

El oept of Ed/navient Last4digitsofaccountnumber u J t z

Nonpriority Creditois Name

PO Box 9635

Number Street

WilkeS Baffe pA 1g773 Asof thedateyoufile,theclaimis:Checkall thaiapply

siate zlP code I contingent

Discover Fin Svcs LLC

Nonpriority Creditofs Name

PO Box 15316

Number Street

Wilminqton DE 19850

Who incurred the debt? Check one.

E oebtor t onty

E Debtor z only

E Debtor 1 and Debtor 2 only

E At least one of the debtors and another

E check if this claim is for a community debt

ls the claim subject to offset?

Eno

fl ves

mAsofthedateyoufile'theclaimis:checkallthatapply

Total claim

$ 3,514.00 Last 4 digits of account number 6 2 2 2

when was the debt incurred? 4810112007

fl Contingent

D unliquidated

E Disputed

Type of NONPRIORIry unsecured claim:

fl Student toans

E Obligations arising out of a separalion agreement or divorce

that you did not report as priority claims

E Debts to pension or profilsharing plans, and other similar debis

d otner. specity Credit Card

0312 $ 16,489.00

Vyhen was the debt incurred? 03!0112010

n Unliquidated

E oisputeo

Type of NONPRIORIry unsecured claim:

d student loans

E Ouigations arising out of a separation agreement or divorce

that you did not report as priority claims

E Debts to pension or profllsharing plans, and olher similar debts

E other. Specify

D Contingent

E Unllquidated

E oisputed

Type of NONPRIORITY unsecured claim:

d studentloans

E Obligaiions arising out of a separation agreement or divorce

that you did not report as priority claims

f] oebts to pension or profit-sharing plans, and other similar debts

E other. Speciry

City

Who incurred the debt? Check one.

E Debtor t only

El Debtor 2 only

E Debtor 1 and Debtor 2 only

E At least one of the debtors and another

E Check if this claim is for a community deH

ls the claim subject to offset?

fl No

E ves

Dept of Ed/navient Last4digitsof accountnumber _-1 --0 --0 -*0 $_*__ j,9q1.09

When was the debt incurred? 1AlO1l2O11 Nonpriority Creditols Name

PO Box 9635

Number Skeet

Wilkes Barre PA 18773 _Asolthedateyoufile,theclaimis:Checkallthatapply

City State ZIP Code

Who incurred the debt? Check one.

I oebtor t onty

E Debtor 2 only

E Debtor 1 and Debtor 2 only

D At bast one of the debto.s and another

E Cnecf if this claim is for a community debt

ls the claim subject to offset?

Euo

E ves

Offieial Fnrm lOGF/F Schar}rle E/F: Credifors Who Have Unsacurarl Claims nane2 ofl

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 25 of 31
Debtoill Karen Anne Ley Case number

Your NONPRIORITY Unsecured Claims - Gontinuation Page

After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth. Total claim

$ 3,391.00

$, u40.0q

929.00

Chase Card

Nonpriority Creditois Name

PO Box 15298

Number Street

Wilmington DE 1 9850

City State ZIP Code

Who incurred the debt? Check one.

I Debtor t only

E Debtor 2 only

E Debtor 1 and Debtor 2 only

E At bast one of the debtors and another

fl Ctrectt if this claim is for a community debt

ls the claim subject to offset?

ENo

E Yes

Richmond VA 23238

City State ZIP Code

Who incurred the debt? Check one.

( Debtoll onty

E Debtor 2 only

E oertor 1 and Debtor 2 only

E At bast one of the debtors and another

E Ctrect< if this claim is for a community debt

ls the claim subject to offset?

