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:

____________________ District of _________________

(State) 

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

Miguel

Northern District of Illinois

Diaz

2 2 6 1

✔

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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

✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁

EI✂

✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁

✄☎✂

 I have not used any business names or EINs.

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.)

_________________________________________________ 

Business name

_________________________________________________ 

Business name

✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁

EI✂

✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁✁

✄☎✂

✔

Cicero

✔

IL

1434 S 57th Avenue

60804

Cook County

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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 2010)). 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 The 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.

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____✆✆____________

✝✞✟✠✡☛ ☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞ ✌ ✞✍✎✠✏✡✑✒✓✏✔ ✠✡ ✕✡✖ ☞☞☞☞☞☞☞☞☎☎☎☎☎☞☞☞☞☞☞☞☞☞☞☞☞☞☞

✝✏✒✠☛✏✗✠ ☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☎☎☎☎☎☞☞☞ ✘✓✞✑ ☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞ ✙✎✒✞ ✑✖✚✟✞☛✛ ✏✜ ✢✑✡✣✑☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞☞

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.

✤✥✦✧★✥✩✧ ✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✫✫✫✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪ ✬✭✮✯ ✪✪✪✪✪✫✪✪✪✪✪✪✪✪ ✰✱✦✮ ✯✲✳✴✮★ ✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪✪

✵✶✷✸✹✶✺✸ ✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫ ✻✼✽✾ ✫✫✫✫✫✫✫✫✫✫✫✫✫✫ ✿❀✷✽ ✾❁❂❃✽✹ ❄❄❄❄❄❄❄❄❄❄❄❄❄❄❄❄❄❄

✵✶✷✸✹✶✺✸ ✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫✫ ✻✼✽✾ ✫✫✫✫✫✫✫✫✫✫✫✫✫✫ ✿❀✷✽ ✾❁❂❃✽✹ ❄❄❄❄❄❄❄❄❄❄❄❄❄❄❄❄❄❄

✔

✔

✔

✔

✔

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Part 3: Report About Any Businesses You Ow n 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 Ow n 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? 

✔

✔

✔

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

15. 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. 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.

✔

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Part 6: Answ er 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

✔

✔

✔

08/15/2016

✔

/s/

✔

08/15/2016

✔

/s/ Miguel Diaz

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 Document Page 6 of 70
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 

Robert Perlstein

630-254-4503

Morton Grove

Robert L. Perlstein

IL

IL

/s/ Robert Perlstein 08/15/2016

perltone5@yahoo.com

8634 Callie Ave

3123553

60053

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✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌✍✠ ✎✏✑✑✒✓✔ ✕✖ ✗✕✏✓ ✘✙✙✚✛✙ ✒✜✢ ✣✤✒✥✤✦✤✛✤✚✙ ✒✜✢ ✧✚✓✛✒✤✜ ✎✛✒✛✤✙✛✤★✒✦ ✩✜✖✕✓✑✒✛✤✕✜ ✪☎✫✬ ✡ ✞✁ ✭

✮✯✯✰✱✰✲✳ ✴✵✶✷ ✸✹✺✻✼✷

Summary of Your Assets and Liabilities and Certain Statistical Information ✽✾✿✽❀

❁✚ ✒✙ ★✕✑❂✦✚✛✚ ✒✜✢ ✒★★✏✓✒✛✚ ✒✙ ❂✕✙✙✤✥✦✚❃ ✩✖ ✛❄✕ ✑✒✓✓✤✚✢ ❂✚✕❂✦✚ ✒✓✚ ✖✤✦✤✜❅ ✛✕❅✚✛❆✚✓❇ ✥✕✛❆ ✒✓✚ ✚❈✏✒✦✦✔ ✓✚✙❂✕✜✙✤✥✦✚ ✖✕✓ ✙✏❂❂✦✔✤✜❅ ★✕✓✓✚★✛

✤✜✖✕✓✑✒✛✤✕✜❃ ❉✤✦✦ ✕✏✛ ✒✦✦ ✕✖ ✔✕✏✓ ✙★❆✚✢✏✦✚✙ ✖✤✓✙✛❊ ✛❆✚✜ ★✕✑❂✦✚✛✚ ✛❆✚ ✤✜✖✕✓✑✒✛✤✕✜ ✕✜ ✛❆✤✙ ✖✕✓✑❃ ✩✖ ✔✕✏ ✒✓✚ ✖✤✦✤✜❅ ✒✑✚✜✢✚✢ ✙★❆✚✢✏✦✚✙ ✒✖✛✚✓ ✔✕✏ ✖✤✦✚

✔✕✏✓ ✕✓✤❅✤✜✒✦ ✖✕✓✑✙❇ ✔✕✏ ✑✏✙✛ ✖✤✦✦ ✕✏✛ ✒ ✜✚❄ Summary ✒✜✢ ★❆✚★❋ ✛❆✚ ✥✕● ✒✛ ✛❆✚ ✛✕❂ ✕✖ ✛❆✤✙ ❂✒❅✚❃

Part 1: Summarize Your Assets

✗✕✏✓ ✒✙✙✚✛✙

❍☎✆✍✬ ✞✁ ■❏☎❑ ▲✞✍ ✞■▼

◆❖ Schedule A/B: Property P✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞◗❘❙❚

◆❯❖ ❱✞✪▲ ✆✂▼✬ ❲❲❳ ❨✞❑☎✆ ✟✬☎✆ ✬❩❑☎❑✬❳ ✁✟✞✠ Schedule A/B ❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬

❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

◆❫❖ ❱✞✪▲ ✆✂▼✬ ☞✭❳ ❨✞❑☎✆ ✪✬✟❩✞▼☎✆ ✪✟✞✪✬✟❑▲❳ ✁✟✞✠ Schedule A/B ❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬ ❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

◆❴❖ ❱✞✪▲ ✆✂▼✬ ☞❵❳ ❨✞❑☎✆ ✞✁ ☎✆✆ ✪✟✞✪✬✟❑▲ ✞▼ Schedule A/B ❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬

❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

Part 2: Summarize Your Liabilities

✗✕✏✓ ✦✤✒✥✤✦✤✛✤✚✙

◗✠✞✍▼❑ ▲✞✍ ✞■✬

❛❖ Schedule D: Creditors Who Have Claims Secured by Property P✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞❜❚

❛❯❖ ❱✞✪▲ ❑❏✬ ❑✞❑☎✆ ▲✞✍ ✆✂❩❑✬❝ ✂▼ ❱✞✆✍✠▼ ◗❳ Amount of claim, ☎❑ ❑❏✬ ❞✞❑❑✞✠ ✞✁ ❑❏✬ ✆☎❩❑ ✪☎✫✬ ✞✁ ❡☎✟❑ ✡ ✞✁ Schedule D ❬❬❬❬❬❬❬❬❬❬❬❬ ❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

❢❖ Schedule E/F: Creditors Who Have Unsecured Claims P✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞❣❘✝❚

❢❯❖ ❱✞✪▲ ❑❏✬ ❑✞❑☎✆ ✄✆☎✂✠❩ ✁✟✞✠ ❡☎✟❑ ✡ P✪✟✂✞✟✂❑▲ ✍▼❩✬✄✍✟✬❝ ✄✆☎✂✠❩❚ ✁✟✞✠ ✆✂▼✬ ☞✬ ✞✁ Schedule E/F ❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬

❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

❢❫❖ ❱✞✪▲ ❑❏✬ ❑✞❑☎✆ ✄✆☎✂✠❩ ✁✟✞✠ ❡☎✟❑ ✭ P▼✞▼✪✟✂✞✟✂❑▲ ✍▼❩✬✄✍✟✬❝ ✄✆☎✂✠❩❚ ✁✟✞✠ ✆✂▼✬ ☞❤ ✞✁ Schedule E/F❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬ ✐ ❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

✗✕✏✓ ✛✕✛✒✦ ✦✤✒✥✤✦✤✛✤✚✙ ❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

Part 3: Summarize Your Income and Expenses

❥❖ Schedule I: Your Income P✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞❦❚

❱✞✪▲ ▲✞✍✟ ✄✞✠❞✂▼✬❝ ✠✞▼❑❏✆▲ ✂▼✄✞✠✬ ✁✟✞✠ ✆✂▼✬ ✡✭ ✞✁ Schedule I ❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬

❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

❧❖ Schedule J: Your Expenses P✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞♠❚

❱✞✪▲ ▲✞✍✟ ✠✞▼❑❏✆▲ ✬♥✪✬▼❩✬❩ ✁✟✞✠ ✆✂▼✬ ✭✭✄ ✞✁ Schedule J ❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬❬ ❭ ❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪❪

♦♣❫qrs ◆ tttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttt

✉✈✇12 3456 7✈8896 3456 10412 3456

♦♣❫qrs ❛ tttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttt

❶❷❸❹❺❻❼❽ ❾❿ ❿❾➀❾➁➂➃ ✉✈✇12 3456 7✈8896 3456 10412 3456

➄➅➆q♣➇ ➈q❯q♣➉ ➊❯➅➋s➌➍q❴➎ ➏r➌sq ➐rs q➑♣➒ ➓➓➓➓➓➓➓➓➓➓➓➓➓➓➓➓➓➓➓➓➓➓ ♦➆➉qs➆❴q r➐ ➓➓➓➓➓➓➓➓➓➓

❶❷➔→➔❼➃

➏❯➉♣ ➅➌➣❫♣s ttttttttttttttttttttttttttttttttttttttttttt

❶↔❿ ↕➁❹➙➁➃

 ❉✤✦✦ ✤✜ ✛❆✤✙ ✤✜✖✕✓✑✒✛✤✕✜ ✛✕ ✤✢✚✜✛✤✖✔ ✔✕✏✓ ★✒✙✚➛

➜ ➝➞➟➠➡ ➢➤ ➥➞➢➦ ➢➦ ➧➨

➧➩➟➨➫➟➫ ➤➢➭➢➨➯

0.00

0.00

254,316.82

44,771.00

0.00

Northern District of Illinois

196.00

44,771.00

159.00

Miguel Diaz

254,316.82

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 8 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰✫ ✱✲✳✳✴✵✶ ✷✸ ✹✷✲✵ ✺✻✻✼✽✻ ✴✾✿ ❀❁✴❂❁❃❁✽❁✼✻ ✴✾✿ ❄✼✵✽✴❁✾ ✱✽✴✽❁✻✽❁❅✴❃ ❆✾✸✷✵✳✴✽❁✷✾ ❇✦❈❉ ❊ ✩✣ ❊

Part 4: Answ er These Questions for Administrative and Statistical Records

❋● ✺✵✼ ✶✷✲ ✸❁❃❁✾❍ ✸✷✵ ❂✴✾■✵✲❏✽❅✶ ✲✾✿✼✵ ❄❑✴❏✽✼✵✻ ▲▼ ◆◆▼ ✷✵ ◆❖P

◗ ❘✩❙ ❚✩✰ ❯✦❱❉ ❲✩❳❯✤❲❈ ❳✩ ✪❉❇✩✪❳ ✩❲ ❳❯✤❨ ❇✦✪❳ ✩✣ ❳❯❉ ✣✩✪✫❙ ❩❯❉✥❬ ❳❯✤❨ ❭✩❪ ✦❲❫ ❨✰❭✫✤❳ ❳❯✤❨ ✣✩✪✫ ❳✩ ❳❯❉ ✥✩✰✪❳ ❴✤❳❯ ❵✩✰✪ ✩❳❯❉✪ ❨✥❯❉❫✰✧❉❨❙