[ruo

fl ves

Capital One Bank USA N

Nonpriority Creditor's Name

15000 Capital One Drive

Number Street

Richmond VA 23238

ZIP Code

Who incurred the debt? Check one,

p Debtor t only

E Debtor z only

E Debto, 1 and Debtor 2 only

E At bast one of the debtors and another

E Check if this claim is for a community debt

ls the claim subject to offset?

fl wo

D ves

Last4 digits ofaccount number 6 1 7 3

when was the debt incurred? 1010112047

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

E Contingent

E Untiquidated

fl oisputeo

Type of NONPRIORITY unsecured claim:

E Student loans

E Obtigations arising out of a separation agreement or divorce thal

you did not report as priority claims

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

Credit Card

Last 4 digits of account number 3 5 4 2

When'! /as the debt incurred? 021A112005

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

fl Contingent

D Unliquldated

E oisputec

Type of NONPRIOR]ry unsecured claim:

fl Student toans

E 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 Credit Card

Last 4 digits of account numuer 5 5 0 3

When was the debt incurred? 0914112010

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

D Contingent

E Unliquidated

fJ Disputeo

Type of NONPRIORITY unsecured claim:

I Student loans

D Obligations arising out of a separation agreement or divorce lhat

you did not report as priority claims

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

Ef ot"r. speciry Credit C?rd

Other

tr

d

mu Capital One

15000 Capital One Drive

Number Streel

tr

d

Offieial Fom 1O6F/F -Scherfille F/F: Credilorc Wha Have lJnsecrrrad Claims naa"3 nr /

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 26 of 31
Karen Anne Ley Case number (,t

Your NONPRIORITY Unsecured Glaims - Gontinuation Page

After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth.

47 52

12t01t2012

Total claim

889.00

s 579.00

$zig .0e

aelJ Capital One Bank USA N

15000 Capital One Drive

Last 4 digits of account number

When was the debt incurred?

Number Street

Richmond VA 23238 As of the date you fil€, the claim is: Check all thai apply

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

fl Student toans

E Ooligations 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 Credit Card

ZIP Code E

tr

Who tr incurred the debt? Check one.

p oebtor t onty

E Debtor 2 only

E Dentor'1 and Debtor 2 only

I At bast one of the debtors and another

E Check if this claim is for a community debt

ls the claim subiect to offset?

E tto

I ves

Capl/bstby

u

d

Nonpriority Credilois Name

50 Northwest Point Road

Last 4 digits of account number

When was the debt incurred?

B 158

12t01t2007

Number Street

Elk Grove Village

ZIP Code

Who incurred the debt? Check one.

fl Debtor t only

E Debtor 2 only

E oebtor 1 and Debtor 2 only

E At least one of the debtors and another

B ctrect it this claim is for a community debt

ls the claim subject to offset?

ENo

E ves

Capital One Bank USA N

Nonpriority Credito/s Name

15000 Capital One Drive

Nmber Street

Richmond VA 23238

ZIP Code

Who incurred the debt? check one.

P Debtor 1 only

E Debtor z onty

I Debtoill and Debtor 2 only

E At bast one of the debtors and another

O Ctrect if this claim is for a community debt

ls the claim subject to offset?

Dno

I ves

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

E Contingent

E Unliquidated

LJ oisputeo

Type of NONPRIORIW unsecured claim:

E Student loans

E Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

E D"bt" to penslon or profit-sharing plans, and other similar debts

Ei[ otnut Credit Card

Last4digitsofaccountnumber 4 A J 0

When was the debt incurred? $1A112015

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

fJ Contingent

D Unliquidated

I oisputed

Type of NONPRIORITY unsecured claim:

fl student loans

E Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

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

Other. Specify Credit Card

IL 60007

City

tr

d

Offinial Fnm 1f)6F/F Schcdule E/F: Crediforc Who Havc llnsccrtrad Claims nonr4 "f 

'7

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 27 of 31
Karen Anne Ley

FiEt Name Middle Name Las{ Name

Case number

Your NONPRIORITY Unsecured Glaims - Continuation Page

After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth.

15.01 | | Dsnb Macys

No'lpr6ritiEred't

PO Box 8218

Last tt digits of account number

When was the debt incurred?

453

a2ta1l200a

Total claim

$ 437.00

$__4?3_.09.