◗ ❚❉❨

❛● ❜❑✴✽ ■❁✾✿ ✷✸ ✿✼❂✽ ✿✷ ✶✷✲ ❑✴❝✼P

◗ ✹✷✲✵ ✿✼❂✽✻ ✴✵✼ ❏✵❁✳✴✵❁❃✶ ❅✷✾✻✲✳✼✵ ✿✼❂✽✻❞ Consumer debts ✦✪❉ ❳❯✩❨❉ ❡✤❲✥✰✪✪❉❫ ❭❵ ✦❲ ✤❲❫✤❱✤❫✰✦✧ ❇✪✤✫✦✪✤✧❵ ✣✩✪ ✦ ❇❉✪❨✩❲✦✧❢

✣✦✫ ✤✧❵❢ ✩✪ ❯✩✰❨❉❯✩✧❫ ❇✰✪❇✩❨❉❙❣ ✬✬ ❤❙✯❙❩❙ ✐ ✬✭✬❥❦❧❙ ★✤✧✧ ✩✰❳ ✧✤❲❉❨ ❦♠♥❈ ✣✩✪ ❨❳✦❳✤❨❳✤✥✦✧ ❇✰✪❇✩❨❉❨❙ ❊❦ ❤❙✯❙❩❙ ✐ ✬♦♥❙

◗ ✹✷✲✵ ✿✼❂✽✻ ✴✵✼ ✾✷✽ ❏✵❁✳✴✵❁❃✶ ❅✷✾✻✲✳✼✵ ✿✼❂✽✻❙ ❚✩✰ ❯✦❱❉ ❲✩❳❯✤❲❈ ❳✩ ✪❉❇✩✪❳ ✩❲ ❳❯✤❨ ❇✦✪❳ ✩✣ ❳❯❉ ✣✩✪✫❙ ❩❯❉✥❬ ❳❯✤❨ ❭✩❪ ✦❲❫ ❨✰❭✫✤❳

❳❯✤❨ ✣✩✪✫ ❳✩ ❳❯❉ ✥✩✰✪❳ ❴✤❳❯ ❵✩✰✪ ✩❳❯❉✪ ❨✥❯❉❫✰✧❉❨❙

♣● q✵✷✳ ✽❑✼ Statement of Your Current Monthly Incomer ❩✩❇❵ ❵✩✰✪ ❳✩❳✦✧ ✥✰✪✪❉❲❳ ✫✩❲❳❯✧❵ ✤❲✥✩✫❉ ✣✪✩✫ ✢✣✣✤✥✤✦✧

★✩✪✫ ✬❊❊s♠✬ t✤❲❉ ✬✬✉ ✈✇❢ ★✩✪✫ ✬❊❊1 t✤❲❉ ✬✬✉ ✈✇❢ ★✩✪✫ ✬❊❊❩♠✬ t✤❲❉ ✬2❙ 3 ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

4● ❄✷❏✶ ✽❑✼ ✸✷❃❃✷5❁✾❍ ✻❏✼❅❁✴❃ ❅✴✽✼❍✷✵❁✼✻ ✷✸ ❅❃✴❁✳✻ ✸✵✷✳ 6✴✵✽ 7▼ ❃❁✾✼ 8 ✷✸ Schedule E/Fr

9✷✽✴❃ ❅❃✴❁✳

q✵✷✳ 6✴✵✽ 7 ✷✾ Schedule E/F▼ ❅✷❏✶ ✽❑✼ ✸✷❃❃✷5❁✾❍10

♥✦❙ ❶✩✫❉❨❳✤✥ ❨✰❇❇✩✪❳ ✩❭✧✤❈✦❳✤✩❲❨ ❥❩✩❇❵ ✧✤❲❉ ✮✦❙❧ 3✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♥❭❙ ❷✦❪❉❨ ✦❲❫ ✥❉✪❳✦✤❲ ✩❳❯❉✪ ❫❉❭❳❨ ❵✩✰ ✩❴❉ ❳❯❉ ❈✩❱❉✪❲✫❉❲❳❙ ❥❩✩❇❵ ✧✤❲❉ ✮❭❙❧ 3✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♥✥❙ ❩✧✦✤✫❨ ✣✩✪ ❫❉✦❳❯ ✩✪ ❇❉✪❨✩❲✦✧ ✤❲❸✰✪❵ ❴❯✤✧❉ ❵✩✰ ❴❉✪❉ ✤❲❳✩❪✤✥✦❳❉❫❙ ❥❩✩❇❵ ✧✤❲❉ ✮✥❙❧ 3✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♥❫❙ ✯❳✰❫❉❲❳ ✧✩✦❲❨❙ ❥❩✩❇❵ ✧✤❲❉ ✮✣❙❧ 3✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♥❉❙ ✢❭✧✤❈✦❳✤✩❲❨ ✦✪✤❨✤❲❈ ✩✰❳ ✩✣ ✦ ❨❉❇✦✪✦❳✤✩❲ ✦❈✪❉❉✫❉❲❳ ✩✪ ❫✤❱✩✪✥❉ ❳❯✦❳ ❵✩✰ ❫✤❫ ❲✩❳ ✪❉❇✩✪❳ ✦❨

❇✪✤✩✪✤❳❵ ✥✧✦✤✫❨❙ ❥❩✩❇❵ ✧✤❲❉ ✮❈❙❧

3✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♥✣❙ ❶❉❭❳❨ ❳✩ ❇❉❲❨✤✩❲ ✩✪ ❇✪✩✣✤❳♠❨❯✦✪✤❲❈ ❇✧✦❲❨❢ ✦❲❫ ✩❳❯❉✪ ❨✤✫✤✧✦✪ ❫❉❭❳❨❙ ❥❩✩❇❵ ✧✤❲❉ ✮❯❙❧ ❹ 3✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♥❈❙ 9✷✽✴❃❞ s❫❫ ✧✤❲❉❨ ♥✦ ❳❯✪✩✰❈❯ ♥✣❙ 3✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✔

0.00

Miguel Diaz

196.00

0.00

0.00

0.00

✔

0.00

0.00

0.00

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 9 of 70
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 Ow n 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: ______________________ District of __________

(State) 

Case number ___________________________________________

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

✁ Check if this is an

amended filing

✂✄☎✆ ✝ ✞✟ ✠✠✠

Northern District of Illinois

✔

10

Miguel Diaz

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 10 of 70
_______________________________________ 

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?

$________________

✆✝✞✟ ✠✠✠ ✡☛ ✠✠

☞✌✍✍✍✍

4,271.00

Condition: Good;

2005

10

4,271.00

Ram

103000

2

0.00

✔

Dodge

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 11 of 70
✁✁✁✂ 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?

$________________

✁✁✁ 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 ............................................................................................................................✝ $_________________

✞✟✠✡ ☛☛☛ ☞✌ ☛☛

4,271.00

10

✔

3

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 12 of 70
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 ........................................................................................................................................................✁ $______________________

✂✄☎✆ ✝✝✝ ✞✟ ✝✝

10

✔

✔

✔

✔

✔

✔

✔

✔

✔

Ordinary Household Goods and Furnishings

Basic Wearing Apparel

450.00

4

150.00

0.00

0.00

0.00

0.00

300.00

0.00

0.00

0.00

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 13 of 70
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:

_____________________________________________________________________ ___________%

_____________________________________________________________________ ___________%

_____________________________________________________________________ ___________%

$__________________

$__________________

$__________________

✁✂✄☎ ✆✆✆ ✝✞ ✆✆

✔

✔

✔

✔

5

50.00

10

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 14 of 70
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: ______________________________________________________________________

✁ental 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:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

$__________________

$__________________

$__________________

✄☎✆✝ ✞✞✞ ✟✠ ✞✞

✔

✔

✔

✔

6 10

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

$______________________

✁✂✄☎ ✆✆✆ ✝✞ ✆✆

✔

✔

✔

✔

✔

✔

✔

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

7 10

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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 Ow n 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....... $_____________________

✄☎✆✝ ✞✞✞ ✟✠ ✞✞

✔

40,050.00

✔

✔

✔

✔

0.00

0.00

40,000.00

0.00

✔

8

Workers Compensation

10

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 17 of 70
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 Ow n 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...........................

$___________________

✂✄☎✆ ✝✝✝ ✞✟ ✝✝

✔

9 10

0.00

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 18 of 70
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 Ow n 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........................................................................................ $_________________

✂✄☎✆ ✝✝✝ ✞✟ ✝✝

✔

44,771.00

40,050.00

0.00

0.00

0.00

0.00

450.00

10

44,771.00 44,771.00

4,271.00

10

0.00

0.00

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 19 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌ ✍✎✏✑✒✓✔✑ ✕✖ ✗✏✑ ✘✙✚✛✑✙✜✢ ✣✚✓ ✕✔✤✥✦ ✤✧ ★✩✑✦✛✜ ✪☎✫✬ ✡ ✞✁ ✭✭

✮✯✯✰✱✰✲✳ ✴✵✶✷ ✸✹✺✻

Schedule C: T he Property You Claim as Exempt ✼✽✾✿

❀✬ ☎❁ ✄✞✠✪✆✬❂✬ ☎❃❄ ☎✄✄❅✟☎❂✬ ☎❁ ✪✞❁❁✂❆✆✬❇ ❈✁ ❂❉✞ ✠☎✟✟✂✬❄ ✪✬✞✪✆✬ ☎✟✬ ✁✂✆✂❃✫ ❂✞✫✬❂❊✬✟❋ ❆✞❂❊ ☎✟✬ ✬●❅☎✆✆❍ ✟✬❁✪✞❃❁✂❆✆✬ ✁✞✟ ❁❅✪✪✆❍✂❃✫ ✄✞✟✟✬✄❂ ✂❃✁✞✟✠☎❂✂✞❃❇

■❁✂❃✫ ❂❊✬ ✪✟✞✪✬✟❂❍ ❍✞❅ ✆✂❁❂✬❄ ✞❃ Schedule A/B: Property ❏✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞❑▲❀▼ ☎❁ ❍✞❅✟ ❁✞❅✟✄✬❋ ✆✂❁❂ ❂❊✬ ✪✟✞✪✬✟❂❍ ❂❊☎❂ ❍✞❅ ✄✆☎✂✠ ☎❁ ✬◆✬✠✪❂❇ ❈✁ ✠✞✟✬

❁✪☎✄✬ ✂❁ ❃✬✬❄✬❄❋ ✁✂✆✆ ✞❅❂ ☎❃❄ ☎❂❂☎✄❊ ❂✞ ❂❊✂❁ ✪☎✫✬ ☎❁ ✠☎❃❍ ✄✞✪✂✬❁ ✞✁ Part 2: Additional Page ☎❁ ❃✬✄✬❁❁☎✟❍❇ ❃ ❂❊✬ ❂✞✪ ✞✁ ☎❃❍ ☎❄❄✂❂✂✞❃☎✆ ✪☎✫✬❁❋ ❉✟✂❂✬

❍✞❅✟ ❃☎✠✬ ☎❃❄ ✄☎❁✬ ❃❅✠❆✬✟ ❏✂✁ ❖❃✞❉❃▼❇

P✚✙ ✑✤✎✏ ✥✜✑✦ ✚◗ ✛✙✚✛✑✙✜✢ ✢✚✓ ✎✔✤✥✦ ✤✧ ✑✩✑✦✛✜❘ ✢✚✓ ✦✓✧✜ ✧✛✑✎✥◗✢ ✜✏✑ ✤✦✚✓❙✜ ✚◗ ✜✏✑ ✑✩✑✦✛✜✥✚❙ ✢✚✓ ✎✔✤✥✦❚ ❯❙✑ ❱✤✢ ✚◗ ✒✚✥❙❲ ✧✚ ✥✧ ✜✚ ✧✜✤✜✑ ✤

✧✛✑✎✥◗✥✎ ✒✚✔✔✤✙ ✤✦✚✓❙✜ ✤✧ ✑✩✑✦✛✜❚ ❳✔✜✑✙❙✤✜✥❨✑✔✢❘ ✢✚✓ ✦✤✢ ✎✔✤✥✦ ✜✏✑ ◗✓✔✔ ◗✤✥✙ ✦✤✙❩✑✜ ❨✤✔✓✑ ✚◗ ✜✏✑ ✛✙✚✛✑✙✜✢ ❬✑✥❙❲ ✑✩✑✦✛✜✑✒ ✓✛ ✜✚ ✜✏✑ ✤✦✚✓❙✜

✚◗ ✤❙✢ ✤✛✛✔✥✎✤❬✔✑ ✧✜✤✜✓✜✚✙✢ ✔✥✦✥✜❚ ✍✚✦✑ ✑✩✑✦✛✜✥✚❙✧—✧✓✎✏ ✤✧ ✜✏✚✧✑ ◗✚✙ ✏✑✤✔✜✏ ✤✥✒✧❘ ✙✥❲✏✜✧ ✜✚ ✙✑✎✑✥❨✑ ✎✑✙✜✤✥❙ ❬✑❙✑◗✥✜✧❘ ✤❙✒ ✜✤✩❭✑✩✑✦✛✜

✙✑✜✥✙✑✦✑❙✜ ◗✓❙✒✧—✦✤✢ ❬✑ ✓❙✔✥✦✥✜✑✒ ✥❙ ✒✚✔✔✤✙ ✤✦✚✓❙✜❚ ❪✚❱✑❨✑✙❘ ✥◗ ✢✚✓ ✎✔✤✥✦ ✤❙ ✑✩✑✦✛✜✥✚❙ ✚◗ ❫❴❴❵ ✚◗ ◗✤✥✙ ✦✤✙❩✑✜ ❨✤✔✓✑ ✓❙✒✑✙ ✤ ✔✤❱ ✜✏✤✜

✔✥✦✥✜✧ ✜✏✑ ✑✩✑✦✛✜✥✚❙ ✜✚ ✤ ✛✤✙✜✥✎✓✔✤✙ ✒✚✔✔✤✙ ✤✦✚✓❙✜ ✤❙✒ ✜✏✑ ❨✤✔✓✑ ✚◗ ✜✏✑ ✛✙✚✛✑✙✜✢ ✥✧ ✒✑✜✑✙✦✥❙✑✒ ✜✚ ✑✩✎✑✑✒ ✜✏✤✜ ✤✦✚✓❙✜❘ ✢✚✓✙ ✑✩✑✦✛✜✥✚❙

❱✚✓✔✒ ❬✑ ✔✥✦✥✜✑✒ ✜✚ ✜✏✑ ✤✛✛✔✥✎✤❬✔✑ ✧✜✤✜✓✜✚✙✢ ✤✦✚✓❙✜❚

Part 1: Identify the Property You Claim as Exempt

✡❇ ❛✏✥✎✏ ✧✑✜ ✚◗ ✑✩✑✦✛✜✥✚❙✧ ✤✙✑ ✢✚✓ ✎✔✤✥✦✥❙❲❜ Check one only, even if your spouse is filing with you.

❝ ❞✞❅ ☎✟✬ ✄✆☎✂✠✂❃✫ ❁❂☎❂✬ ☎❃❄ ✁✬❄✬✟☎✆ ❃✞❃❆☎❃❖✟❅✪❂✄❍ ✬◆✬✠✪❂✂✞❃❁❇ ✡✡ ■❇❡❇✌❇ ❢ ❣❤❤❏❆▼❏✐▼

❝ ❞✞❅ ☎✟✬ ✄✆☎✂✠✂❃✫ ✁✬❄✬✟☎✆ ✬◆✬✠✪❂✂✞❃❁❇ ✡✡ ■❇❡❇✌❇ ❢ ❣❤❤❏❆▼❏❤▼

❤❇ P✚✙ ✤❙✢ ✛✙✚✛✑✙✜✢ ✢✚✓ ✔✥✧✜ ✚❙ Schedule A/B ✜✏✤✜ ✢✚✓ ✎✔✤✥✦ ✤✧ ✑✩✑✦✛✜❘ ◗✥✔✔ ✥❙ ✜✏✑ ✥❙◗✚✙✦✤✜✥✚❙ ❬✑✔✚❱❚

❥❦❧♠♥ ♦♠♣q❦❧rs❧t✉ t♥ s✈♠ r❦tr♠❦s✇ 1✉♦ 2❧✉♠ t✉

Schedule A/B s✈1s 2❧♣s♣ s✈❧♣ r❦tr♠❦s✇

34❦❦♠✉s 5124♠ t♥ s✈♠

rt❦s❧t✉ ✇t4 t6✉

78910 ❶❷❸ ❹❺❻❼❸ ❽❾8❿

Schedule A/B

➀➁t4✉s t♥ s✈♠ ♠➂♠➁rs❧t✉ ✇t4 q21❧➁

Check only one box for each exemption. 

❀✟✂✬✁

❄✬❁✄✟✂✪❂✂✞❃➃ ➄✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭ ❝ ➄ ✭✭✭✭✭✭✭✭✭✭✭✭

❝ ✡☛☛➅ ✞✁ ✁☎✂✟ ✠☎✟❖✬❂ ➆☎✆❅✬❋ ❅✪ ❂✞

☎❃❍ ☎✪✪✆✂✄☎❆✆✬ ❁❂☎❂❅❂✞✟❍ ✆✂✠✂❂

✭✭✭✭✭✭

❀✟✂✬✁

❄✬❁✄✟✂✪❂✂✞❃➃ ➄✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭ ❝ ➄ ✭✭✭✭✭✭✭✭✭✭✭✭

❝ ✡☛☛➅ ✞✁ ✁☎✂✟ ✠☎✟❖✬❂ ➆☎✆❅✬❋ ❅✪ ❂✞

☎❃❍ ☎✪✪✆✂✄☎❆✆✬ ❁❂☎❂❅❂✞✟❍ ✆✂✠✂❂

❀✟✂✬✁

❄✬❁✄✟✂✪❂✂✞❃➃ ➄✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭ ❝ ➄ ✭✭✭✭✭✭✭✭✭✭✭✭

❝ ✡☛☛➅ ✞✁ ✁☎✂✟ ✠☎✟❖✬❂ ➆☎✆❅✬❋ ❅✪ ❂✞

➇✂❃✬ ☎❃❍ ☎✪✪✆✂✄☎❆✆✬ ❁❂☎❂❅❂✞✟❍ ✆✂✠✂❂✁✟✞✠

Schedule A/B: ✭✭✭✭✭✭

➈➉ ❳✙✑ ✢✚✓ ✎✔✤✥✦✥❙❲ ✤ ✏✚✦✑✧✜✑✤✒ ✑✩✑✦✛✜✥✚❙ ✚◗ ✦✚✙✑ ✜✏✤❙ ➊➋➌➍➎➏➐➑❜

❏❡❅❆➒✬✄❂ ❂✞ ☎❄➒❅❁❂✠✬❃❂ ✞❃ ➓▲☛✡▲✡➔ ☎❃❄ ✬➆✬✟❍ ✐ ❍✬☎✟❁ ☎✁❂✬✟ ❂❊☎❂ ✁✞✟ ✄☎❁✬❁ ✁✂✆✬❄ ✞❃ ✞✟ ☎✁❂✬✟ ❂❊✬ ❄☎❂✬ ✞✁ ☎❄➒❅❁❂✠✬❃❂❇▼

→ ➣✞

→ ❞✬❁❇ ↔✂❄ ❍✞❅ ☎✄●❅✂✟✬ ❂❊✬ ✪✟✞✪✬✟❂❍ ✄✞➆✬✟✬❄ ❆❍ ❂❊✬ ✬◆✬✠✪❂✂✞❃ ❉✂❂❊✂❃ ✡❋❤✡❣ ❄☎❍❁ ❆✬✁✞✟✬ ❍✞❅ ✁✂✆✬❄ ❂❊✂❁ ✄☎❁✬↕

→ ➣✞

→ ❞✬❁

➙➛➜➝➞➟ ➠ ➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡

➢➤➥➦➧ ➨➩➫➭ ➯➤➲➲➳➭ ➨➩➫➭ ➵➩➦➧ ➨➩➫➭

➙➛➜➝➞➟ ➸ ➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡

➺➻➼➽➾➚➪➶ ➹➘ ➘➹➴➹➷➬➮ ➢➤➥➦➧ ➨➩➫➭ ➯➤➲➲➳➭ ➨➩➫➭ ➵➩➦➧ ➨➩➫➭

➱✃❐➝➛❒ ❮➝❰➝➛Ï Ð❰✃Ñ➟ÒÓ➝ÔÕ Ö➞Ò➟➝ ×➞➟ ➝Ø➛Ù ✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭ ➙❐Ï➝➟❐Ô➝ ➞× ✭✭✭✭✭✭✭✭✭✭

➺➻ÚÛÚ➪➮

Ö❰Ï➛ ✃ÒÜ➜➛➟ ➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡➡

➺Ý➘ Þ➷➽ß➷➮

 P✥✔✔ ✥❙ ✜✏✥✧ ✥❙◗✚✙✦✤✜✥✚❙ ✜✚ ✥✒✑❙✜✥◗✢ ✢✚✓✙ ✎✤✧✑✖

à áâãäå æç èâæé æé êë

êìãëíãí çæîæëï

ðñòóôõôó ö÷øù úû÷ú ÷ööüø òýòþñúôüÿ

➇✂❃✬ ✁✟✞✠

Schedule A/B: ✭✭✭✭✭✭

➇✂❃✬ ✁✟✞✠

Schedule A/B: ✭✭✭✭✭✭

6

11

Clothing - Basic Wearing Apparel

4,271.00

Household goods - Ordinary

Household Goods and

Furnishings

150.00

2005 Dodge Ram

300.00

✔

735 Ill. Comp. Stat. 5/12-1001 (a)

735 Ill. Comp. Stat. 5/12-1001 (b)

✔

735 Ill. Comp. Stat. 5/12-1001 (b) 735

✔ Ill. Comp. Stat. 5/12-1001 (c)

✔

✔

Northern District of Illinois

300.00

150.00

4,271.00

Miguel Diaz

2

3.1

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 20 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯ ✰✱✲✳✴✵✶✳ ✷✸ ✹✲✳ ✺✻✼✽✳✻✾✿ ❀✼✵ ✷✶❁❂❃ ❁❄ ❅❆✳❃✽✾ ❇✦❈❉ ❊❊❊ ✼❋ ❊❊

Part 2: Additional Page

●❍■❏❑ ▲❏▼◆❍■❖P■◗❘ ◗❑ P❙❏ ❖❍◗❖❏❍P❚ ❯❘▲ ❱■❘❏

◗❘ Schedule A/B P❙❯P ❱■▼P▼ P❙■▼ ❖❍◗❖❏❍P❚

❲❳❍❍❏❘P ❨❯❱❳❏ ◗❑ P❙❏

❖◗❍P■◗❘ ❚◗❳ ◗❩❘

❬❭❪❫ ❴❵❛ ❜❝❞❡❛ ❢❣❭❤

Schedule A/B

✐❥◗❳❘P ◗❑ P❙❏ ❏❦❏❥❖P■◗❘ ❚◗❳ ◆❱❯■❥

Check only one box for each exemption

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

❧✪✤❉✣

♠❉♥✥✪✤❇♦✤✩♣q

r✤♣❉ ✣✪✩✫

Schedule A/B:

stttttttttttttttt ✉ s tttttttttttt

✉ ✬✭✭✈ ✩✣ ✣✦✤✪ ✫✦✪✇❉♦ 1✦✧2❉3 2❇ ♦✩

✦♣4 ✦❇❇✧✤✥✦5✧❉ ♥♦✦♦2♦✩✪4 ✧✤✫✤♦

678910❶109 ❷❸❹❺ ❻❼❸❻ ❸❷❷❽❹ 8❾8❿7❻10❽➀

820 Ill. Comp. Stat. 305/21

735 Ill. Comp. Stat. 5/12-1001 (b)

✔

✔

2

Miguel Diaz

50.00

40,000.00

2

40,000.00

16

50.00

33

Workers Compensation (owed

to debtor)