$__ 31!.0q

0

Number

Mason OH 45040 As of the date you file, the claim is: Check all that apply.

E Contingent

E unliquidated

E Disputed

Type of NONPRIORITY unsecured claim:

El student loans

f3 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 Credit Card

Last 4 digits of account number 3 4 I 8

when was the debt incurred? 1110112014

As of the date you file, the claim isr Check all that applv.

E Contingent

E Unliquidated

I oisputed

Type of NONPRIORITY unsecured claim:

E Studentloans

E 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 Credit Card

City ZIP Code

Who incurred the debt? Check one.

I oebtor t onty

E Debtor z only

I o"btor l and Debtor 2 only

E At bast one of the debtors and another

f,l Check if this claim is for a community debt

ls the claim subject to offset?

E tto

E ves

Bk of America

tr

d

Nonpriority Creditofs Name

PO Box 982238

Number Streei

El Paso TX 79998

City State

Who incurred the debt? Check one.

I Debtor t onty

E Debtor z only

I Debtor 1 and Debtor 2 only

E At least one of the debtoB and another

I Cnecf if this claim is for a community debt

ls the claim subject to offset?

ENo

E ves

citi

ZIP Code

tlil

Nonpriority Creditols Name

Pob 6241

Last 4 digiG of account number

When was the debt incurred?

978.3

10t0112011

Who incurred the debt? Check one.

@ Debtor t onty

I Debtor 2 only

E Debtor 1 and Debtor 2 only

E At leasi one of the debtors and another

E Check if this claim is for a community debt

ls the elaim subject to offset?

El no

E ves

SD 57117

ZIP Code

Number Sireel

Sioux Falls

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

El Contingent

E Untiquidated

O Disputed

Type of NONPRIORITY unsecured claim:

f,l student loans

O Obtigations arising out of a separation agreement or divorce that

you did not report as priority claims

fl oeots to pension or profilsharing plans, and other similar debts

U otn"r. sp""iry Credit Card

Official Fnrm 1O6FiF Schadrlle E/F: Crediforc Who Have Unsactrrnd Claims nrn"5 "+7

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 28 of 31
Karen Anne Ley Case number

Your NONPRIORITY Unsecured Glaims - Continuation Page

Middle Namc

After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth.

Syncb/walmart Last 4 digits of account number 4 4 0 0

Nonpriority Creditois Name

PO Box 965024 when was the debt incurred? Og/t: o ftt$ ; S

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

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

E Student loans

E Onligations arising out of a separaiion agreement or divorce that

you did not report as priority claims

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

Other. Speciry Credit Card

998

10/01/1996

2812

04ta1t2016

Total elaim

$__!!2.0q

$___154_.0q.

90.00

Number Street

Orlando FL 32896

tr

tr

tr

City

tr

d

ZIP Code

Who incurred the debt? Check one.

p Debtor t only

I Debtor 2 only

E Dubtor 1 and Debtor 2 only

E At least one of the debtors and another

E Ctrecl if this claim is for a community debt

ls the claim subject to offset?

INo

D Y""

E syn.olop

Nonpriority Creditof s Name

PO Box 965024

Last 4 digits of account number

when was the debt incurred?

Last 4 digits of account number

When was the debt incurred?

Number Street

Orlando FL 32896 As of the date you file, the claim is: Check all that apply

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

E Student loans

f] obligations arising oui of a separation agreement or divorce that

you did not report as priority claims

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

6 otn"r. sp"ciry Credit Card

tr

n

tr

City ZIP Code

Who incurred the debt? Check one.

I Debtort onty

E Debtor 2 onty

fl Debtor 1 and Debtor 2 only

E Ai least one of the debtors and another

E Cnect if this claim is for a community debt

ls the claim subject to offset?

[]ruo

E ves

H&R Accounts, lnc.

Nonpriority Creditods Name

7017 John Deere Pa

Who incurred the debt? Check one.

I Debtor t only

f,J Debtor 2 only

f] oebtor 1 and Debtor 2 only

E At least one ol the debtors and another

B Ctrect if this claim is for a community debt

ls the claim subject to offset?