Cash On Hand

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 21 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌ ✍✎✏✑✒✓✔✑ ✕✖ ✗✘✑✒✙✚✛✘✜ ✢✏✛ ✣✤✥✑ ✗✔✤✙✦✜ ✍✑✎✓✘✑✒ ✧★ ✩✘✛✪✑✘✚★ ✫☎✬✭ ✡ ✞✁ ✮✮✮

✯✰✰✱✲✱✳✴ ✵✶✷✸ ✹✺✻✼

Schedule D: Creditors Who Have Claims Secured by Property ✽✾✿✽❀

❁✑ ✤✜ ✎✛✦✪✔✑✚✑ ✤❂✒ ✤✎✎✓✘✤✚✑ ✤✜ ✪✛✜✜✙✧✔✑❃ ❄❅ ✚❆✛ ✦✤✘✘✙✑✒ ✪✑✛✪✔✑ ✤✘✑ ❅✙✔✙❂❇ ✚✛❇✑✚✏✑✘❈ ✧✛✚✏ ✤✘✑ ✑❉✓✤✔✔★ ✘✑✜✪✛❂✜✙✧✔✑ ❅✛✘ ✜✓✪✪✔★✙❂❇ ✎✛✘✘✑✎✚

✙❂❅✛✘✦✤✚✙✛❂❃ ❄❅ ✦✛✘✑ ✜✪✤✎✑ ✙✜ ❂✑✑✒✑✒❈ ✎✛✪★ ✚✏✑ ❊✒✒✙✚✙✛❂✤✔ ✩✤❇✑❈ ❅✙✔✔ ✙✚ ✛✓✚❈ ❂✓✦✧✑✘ ✚✏✑ ✑❂✚✘✙✑✜❈ ✤❂✒ ✤✚✚✤✎✏ ✙✚ ✚✛ ✚✏✙✜ ❅✛✘✦❃ ❋❂ ✚✏✑ ✚✛✪ ✛❅ ✤❂★

✤✒✒✙✚✙✛❂✤✔ ✪✤❇✑✜❈ ❆✘✙✚✑ ★✛✓✘ ❂✤✦✑ ✤❂✒ ✎✤✜✑ ❂✓✦✧✑✘ ●✙❅ ❍❂✛❆❂■❃

❏❑ ✕✛ ✤❂★ ✎✘✑✒✙✚✛✘✜ ✏✤✥✑ ✎✔✤✙✦✜ ✜✑✎✓✘✑✒ ✧★ ★✛✓✘ ✪✘✛✪✑✘✚★▲

▼ ◆✞❖ P◗✭✄❘ ❙◗✂❚ ❯✞❱ ☎❲❳ ❚❨❯✠✂❙ ❙◗✂❚ ✁✞✟✠ ❙✞ ❙◗✭ ✄✞❨✟❙ ❩✂❙◗ ❬✞❨✟ ✞❙◗✭✟ ❚✄◗✭❳❨✆✭❚❖ ❭✞❨ ◗☎❪✭ ❲✞❙◗✂❲✬ ✭✆❚✭ ❙✞ ✟✭✫✞✟❙ ✞❲ ❙◗✂❚ ✁✞✟✠❖

▼ ❭✭❚❖ ✝✂✆✆ ✂❲ ☎✆✆ ✞✁ ❙◗✭ ✂❲✁✞✟✠☎❙✂✞❲ ❯✭✆✞❩❖

Part 1: List All Secured Claims

❫❑ ❴✙✜✚ ✤✔✔ ✜✑✎✓✘✑✒ ✎✔✤✙✦✜❃ ❵✁ ☎ ✄✟✭❳✂❙✞✟ ◗☎❚ ✠✞✟✭ ❙◗☎❲ ✞❲✭ ❚✭✄❨✟✭❳ ✄✆☎✂✠❛ ✆✂❚❙ ❙◗✭ ✄✟✭❳✂❙✞✟ ❚✭✫☎✟☎❙✭✆❬

✁✞✟ ✭☎✄◗ ✄✆☎✂✠❖ ❵✁ ✠✞✟✭ ❙◗☎❲ ✞❲✭ ✄✟✭❳✂❙✞✟ ◗☎❚ ☎ ✫☎✟❙✂✄❨✆☎✟ ✄✆☎✂✠❛ ✆✂❚❙ ❙◗✭ ✞❙◗✭✟ ✄✟✭❳✂❙✞✟❚ ✂❲ ❜☎✟❙ ❝❖

❞❚ ✠❨✄◗ ☎❚ ✫✞❚❚✂❯✆✭❛ ✆✂❚❙ ❙◗✭ ✄✆☎✂✠❚ ✂❲ ☎✆✫◗☎❯✭❙✂✄☎✆ ✞✟❳✭✟ ☎✄✄✞✟❳✂❲✬ ❙✞ ❙◗✭ ✄✟✭❳✂❙✞✟❡❚ ❲☎✠✭❖

Column A

❢❣❤✐❥❦ ❤❧ ♠♥♦♣❣

qr srt ✉✈✉✇1t t2✈

345✇✈ r6 1r554t✈7458

Column B

9♦♥✐10 ❤❧ ♠❤♥♥♦❦10❶♦♥

❦❷♦❦ ❸✐❹❹❤❶❦❸ ❦❷♣❸

♠♥♦♣❣

Column C

❺❥❸10♠✐❶10❻

❹❤❶❦♣❤❥

❼6 4s❽

❝❖✡

❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

❿➀➁➂➃➄➅➀➆➇ ➈➉➊➁

❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

➈➋➊➌➁➀ ➍➄➀➁➁➄

❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

❿➃➄➎ ➍➄➉➄➁ ➏➐➑ ❿➅➂➁

➒10❸♠❶♣➓10 ❦❷10 ❹❶❤❹10❶❦➔ ❦❷♦❦ ❸10♠✐❶10❸ ❦❷10 ♠♥♦♣❣→ ➣❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾ ➣❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾ ➣❾❾❾❾❾❾❾❾❾❾❾❾

❢❸ ❤❧ ❦❷10 ❻♦❦10 ➔❤✐ ❧♣♥10↔ ❦❷10 ♠♥♦♣❣ ♣❸→ ↕2✈1➙ 455 t24t 4➛➛5❽8

➜ ↕rst➝s➞✈st

➜ ➟s5➝➠✇➝✉4t✈✉

➜ q➝➡➛✇t✈✉

➢♦❦✐❶10 ❤❧ ♥♣10❥8 ↕2✈1➙ 455 t24t 4➛➛5❽8

➜ ➤s 4➞7✈✈➥✈st ❽r✇ ➥4✉✈ ➦➡✇12 4➡ ➥r7t➞4➞✈ r7 ➡✈1✇7✈✉

147 5r4s➧

➜ ➨t4t✇tr7❽ 5➝✈s ➦➡✇12 4➡ t4➩ 5➝✈s➫ ➥✈124s➝1➭➡ 5➝✈s➧

➜ ➯✇✉➞➥✈st 5➝✈s 67r➥ 4 54➲➡✇➝t

➜ ➳t2✈7 ➦➝s15✇✉➝s➞ 4 7➝➞2t tr r66➡✈t➧ ❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

➵❷❤ ❤➸10❸ ❦❷10 ❻10➓❦➺ ↕2✈1➙ rs✈8

➜ q✈➻tr7 ➼ rs5❽

➜ q✈➻tr7 ➽ rs5❽

➜ q✈➻tr7 ➼ 4s✉ q✈➻tr7 ➽ rs5❽

➜ ➤t 5✈4➡t rs✈ r6 t2✈ ✉✈➻tr7➡ 4s✉ 4srt2✈7

➜ ➾❷10♠➚ ♣❧ ❦❷♣❸ ♠♥♦♣❣ ❶10♥♦❦10❸ ❦❤ ♦

♠❤❣❣✐❥♣❦➔ ❻10➓❦

➒♦❦10 ❻10➓❦ ➸♦❸ ♣❥♠✐❶❶10❻ ➪➪➪➪➪➪➪➪➪➪➪➪ ➶♦❸❦ ➹ ❻♣➘♣❦❸ ❤❧ ♦♠♠❤✐❥❦ ❥✐❣➓10❶

❝❖❝

❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

❿➀➁➂➃➄➅➀➆➇ ➈➉➊➁

❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

➈➋➊➌➁➀ ➍➄➀➁➁➄

❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

❿➃➄➎ ➍➄➉➄➁ ➏➐➑ ❿➅➂➁

➒10❸♠❶♣➓10 ❦❷10 ❹❶❤❹10❶❦➔ ❦❷♦❦ ❸10♠✐❶10❸ ❦❷10 ♠♥♦♣❣→ ➣❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾ ➣❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾ ➣❾❾❾❾❾❾❾❾❾❾❾❾

❢❸ ❤❧ ❦❷10 ❻♦❦10 ➔❤✐ ❧♣♥10↔ ❦❷10 ♠♥♦♣❣ ♣❸→ ↕2✈1➙ 455 t24t 4➛➛5❽8

➜ ↕rst➝s➞✈st

➜ ➟s5➝➠✇➝✉4t✈✉

➜ q➝➡➛✇t✈✉

➢♦❦✐❶10 ❤❧ ♥♣10❥8 ↕2✈1➙ 455 t24t 4➛➛5❽8

➜ ➤s 4➞7✈✈➥✈st ❽r✇ ➥4✉✈ ➦➡✇12 4➡ ➥r7t➞4➞✈ r7 ➡✈1✇7✈✉

147 5r4s➧

➜ ➨t4t✇tr7❽ 5➝✈s ➦➡✇12 4➡ t4➩ 5➝✈s➫ ➥✈124s➝1➭➡ 5➝✈s➧

➜ ➯✇✉➞➥✈st 5➝✈s 67r➥ 4 54➲➡✇➝t

➜ ➳t2✈7 ➦➝s15✇✉➝s➞ 4 7➝➞2t tr r66➡✈t➧ ❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

➵❷❤ ❤➸10❸ ❦❷10 ❻10➓❦➺ ↕2✈1➙ rs✈8

➜ q✈➻tr7 ➼ rs5❽

➜ q✈➻tr7 ➽ rs5❽

➜ q✈➻tr7 ➼ 4s✉ q✈➻tr7 ➽ rs5❽

➜ ➤t 5✈4➡t rs✈ r6 t2✈ ✉✈➻tr7➡ 4s✉ 4srt2✈7

➜ ➾❷10♠➚ ♣❧ ❦❷♣❸ ♠♥♦♣❣ ❶10♥♦❦10❸ ❦❤ ♦

♠❤❣❣✐❥♣❦➔ ❻10➓❦

➒♦❦10 ❻10➓❦ ➸♦❸ ♣❥♠✐❶❶10❻ ➪➪➪➪➪➪➪➪➪➪➪➪ ➶♦❸❦ ➹ ❻♣➘♣❦❸ ❤❧ ♦♠♠❤✐❥❦ ❥✐❣➓10❶

❊✒✒ ✚✏✑ ✒✛✔✔✤✘ ✥✤✔✓✑ ✛❅ ★✛✓✘ ✑❂✚✘✙✑✜ ✙❂ ✗✛✔✓✦❂ ❊ ✛❂ ✚✏✙✜ ✪✤❇✑❃ ✢✘✙✚✑ ✚✏✤✚ ❂✓✦✧✑✘ ✏✑✘✑✖ ➣❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

q✈➻tr7 ➼ ❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

➴➷➬➮➱ ✃❐❒❮ ❰➷ÏÏÐ❮ ✃❐❒❮ Ñ❐➮➱ ✃❐❒❮

q✈➻tr7 ➽ ❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

Ò➍Ó➅➋➇➁Ô ➃Õ Õ➃Ö➃×ØÙ ➴➷➬➮➱ ✃❐❒❮ ❰➷ÏÏÐ❮ ✃❐❒❮ Ñ❐➮➱ ✃❐❒❮

➟s➝t✈✉ ➨t4t✈➡ Ú4s➙7✇➛t1❽ ↕r✇7t 6r7 t2✈Û ✮✮✮✮✮✮✮✮✮✮✮✮✮✮✮✮✮✮✮✮✮✮ q➝➡t7➝1t r6 ✮✮✮✮✮✮✮✮✮✮

Ò➍➄➉➄➁Ù

↕4➡✈ s✇➥➻✈7 ❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾❾

Ò➐Õ Ü×➅Ý×Ù

 Þ✙✔✔ ✙❂ ✚✏✙✜ ✙❂❅✛✘✦✤✚✙✛❂ ✚✛ ✙✒✑❂✚✙❅★ ★✛✓✘ ✎✤✜✑✖

ß àáâãä åæ çáåè åè éê

éëâêìâì æåíåêî

✔

0.00

2

Northern District of Illinois

Miguel Diaz

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 22 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡☛ ☞✌✍✎☛✏ ✑if known✒✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✓✔✕✖✗ ✘✙✚✛ ✜✔✢✢✣✛ ✘✙✚✛ ✤✙✖✗ ✘✙✚✛

✥✦✦✧★✧✩✪ ✫✬✭✮ ✯✰✱✲ ✳✩✭✴ ✵ ✬✦ ✶✷✸✹✺✻✼✹ ✽✾ ✿❀✹✺❁❂❃❀❄ ❅✸❃ ❆❇❈✹ ✿✼❇❁❉❄ ✶✹✷✻❀✹✺ ❊❋ ●❀❃❍✹❀❂❋ ■✩❏❑ ▲▲▲ ✬✦ ▲▲▲

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

▼◆❖ P◗❘◆ ❙❚❯❖ ❱❲❳❨ ❘❩ ❨❱❬ ◗❚❭❖ ❱P◗❖❪◆ P❱ ❫❖ ❲❱P❘❩❘❖❴ ❚❫❱❬P ❨❱❬❪ ❫❚❲❵❪❬❙P❛❨ ❩❱❪ ❚ ❴❖❫P P◗❚P ❨❱❬ ❚❳❪❖❚❴❨ ❳❘◆P❖❴ ❘❲ ❜❚❪P ❝❞ ❡❱❪ ❖❢❚❣❙❳❖❤ ❘❩ ❚ ❛❱❳❳❖❛P❘❱❲

❚❯❖❲❛❨ ❘◆ P❪❨❘❲❯ P❱ ❛❱❳❳❖❛P ❩❪❱❣ ❨❱❬ ❩❱❪ ❚ ❴❖❫P ❨❱❬ ❱✐❖ P❱ ◆❱❣❖❱❲❖ ❖❳◆❖❤ ❳❘◆P P◗❖ ❛❪❖❴❘P❱❪ ❘❲ ❜❚❪P ❝❤ ❚❲❴ P◗❖❲ ❳❘◆P P◗❖ ❛❱❳❳❖❛P❘❱❲ ❚❯❖❲❛❨ ◗❖❪❖❞ ❥❘❣❘❳❚❪❳❨❤ ❘❩

❨❱❬ ◗❚❭❖ ❣❱❪❖ P◗❚❲ ❱❲❖ ❛❪❖❴❘P❱❪ ❩❱❪ ❚❲❨ ❱❩ P◗❖ ❴❖❫P◆ P◗❚P ❨❱❬ ❳❘◆P❖❴ ❘❲ ❜❚❪P ❝❤ ❳❘◆P P◗❖ ❚❴❴❘P❘❱❲❚❳ ❛❪❖❴❘P❱❪◆ ◗❖❪❖❞ ❦❩ ❨❱❬ ❴❱ ❲❱P ◗❚❭❖ ❚❴❴❘P❘❱❲❚❳ ❙❖❪◆❱❲◆ P❱

❫❖ ❲❱P❘❩❘❖❴ ❩❱❪ ❚❲❨ ❴❖❫P◆ ❘❲ ❜❚❪P ❝❤ ❴❱ ❲❱P ❩❘❳❳ ❱❬P ❱❪ ◆❬❫❣❘P P◗❘◆ ❙❚❯❖❞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❧✠✍☛

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♠♥✏☛☛♥

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✟♦♥♣ ♠♥✠♥☛ qrs ✟t✉☛

✈❲ ✐◗❘❛◗ ❳❘❲❖ ❘❲ ❜❚❪P ❝ ❴❘❴ ❨❱❬ ❖❲P❖❪ P◗❖ ❛❪❖❴❘P❱❪✇ 11111

2❚◆P 3 ❴❘❯❘P◆ ❱❩ ❚❛❛❱❬❲P ❲❬❣❫❖❪

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❧✠✍☛

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♠♥✏☛☛♥

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✟♦♥♣ ♠♥✠♥☛ qrs ✟t✉☛

✈❲ ✐◗❘❛◗ ❳❘❲❖ ❘❲ ❜❚❪P ❝ ❴❘❴ ❨❱❬ ❖❲P❖❪ P◗❖ ❛❪❖❴❘P❱❪✇ 11111

2❚◆P 3 ❴❘❯❘P◆ ❱❩ ❚❛❛❱❬❲P ❲❬❣❫❖❪

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❧✠✍☛

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♠♥✏☛☛♥

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✟♦♥♣ ♠♥✠♥☛ qrs ✟t✉☛

✈❲ ✐◗❘❛◗ ❳❘❲❖ ❘❲ ❜❚❪P ❝ ❴❘❴ ❨❱❬ ❖❲P❖❪ P◗❖ ❛❪❖❴❘P❱❪✇ 11111

2❚◆P 3 ❴❘❯❘P◆ ❱❩ ❚❛❛❱❬❲P ❲❬❣❫❖❪

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❧✠✍☛

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♠♥✏☛☛♥

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✟♦♥♣ ♠♥✠♥☛ qrs ✟t✉☛

✈❲ ✐◗❘❛◗ ❳❘❲❖ ❘❲ ❜❚❪P ❝ ❴❘❴ ❨❱❬ ❖❲P❖❪ P◗❖ ❛❪❖❴❘P❱❪✇ 11111

2❚◆P 3 ❴❘❯❘P◆ ❱❩ ❚❛❛❱❬❲P ❲❬❣❫❖❪

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❧✠✍☛

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♠♥✏☛☛♥

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✟♦♥♣ ♠♥✠♥☛ qrs ✟t✉☛

✈❲ ✐◗❘❛◗ ❳❘❲❖ ❘❲ ❜❚❪P ❝ ❴❘❴ ❨❱❬ ❖❲P❖❪ P◗❖ ❛❪❖❴❘P❱❪✇ 11111

2❚◆P 3 ❴❘❯❘P◆ ❱❩ ❚❛❛❱❬❲P ❲❬❣❫❖❪

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❧✠✍☛

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♠♥✏☛☛♥

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✟♦♥♣ ♠♥✠♥☛ qrs ✟t✉☛

✈❲ ✐◗❘❛◗ ❳❘❲❖ ❘❲ ❜❚❪P ❝ ❴❘❴ ❨❱❬ ❖❲P❖❪ P◗❖ ❛❪❖❴❘P❱❪✇ 44444

2❚◆P 3 ❴❘❯❘P◆ ❱❩ ❚❛❛❱❬❲P ❲❬❣❫❖❪

2 2

Miguel Diaz

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 23 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌✍✝ ✎✏✑✒✓✔✕✒ ✖✗✘✙ ✚✛✒✓✜✢✣✛✤ ✥✑✣ ✦✧★✒ ✩✪✤✒✏✔✛✒✓ ✚✕✧✜✫✤ ✬☎✭✮ ✡ ✞✁ ✯✯✯

✰✱✱✲✳✲✴✵ ✶✷✸✹ ✺✻✼✽✾✶

Schedule E/F: Creditors Who Have Unsecured Claims ✿❀❁✿❂

❃✒ ✧✤ ✏✣✫❄✕✒✢✒ ✧✪✓ ✧✏✏✔✛✧✢✒ ✧✤ ❄✣✤✤✜❅✕✒❆ ✩✤✒ ❇✧✛✢ ❈ ❉✣✛ ✏✛✒✓✜✢✣✛✤ ❊✜✢✑ ❇❋●❍❋●■❏ ✏✕✧✜✫✤ ✧✪✓ ❇✧✛✢ ❑ ❉✣✛ ✏✛✒✓✜✢✣✛✤ ❊✜✢✑ ▲❍▲❇❋●❍❋●■❏ ✏✕✧✜✫✤❆

▼✜✤✢ ✢✑✒ ✣✢✑✒✛ ❄✧✛✢◆ ✢✣ ✧✪◆ ✒❖✒✏✔✢✣✛◆ ✏✣✪✢✛✧✏✢✤ ✣✛ ✔✪✒❖❄✜✛✒✓ ✕✒✧✤✒✤ ✢✑✧✢ ✏✣✔✕✓ ✛✒✤✔✕✢ ✜✪ ✧ ✏✕✧✜✫❆ P✕✤✣ ✕✜✤✢ ✒❖✒✏✔✢✣✛◆ ✏✣✪✢✛✧✏✢✤ ✣✪ Schedule 

A/B: Property ◗❍❉❉✜✏✜✧✕ ✘✣✛✫ ❈❘❙P✗❃❚ ✧✪✓ ✣✪ Schedule G: Executory Contracts and Unexpired Leases ◗❍❉❉✜✏✜✧✕ ✘✣✛✫ ❈❘❙❯❚❆ ❱✣ ✪✣✢ ✜✪✏✕✔✓✒ ✧✪◆

✏✛✒✓✜✢✣✛✤ ❊✜✢✑ ❄✧✛✢✜✧✕✕◆ ✤✒✏✔✛✒✓ ✏✕✧✜✫✤ ✢✑✧✢ ✧✛✒ ✕✜✤✢✒✓ ✜✪ Schedule D: Creditors Who Have Claims Secured by Property❆ ●❉ ✫✣✛✒ ✤❄✧✏✒ ✜✤

✪✒✒✓✒✓❲ ✏✣❄◆ ✢✑✒ ❇✧✛✢ ◆✣✔ ✪✒✒✓❲ ❉✜✕✕ ✜✢ ✣✔✢❲ ✪✔✫❅✒✛ ✢✑✒ ✒✪✢✛✜✒✤ ✜✪ ✢✑✒ ❅✣❖✒✤ ✣✪ ✢✑✒ ✕✒❉✢❆ P✢✢✧✏✑ ✢✑✒ ✚✣✪✢✜✪✔✧✢✜✣✪ ❇✧❳✒ ✢✣ ✢✑✜✤ ❄✧❳✒❆ ❍✪ ✢✑✒ ✢✣❄ ✣❉