Eno

fl ves

IL 61265

ZIP Code

Number Street

Moline

As of the date you file, the claim i6: Check all that apply

Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:

fl student loans

I 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 Credit Card

tr

tr

E

tr

d

Offieirl Fnm 1O6tr/F Schedule E/F: Crcdifors Who Havc llnsacnrerl Claims o^o.6 *'/

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 29 of 31
Karen Anne Ley Case number

Your NONPRIORITY Unsecured Glaims - Continuation Page

After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth, Total claim

$_lJrz.0q

$J,u6..22

$*l,e1q.2g

First Data

Who incurred the debt? Check one.

f Debtor 1 only

E Debtor 2 only

E Debtor l and Debtor 2 only

E At least one of ihe debtors and another

E Chect if this claim is for a community debt

ls the claim subject to offset?

ENo

D ves

PayPal

Nonpriority Credito!'s Name

PO Box 5138

NrmtE. Streel

Timonium MD 21494

ZIP Code

Who incurred the debt? Check one.

p oebtor t only

E Debtor 2 only

E Debtor 1 and Debtor 2 only

f] At least one of the debtors and another

I Cnecf if this claim is for a community debt

ls the claim subject to offset?

Euo

fl ves

Last 4 digits of account number 0 0 0 0

when was the debt incurred? 0610112015

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

I Contingent

E Unliquidated

fl Disputeo

Type of NONPRIORITY unsecured claim:

E Studentloans

D Obtigations arising out of a separation agreement or divorce that

you did not report as priority claims

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

d otner, Speciny lnstallment Lease

Last 4 digits of account number 2 I 6 3

When Yvas the debt inourred?

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

E Contingent

E Unliquidated

E Disputed

Type of NONPRIORITY unsecured claim:

E Student loans

B Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

E Debts to pension or proft-sharing plans, and other similar debis

U otnur. speciry Business Loan

Last 4 digits of account number 2 2 5 5

When was the debt incurred?

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

E Contingent

E Unliquidated

E Disputed

Type of NONPRIORITY unsecured claim:

fl student loans

D Obligations arising out of a separation agreernent or divorce thal

you did not report as p.iority claims

D oeots to pension or profilsharing plans, and other similar debts

d otn"r speciry Revolvinq

Nonpriority Creditofs Name

265 Broad Hollow Rd.

Number Street

Melville NY 11747

City ZIP Code

Who incurred the debt? Check one.

I Debtor t only

E Debtor 2 onty

E Debtor 1 and Debtor 2 only

E At least one of the debtors and another

U Cfreck if this claim is for a community debt

ls the claim subiect to offset?

Eruo

E Yes

OnDeck

Nonpriority Creditofs Name

901 N. Stuart Street, Ste 700

Number Street

Arlington VA 22243

Offieial Farm 1Ofitr/tr SchE.ftrle E/F: Credifors Who Have llnsecrrrerl Claims n^n 7 aI7

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 30 of 31
Karen Anne LeY Case number (ffk owr)

Add the Amounts for Each Type of Unsecured Glaim

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

Add the amounts for each type of unsecured claim.

Total claim

6a. Domestic support obligations

6b. Taxes and certain other debts you owe the

government

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

intoxicated

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

Write that amount here.

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

6f. Student loans

69. 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. Add all other nonpriority unsecured claims.

Write that amount here.

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

0.00

$

0.00

6a. 0.00 Total claims

from Part 1

Total claims

from Part 2

6b

6c.

0.00

0.00

6d. *g

6e.

Total claim

$ 22,423.00 6f

69.

6h"

0.00

6h

6i.

0.00

6i. *g 24,034.54

6j

$

46,457.50

Offieiel Form 1O6FIF Schodrrla FIF' Creriilars Who }lava Unscnrrrad Claims nrda nf

Case 16-28276 Doc 1 Filed 09/01/16 Entered 09/01/16 16:11:35 Desc Main

 Document Page 31 of 31