✧✪◆ ✧✓✓✜✢✜✣✪✧✕ ❄✧❳✒✤❲ ❊✛✜✢✒ ◆✣✔✛ ✪✧✫✒ ✧✪✓ ✏✧✤✒ ✪✔✫❅✒✛ ◗✜❉ ❨✪✣❊✪❚❆

Part 1: List All of Your PRIORITY Unsecured Claims

❩❬ ❱✣ ✧✪◆ ✏✛✒✓✜✢✣✛✤ ✑✧★✒ ❄✛✜✣✛✜✢◆ ✔✪✤✒✏✔✛✒✓ ✏✕✧✜✫✤ ✧❳✧✜✪✤✢ ◆✣✔❭

❪ ❫✞❴ ❵✞ ❛✞ ❜☎✟❛ ❝❴

❪ ❞✮❡❴

❢❬ ▼✜✤✢ ✧✕✕ ✣❉ ◆✣✔✛ ❄✛✜✣✛✜✢◆ ✔✪✤✒✏✔✛✒✓ ✏✕✧✜✫✤❆ ❣✁ ☎ ✄✟✮❤✂❛✞✟ ✐☎❡ ✠✞✟✮ ❛✐☎❥ ✞❥✮ ✬✟✂✞✟✂❛❦ ❧❥❡✮✄❧✟✮❤ ✄✆☎✂✠♠ ✆✂❡❛ ❛✐✮ ✄✟✮❤✂❛✞✟ ❡✮✬☎✟☎❛✮✆❦ ✁✞✟ ✮☎✄✐ ✄✆☎✂✠❴ ✝✞✟

✮☎✄✐ ✄✆☎✂✠ ✆✂❡❛✮❤♠ ✂❤✮❥❛✂✁❦ ♥✐☎❛ ❛❦✬✮ ✞✁ ✄✆☎✂✠ ✂❛ ✂❡❴ ❣✁ ☎ ✄✆☎✂✠ ✐☎❡ ♦✞❛✐ ✬✟✂✞✟✂❛❦ ☎❥❤ ❥✞❥✬✟✂✞✟✂❛❦ ☎✠✞❧❥❛❡♠ ✆✂❡❛ ❛✐☎❛ ✄✆☎✂✠ ✐✮✟✮ ☎❥❤ ❡✐✞♥ ♦✞❛✐ ✬✟✂✞✟✂❛❦ ☎❥❤

❥✞❥✬✟✂✞✟✂❛❦ ☎✠✞❧❥❛❡❴ ♣❡ ✠❧✄✐ ☎❡ ✬✞❡❡✂♦✆✮♠ ✆✂❡❛ ❛✐✮ ✄✆☎✂✠❡ ✂❥ ☎✆✬✐☎♦✮❛✂✄☎✆ ✞✟❤✮✟ ☎✄✄✞✟❤✂❥✭ ❛✞ ❛✐✮ ✄✟✮❤✂❛✞✟q❡ ❥☎✠✮❴ ❣✁ ❦✞❧ ✐☎r✮ ✠✞✟✮ ❛✐☎❥ ❛♥✞ ✬✟✂✞✟✂❛❦

❧❥❡✮✄❧✟✮❤ ✄✆☎✂✠❡♠ ✁✂✆✆ ✞❧❛ ❛✐✮ s✞❥❛✂❥❧☎❛✂✞❥ ❜☎✭✮ ✞✁ ❜☎✟❛ ✡❴ ❣✁ ✠✞✟✮ ❛✐☎❥ ✞❥✮ ✄✟✮❤✂❛✞✟ ✐✞✆❤❡ ☎ ✬☎✟❛✂✄❧✆☎✟ ✄✆☎✂✠♠ ✆✂❡❛ ❛✐✮ ✞❛✐✮✟ ✄✟✮❤✂❛✞✟❡ ✂❥ ❜☎✟❛ t❴

✉✝✞✟ ☎❥ ✮✈✬✆☎❥☎❛✂✞❥ ✞✁ ✮☎✄✐ ❛❦✬✮ ✞✁ ✄✆☎✂✠♠ ❡✮✮ ❛✐✮ ✂❥❡❛✟❧✄❛✂✞❥❡ ✁✞✟ ❛✐✂❡ ✁✞✟✠ ✂❥ ❛✐✮ ✂❥❡❛✟❧✄❛✂✞❥ ♦✞✞✇✆✮❛❴1

23456 76589 10❶83❶84❷

593❸❹4

❺3❹❻❶83❶84❷

593❸❹4

❼❽❾

❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

➀➁➂➃➁➂➄➅ ➆➁➇➈➂➄➃➁➉➊ ➋➌➍➇

❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

➋➎➍➏➇➁ ➐➄➁➇➇➄

❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

➆➂➄➅ ➐➄➌➄➇ ➑➒➀ ➆➃➈➇

➓5➔4 → ➣8↔84➔ 3↕ 5773❸❹4 ❹❸9➙➛❶ ➜❿❿❿❿❿❿❿❿❿❿❿❿❿ ➜❿❿❿❿❿❿❿❿❿❿❿ ➜❿❿❿❿❿❿❿❿❿❿❿❿

➝➞➛❹ ➟5➔ 4➞➛ ➣➛➙4 8❹7❸❶❶➛➣➠ ❿❿❿❿❿❿❿❿❿❿❿❿

➡➔ 3↕ 4➞➛ ➣54➛ ❷3❸ ↕86➛➢ 4➞➛ 76589 8➔➤ ➥➦➧➨➩ ➫➭➭ ➯➦➫➯ ➫➲➲➭➳❽

➵ ➥➸➺➯➻➺➼➧➺➯

➵ ➽➺➭➻➾➚➻➪➫➯➧➪

➵ ➶➻➹➲➚➯➧➪

■◆❄✒ ✣❉ ❇❋●❍❋●■❏ ✔✪✤✒✏✔✛✒✓ ✏✕✧✜✫✙

➵ ➶➸➘➧➹➯➻➨ ➹➚➲➲➸➴➯ ➸➷➭➻➼➫➯➻➸➺➹

➵ ➬➫➮➧➹ ➫➺➪ ➨➧➴➯➫➻➺ ➸➯➦➧➴ ➪➧➷➯➹ ➳➸➚ ➸➱➧ ➯➦➧ ➼➸✃➧➴➺➘➧➺➯

➵ ➥➭➫➻➘➹ ❐➸➴ ➪➧➫➯➦ ➸➴ ➲➧➴➹➸➺➫➭ ➻➺❒➚➴➳ ➱➦➻➭➧ ➳➸➚ ➱➧➴➧

➻➺➯➸➮➻➨➫➯➧➪

➵ ❮➯➦➧➴❽ ❰➲➧➨➻❐➳ ❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

➝➞3 8❹7❸❶❶➛➣ 4➞➛ ➣➛➙4➠ ➥➦➧➨➩ ➸➺➧❽

➵ ➶➧➷➯➸➴ ❾ ➸➺➭➳

➵ ➶➧➷➯➸➴ ❼ ➸➺➭➳

➵ ➶➧➷➯➸➴ ❾ ➫➺➪ ➶➧➷➯➸➴ ❼ ➸➺➭➳

➵ Ï➯ ➭➧➫➹➯ ➸➺➧ ➸❐ ➯➦➧ ➪➧➷➯➸➴➹ ➫➺➪ ➫➺➸➯➦➧➴

➵ Ð➞➛7Ñ 8↕ 4➞8➔ 76589 8➔ ↕3❶ 5 7399❸❹84❷ ➣➛➙4

Ò➔ 4➞➛ 76589 ➔❸➙Ó➛74 43 3↕↕➔➛4➠

➵ Ô➸

➵ Õ➧➹

❼❽❼

❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

➀➁➂➃➁➂➄➅ ➆➁➇➈➂➄➃➁➉➊ ➋➌➍➇

❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

➋➎➍➏➇➁ ➐➄➁➇➇➄

❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

➆➂➄➅ ➐➄➌➄➇ ➑➒➀ ➆➃➈➇

➝➞3 8❹7❸❶❶➛➣ 4➞➛ ➣➛➙4➠ ➥➦➧➨➩ ➸➺➧❽

➵ ➶➧➷➯➸➴ ❾ ➸➺➭➳

➵ ➶➧➷➯➸➴ ❼ ➸➺➭➳

➵ ➶➧➷➯➸➴ ❾ ➫➺➪ ➶➧➷➯➸➴ ❼ ➸➺➭➳

➵ Ï➯ ➭➧➫➹➯ ➸➺➧ ➸❐ ➯➦➧ ➪➧➷➯➸➴➹ ➫➺➪ ➫➺➸➯➦➧➴

➵ Ð➞➛7Ñ 8↕ 4➞8➔ 76589 8➔ ↕3❶ 5 7399❸❹84❷ ➣➛➙4

Ò➔ 4➞➛ 76589 ➔❸➙Ó➛74 43 3↕↕➔➛4➠

➵ Ô➸

➵ Õ➧➹

➓5➔4 → ➣8↔84➔ 3↕ 5773❸❹4 ❹❸9➙➛❶

➝➞➛❹ ➟5➔ 4➞➛ ➣➛➙4 8❹7❸❶❶➛➣➠ ÖÖÖÖÖÖÖÖÖÖÖÖ

➡➔ 3↕ 4➞➛ ➣54➛ ❷3❸ ↕86➛➢ 4➞➛ 76589 8➔➤ ➥➦➧➨➩ ➫➭➭ ➯➦➫➯ ➫➲➲➭➳❽

➵ ➥➸➺➯➻➺➼➧➺➯

➵ ➽➺➭➻➾➚➻➪➫➯➧➪

➵ ➶➻➹➲➚➯➧➪

■◆❄✒ ✣❉ ❇❋●❍❋●■❏ ✔✪✤✒✏✔✛✒✓ ✏✕✧✜✫✙

➵ ➶➸➘➧➹➯➻➨ ➹➚➲➲➸➴➯ ➸➷➭➻➼➫➯➻➸➺➹

➵ ➬➫➮➧➹ ➫➺➪ ➨➧➴➯➫➻➺ ➸➯➦➧➴ ➪➧➷➯➹ ➳➸➚ ➸➱➧ ➯➦➧ ➼➸✃➧➴➺➘➧➺➯

➵ ➥➭➫➻➘➹ ❐➸➴ ➪➧➫➯➦ ➸➴ ➲➧➴➹➸➺➫➭ ➻➺❒➚➴➳ ➱➦➻➭➧ ➳➸➚ ➱➧➴➧

➻➺➯➸➮➻➨➫➯➧➪

➵ ❮➯➦➧➴❽ ❰➲➧➨➻❐➳ ❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

➜❿❿❿❿❿❿❿❿❿❿❿❿❿ ➜❿❿❿❿❿❿❿❿❿❿❿ ➜❿❿❿❿❿❿❿❿❿❿❿❿

➶➧➷➯➸➴ ❾ ❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

×ØÙÚÛ ÜÝÞß àØááâß ÜÝÞß ãÝÚÛ ÜÝÞß

➶➧➷➯➸➴ ❼ ❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

ä➐å➃➎➊➇æ ➂ç ç➂è➂éêë ×ØÙÚÛ ÜÝÞß àØááâß ÜÝÞß ãÝÚÛ ÜÝÞß

➽➺➻➯➧➪ ❰➯➫➯➧➹ ì➫➺➩➴➚➲➯➨➳ ➥➸➚➴➯ ❐➸➴ ➯➦➧í ✯✯✯✯✯✯✯✯✯✯✯✯✯✯✯✯✯✯✯✯✯✯ ➶➻➹➯➴➻➨➯ ➸❐ ✯✯✯✯✯✯✯✯✯✯

ä➐➄➌➄➇ë

➥➫➹➧ ➺➚➘➷➧➴ ❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿❿

ä➒ç îé➃ïéë

 ✘✜✕✕ ✜✪ ✢✑✜✤ ✜✪❉✣✛✫✧✢✜✣✪ ✢✣ ✜✓✒✪✢✜❉◆ ◆✣✔✛ ✏✧✤✒✙

❪ ðñòóô õö ÷ñõø õø ùú

ùûòúüòü öõýõúþ

Northern District of Illinois

✔

Miguel Diaz

13

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 24 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

st✉

✈✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✇123 4 567632 89 110108❶❷3 ❷❶❸❹❺❻

❼❽❺❷ ❾12 3❽❺ 5❺❹3 6❷10❶❻❻❺5❿ ➀➀➀➀➀➀➀➀➀➀➀➀

➁2 89 3❽❺ 513❺ ➂8❶ 96➃❺➄ 3❽❺ 10➃16❸ 62➅ ✟➆✁➇➈ ✠➉➉ ✄➆✠✄ ✠➊➊➉➋➌

➍ ✟☎☛✄➎☛➏✁☛✄

➍ ➐☛➉➎➑☞➎➒✠✄✁➒

➍ ➎✡➊☞✄✁➒

➓❑▲✴ ❀❵ ➔→➔➣↔↕→↔↕➓➙ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➍ ➛✄☞➒✁☛✄ ➉☎✠☛✡

➍ ➜✂➉➎➏✠✄➎☎☛✡ ✠✆➎✡➎☛➏ ☎☞✄ ☎➝ ✠ ✡✁➊✠✆✠✄➎☎☛ ✠➏✆✁✁✌✁☛✄ ☎✆ ➒➎➞☎✆➇✁

✄➆✠✄ ➋☎☞ ➒➎➒ ☛☎✄ ✆✁➊☎✆✄ ✠✡ ➊✆➎☎✆➎✄➋ ➇➉✠➎✌✡

➍ ✁✂✄✡ ✄☎ ➊✁☛✡➎☎☛ ☎✆ ➊✆☎➝➎✄➟✡➆✠✆➎☛➏ ➊➉✠☛✡➠ ✠☛➒ ☎✄➆✁✆ ✡➎✌➎➉✠✆ ➒✁✂✄✡

➍ ➜✄➆✁✆➌ ➛➊✁➇➎➝➋ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➡➢➤➥➦➧➢➦➧➨➩ ➫➦➭➯➧➨➢➦➲➳ ➡➵➸➭

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➡➺➸➻➭➦ ➼➨➦➭➭➨

➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽➽

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➫➧➨➩ ➼➨➵➨➭ ➾➚➪ ➫➢➯➭

❼❽8 6❷10❶❻❻❺5 3❽❺ 5❺❹3❿ ✟➆✁➇➈ ☎☛✁➌

➍ ✁✂✄☎✆ ✝ ☎☛➉➋

➍ ✁✂✄☎✆ ➶ ☎☛➉➋

➍ ✁✂✄☎✆ ✝ ✠☛➒ ✁✂✄☎✆ ➶ ☎☛➉➋

➍ ➹✄ ➉✁✠✡✄ ☎☛✁ ☎➝ ✄➆✁ ➒✁✂✄☎✆✡ ✠☛➒ ✠☛☎✄➆✁✆

➍ ➘❽❺10➴ 69 3❽62 10➃16❸ 62 98❻ 1 108❸❸❶❷63➂ 5❺❹3

➷2 3❽❺ 10➃16❸ 2❶❹➬❺103 38 8992❺3❿

➍ ➮☎

➍ ➱✁✡

st✃ ✇123 4 567632 89 110108❶❷3 ❷❶❸❹❺❻ ✈✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❼❽❺❷ ❾12 3❽❺ 5❺❹3 6❷10❶❻❻❺5❿ ➀➀➀➀➀➀➀➀➀➀➀➀

➁2 89 3❽❺ 513❺ ➂8❶ 96➃❺➄ 3❽❺ 10➃16❸ 62➅ ✟➆✁➇➈ ✠➉➉ ✄➆✠✄ ✠➊➊➉➋➌

➍ ✟☎☛✄➎☛➏✁☛✄

➍ ➐☛➉➎➑☞➎➒✠✄✁➒

➍ ➎✡➊☞✄✁➒

➓❑▲✴ ❀❵ ➔→➔➣↔↕→↔↕➓➙ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➍ ➛✄☞➒✁☛✄ ➉☎✠☛✡

➍ ➜✂➉➎➏✠✄➎☎☛✡ ✠✆➎✡➎☛➏ ☎☞✄ ☎➝ ✠ ✡✁➊✠✆✠✄➎☎☛ ✠➏✆✁✁✌✁☛✄ ☎✆ ➒➎➞☎✆➇✁

✄➆✠✄ ➋☎☞ ➒➎➒ ☛☎✄ ✆✁➊☎✆✄ ✠✡ ➊✆➎☎✆➎✄➋ ➇➉✠➎✌✡

➍ ✁✂✄✡ ✄☎ ➊✁☛✡➎☎☛ ☎✆ ➊✆☎➝➎✄➟✡➆✠✆➎☛➏ ➊➉✠☛✡➠ ✠☛➒ ☎✄➆✁✆ ✡➎✌➎➉✠✆ ➒✁✂✄✡

➍ ➜✄➆✁✆➌ ➛➊✁➇➎➝➋ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➡➢➤➥➦➧➢➦➧➨➩ ➫➦➭➯➧➨➢➦➲➳ ➡➵➸➭

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➡➺➸➻➭➦ ➼➨➦➭➭➨

❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐❐

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➫➧➨➩ ➼➨➵➨➭ ➾➚➪ ➫➢➯➭

❼❽8 6❷10❶❻❻❺5 3❽❺ 5❺❹3❿ ✟➆✁➇➈ ☎☛✁➌

➍ ✁✂✄☎✆ ✝ ☎☛➉➋

➍ ✁✂✄☎✆ ➶ ☎☛➉➋

➍ ✁✂✄☎✆ ✝ ✠☛➒ ✁✂✄☎✆ ➶ ☎☛➉➋

➍ ➹✄ ➉✁✠✡✄ ☎☛✁ ☎➝ ✄➆✁ ➒✁✂✄☎✆✡ ✠☛➒ ✠☛☎✄➆✁✆

➍ ➘❽❺10➴ 69 3❽62 10➃16❸ 62 98❻ 1 108❸❸❶❷63➂ 5❺❹3

➷2 3❽❺ 10➃16❸ 2❶❹➬❺103 38 8992❺3❿

➍ ➮☎

➍ ➱✁✡

❒❮❰

✈✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✇123 4 567632 89 110108❶❷3 ❷❶❸❹❺❻

❼❽❺❷ ❾12 3❽❺ 5❺❹3 6❷10❶❻❻❺5❿ ➀➀➀➀➀➀➀➀➀➀➀➀

➁2 89 3❽❺ 513❺ ➂8❶ 96➃❺➄ 3❽❺ 10➃16❸ 62➅ ✟➆✁➇➈ ✠➉➉ ✄➆✠✄ ✠➊➊➉➋➌

➍ ✟☎☛✄➎☛➏✁☛✄

➍ ➐☛➉➎➑☞➎➒✠✄✁➒

➍ ➎✡➊☞✄✁➒

➓❑▲✴ ❀❵ ➔→➔➣↔↕→↔↕➓➙ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➍ ➛✄☞➒✁☛✄ ➉☎✠☛✡

➍ ➜✂➉➎➏✠✄➎☎☛✡ ✠✆➎✡➎☛➏ ☎☞✄ ☎➝ ✠ ✡✁➊✠✆✠✄➎☎☛ ✠➏✆✁✁✌✁☛✄ ☎✆ ➒➎➞☎✆➇✁

✄➆✠✄ ➋☎☞ ➒➎➒ ☛☎✄ ✆✁➊☎✆✄ ✠✡ ➊✆➎☎✆➎✄➋ ➇➉✠➎✌✡

➍ ✁✂✄✡ ✄☎ ➊✁☛✡➎☎☛ ☎✆ ➊✆☎➝➎✄➟✡➆✠✆➎☛➏ ➊➉✠☛✡➠ ✠☛➒ ☎✄➆✁✆ ✡➎✌➎➉✠✆ ➒✁✂✄✡

➍ ➜✄➆✁✆➌ ➛➊✁➇➎➝➋ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➡➢➤➥➦➧➢➦➧➨➩ ➫➦➭➯➧➨➢➦➲➳ ➡➵➸➭

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➡➺➸➻➭➦ ➼➨➦➭➭Ï

ÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐ

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➫➧➨➩ ➼➨➵➨➭ ➾➚➪ ➫➢➯➭

❼❽8 6❷10❶❻❻❺5 3❽❺ 5❺❹3❿ ✟➆✁➇➈ ☎☛✁➌

➍ ✁✂✄☎✆ ✝ ☎☛➉➋

➍ ✁✂✄☎✆ ➶ ☎☛➉➋

➍ ✁✂✄☎✆ ✝ ✠☛➒ ✁✂✄☎✆ ➶ ☎☛➉➋

➍ ➹✄ ➉✁✠✡✄ ☎☛✁ ☎➝ ✄➆✁ ➒✁✂✄☎✆✡ ✠☛➒ ✠☛☎✄➆✁✆

➍ ➘❽❺10➴ 69 3❽62 10➃16❸ 62 98❻ 1 108❸❸❶❷63➂ 5❺❹3

➷2 3❽❺ 10➃16❸ 2❶❹➬❺103 38 8992❺3❿

➍ ➮☎

➍ ➱✁✡

Carol Stream

Carol Stream

Chicago

✔

13

Medical Services

Medical Services

Medical Services

Miguel Diaz

Accredited Ambulatory Care

Affiliated Radiologists SC

Archer Open MRI

✔

✔

✔

I001

4289

1000

✔

✔

41,256.19

✔

320.00

8,150.00

2

2014

2011

Dept 4668 2012

Dept 4104

4365 S Archer Ave

IL

IL

IL

60632-2826

60122-4104

✔

✔

60122-4668

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 25 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

Burr Ridge

Orland Park

4.4

Carol Stream

4.5

4.6

✔

13

Foreclosure on Home

Medical Services

Medical Services

Miguel Diaz

BMO Harris Bank NA c/o Codilis & Assoc

Cardiac Billing Services

Chicago Pain & Orthopedic

✔

✔

✔

3602

273A

I001

✔

✔

Unknown

✔

35.00

5,276.93

3

2012

2012

15W030 N Frontage Rd 2012

9410 Compubill Drive

Dept 4664

IL

IL

IL

60122-4664

60462

✔

✔

60527

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 26 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

McHenry

Chicago

4.7

LaGrange

4.8

4.9

✔

13

Medical Services

Medical Services

Medical Services

Miguel Diaz

EQMD Inc

Elite Physical Therapy

G&U Orthopedic LLC

P O Box 337

Suite A

#127

✔

✔

✔

Diaz

3794

1108

✔

✔

767.39

✔

1,835.84

5,887.00

4

2011

2012

Billing Dept 2012

1921 S Michigan Ave

106 W Calendar Ave

IL

IL

IL

60525

60616

✔

✔

60051-0337

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 27 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

Chicago

Oak Brook

4.10

Bedford Park

4.11

4.12

✔

13

Medical Services

Medical Services

Medical Services

Miguel Diaz

Gray Medical Inc

Gregory G Markarian MD

Holy Cross Hospital

P O Box 2166

✔

✔

✔

1000

0897

4382

✔

✔

13,175.00

✔

23,417.00

1,089.00

5

2012

2015

1626 W Lake Street 2012

P O Box 3098

Attn Patient Financial Serv Dept

IL

IL

IL

60499

60522

✔

✔

60612

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 28 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

Methuen

Elmhurst

4.13

Glendale

4.14

4.15

✔

13

Medical Services

Medical Services

Medical Services

Miguel Diaz

IWP

Illinois Medi-Car Inc

Integrity Billing Solutions

✔

✔

✔

1275

9INF

✔

✔

205.16

✔

897.00

17,591.60

6

2015

2012

P O Box 338 2011

P O Box 499

6635 W Happy Valley Rd A104

AZ

IL

MA

85310

60126

✔

✔

01844

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 29 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

Chicago

Lisle

4.16

Carol Stream

4.17

4.18

✔

13

Medical Services

Medical Services

Medical Services

Miguel Diaz

La Clinica SC

M&M Orthopaedics Ltd

MRI Lincoln Imaging Ctr

Suite 230

✔

✔

✔

1896

6914

MRIL

✔

✔

80,445.00

✔

3,747.00

2,100.00

7

2014

2013

P O Box 4782 2011

4300 Commerce Ct

P O Box 2957

IL

IL

IL

60132-0001

60532-3698

✔

✔

60680-4782

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 30 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

Chicago

Chicago

4.19

Miami

4.20

4.21

✔

13

Medical Services

Medical Services

Medical Services

Miguel Diaz

Montanari Medical Inc

Preferred Open MRI

Prescription Partners LLC

Suite A

✔

✔

✔

1000

0986

4053

✔

✔

1,400.00

✔

12,887.08

1,271.88

8

2011

2011

1626 W Lake Street 2014

4200 W 63rd Street

P O Box 166363

FL

IL

IL

33116-6363

60629-5010

✔

✔

60612

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 31 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

Dallas

Clinton TWP

4.22

Chicago

4.23

4.24

✔

13

Medical Services

Medical Services

Medical Services

Miguel Diaz

RX Development Associates

Radadvantage APC

Rush University Medical Center

Attn Billing Dept

✔

✔

✔

ZFKH

4951

2006

✔

✔

25,852.50

✔

49.00

838.25

9

2012

2012

P O Box 844624 2014

44000 Garfield Road

1653 W Congress Parkway

IL

MI

TX

60612-3833

48038

✔

✔

75284

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 32 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

Chicago

Chicago

4.25

Wheaton

4.26

4.27

✔

13

Medical Services

Medical Services

Medical Services

Miguel Diaz

Rush University Medical Group

Rush University Medical Group

Specialized Radiology Consultants

Suite 1611

✔

✔

✔

3112

9629

7104

✔

✔

71.00

✔

346.00

52.00

10

2014

2012

75 Remittance Dr Dept 1611 2011

75 Remittance Dr

1039 College Ave Ste A

IL

IL

IL

60187

60675-1611

✔

✔

60675-1611

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 33 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

Part 2: List All of Your NONPRIORITY Unsecured Claims

❍■ ❏❀ ❄❇❑ ✲✽✴✵✾✿❀✽❁ ✳❄❅✴ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ❄▼❄✾❇❁✿ ❑❀✶◆

❖ P✩◗ ❘✩❙ ❚✦❯❋ ❱✩❲❚✤❱❊ ❲✩ ✪❋❉✩✪❲ ✤❱ ❲❚✤❳ ❉✦✪❲◗ ❨❙❩✫ ✤❲ ❲❚✤❳ ✣✩✪✫ ❲✩ ❲❚❋ ✥✩❙✪❲ ❬✤❲❚ ❭✩❙✪ ✩❲❚❋✪ ❳✥❚❋❪❙✧❋❳◗

❖ ❘❋❳

❫■ ❴✾❁✿ ❄✷✷ ❀❵ ❑❀✶✽ ❇❀❇▲✽✾❀✽✾✿❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁ ✾❇ ✿✳✴ ❄✷▲✳❄❛✴✿✾✲❄✷ ❀✽✵✴✽ ❀❵ ✿✳✴ ✲✽✴✵✾✿❀✽ ❜✳❀ ✳❀✷✵❁ ✴❄✲✳ ✲✷❄✾❈❝ ❞✣ ✦ ✥✪❋❪✤❲✩✪ ❚✦❳ ✫✩✪❋ ❲❚✦❱ ✩❱❋

❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✥✪❋❪✤❲✩✪ ❳❋❉✦✪✦❲❋✧❭ ✣✩✪ ❋✦✥❚ ✥✧✦✤✫◗ ★✩✪ ❋✦✥❚ ✥✧✦✤✫ ✧✤❳❲❋❪❡ ✤❪❋❱❲✤✣❭ ❬❚✦❲ ❲❭❉❋ ✩✣ ✥✧✦✤✫ ✤❲ ✤❳◗ ❢✩ ❱✩❲ ✧✤❳❲ ✥✧✦✤✫❳ ✦✧✪❋✦❪❭

✤❱✥✧❙❪❋❪ ✤❱ ❣✦✪❲ ✬◗ ❞✣ ✫✩✪❋ ❲❚✦❱ ✩❱❋ ✥✪❋❪✤❲✩✪ ❚✩✧❪❳ ✦ ❉✦✪❲✤✥❙✧✦✪ ✥✧✦✤✫❡ ✧✤❳❲ ❲❚❋ ✩❲❚❋✪ ✥✪❋❪✤❲✩✪❳ ✤❱ ❣✦✪❲ ❤◗❞✣ ❭✩❙ ❚✦❯❋ ✫✩✪❋ ❲❚✦❱ ❲❚✪❋❋ ❱✩❱❉✪✤✩✪✤❲❭ ❙❱❳❋✥❙✪❋❪

✥✧✦✤✫❳ ✣✤✧✧ ✩❙❲ ❲❚❋ ✐✩❱❲✤❱❙✦❲✤✩❱ ❣✦❊❋ ✩✣ ❣✦✪❲ ❥◗

❦❧♠♥♦ ♣♦♥qr

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺➺

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸ s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➥

➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬➬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

s✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

t✉✈✇ 1 2343✇✈ 56 ✉77589✇ 9810❶❷❸

❹❺❷9 ❻✉✈ ✇❺❷ 2❷❶✇ 3978❸❸❷2❼ ❽❽❽❽❽❽❽❽❽❽❽❽

❾✈ 56 ✇❺❷ 2✉✇❷ ❿58 63➀❷➁ ✇❺❷ 7➀✉310 3✈➂ ✟➃✁➄➅ ✠➆➆ ✄➃✠✄ ✠➇➇➆➈➉

➊ ✟☎☛✄➋☛➌✁☛✄

➊ ➍☛➆➋➎☞➋➏✠✄✁➏

➊ ➋✡➇☞✄✁➏

➐❑▲✴ ❀❵ ➑➒➑➓➔→➒➔→➐➣ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈✻

➊ ↔✄☞➏✁☛✄ ➆☎✠☛✡

➊ ↕✂➆➋➌✠✄➋☎☛✡ ✠✆➋✡➋☛➌ ☎☞✄ ☎➙ ✠ ✡✁➇✠✆✠✄➋☎☛ ✠➌✆✁✁✌✁☛✄ ☎✆ ➏➋➛☎✆➄✁

✄➃✠✄ ➈☎☞ ➏➋➏ ☛☎✄ ✆✁➇☎✆✄ ✠✡ ➇✆➋☎✆➋✄➈ ➄➆✠➋✌✡

➊ ✁✂✄✡ ✄☎ ➇✁☛✡➋☎☛ ☎✆ ➇✆☎➙➋✄➜✡➃✠✆➋☛➌ ➇➆✠☛✡➝ ✠☛➏ ☎✄➃✁✆ ✡➋✌➋➆✠✆ ➏✁✂✄✡

➊ ↕✄➃✁✆➉ ↔➇✁➄➋➙➈ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➟➠➡➢➤➟➢➤➥➦ ➧➢➨➩➤➥➟➢➫➭ ➞➯➲➨

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➞➳➲➵➨➢ ➸➥➢➨➨➮

➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱➱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

➧➤➥➦ ➸➥➯➥➨ ➻➼➽ ➧➟➩➨

❹❺5 3978❸❸❷2 ✇❺❷ 2❷❶✇❼ ✟➃✁➄➅ ☎☛✁➉

➊ ✁✂✄☎✆ ✝ ☎☛➆➈

➊ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ✁✂✄☎✆ ✝ ✠☛➏ ✁✂✄☎✆ ➾ ☎☛➆➈

➊ ➚✄ ➆✁✠✡✄ ☎☛✁ ☎➙ ✄➃✁ ➏✁✂✄☎✆✡ ✠☛➏ ✠☛☎✄➃✁✆

➊ ➪❺❷7➶ 36 ✇❺3✈ 7➀✉310 3✈ 65❸ ✉ 751010893✇❿ 2❷❶✇

➹✈ ✇❺❷ 7➀✉310 ✈8❶➘❷7✇ ✇5 566✈❷✇❼

➊ ➴☎

➊ ➷✁✡

Naperville

Frankfort

4.28

4.29

✔

13

Medical Services

Medical Services

Miguel Diaz

Suburban Paincare Center

Windy City Anesthesia PC

Suite 22

✔

✔

5820

9219

✔

1,754.00

✔

3,600.00

11

2012

535 S Washington St 2014

21120 Washington Parkway

IL

IL

60423-3112

✔

60540-6695

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 34 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

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

❍■ ❆❁✴ ✿✳✾❁ ❏❄❑✴ ❀❇✷▲ ✾▼ ▲❀✶ ✳❄❅✴ ❀✿✳✴✽❁ ✿❀ ◆✴ ❇❀✿✾▼✾✴✵ ❄◆❀✶✿ ▲❀✶✽ ◆❄❇❖✽✶❏✿✲▲P ▼❀✽ ❄ ✵✴◆✿ ✿✳❄✿ ▲❀✶ ❄✷✽✴❄✵▲ ✷✾❁✿✴✵ ✾❇ ◗❄✽✿❁ ❘ ❀✽ ❙❚ ✺❀✽

✴❯❄❈❏✷✴P ✾▼ ❄ ✲❀✷✷✴✲✿✾❀❇ ❄❑✴❇✲▲ ✾❁ ✿✽▲✾❇❑ ✿❀ ✲❀✷✷✴✲✿ ▼✽❀❈ ▲❀✶ ▼❀✽ ❄ ✵✴◆✿ ▲❀✶ ❀❱✴ ✿❀ ❁❀❈✴❀❇✴ ✴✷❁✴P ✷✾❁✿ ✿✳✴ ❀✽✾❑✾❇❄✷ ✲✽✴✵✾✿❀✽ ✾❇ ◗❄✽✿❁ ❘ ❀✽

❙P ✿✳✴❇ ✷✾❁✿ ✿✳✴ ✲❀✷✷✴✲✿✾❀❇ ❄❑✴❇✲▲ ✳✴✽✴❚ ❲❳❨❳❩❬❭❩❪❫ ❳❴ ❪❵❛ ❜❬❝❞ ❨❵❭❞ ❡❜❬❢ ❵❢❞ ❣❭❞❤❳❡❵❭ ❴❵❭ ❬❢❪ ❵❴ ❡❜❞ ❤❞✐❡❥ ❡❜❬❡ ❪❵❛ ❩❳❥❡❞❤ ❳❢ ❦❬❭❡❥ ❧ ❵❭ ♠❫ ❩❳❥❡ ❡❜❞

❬❤❤❳❡❳❵❢❬❩ ❣❭❞❤❳❡❵❭❥ ❜❞❭❞♥ ♦▼ ▲❀✶ ✵❀ ❇❀✿ ✳❄❅✴ ❬❤❤❳❡❳❵❢❬❩ ♣❞❭❥❵❢❥ ❡❵ ✐❞ ❢❵❡❳❴❳❞❤ ❴❵❭ ❬❢❪ ❤❞✐❡❥ ❳❢ ❦❬❭❡❥ ❧ ❵❭ ♠P ✵❀ ❇❀✿ ▼✾✷✷ ❀✶✿ ❀✽ ❁✶◆❈✾✿ ✿✳✾❁ ❏❄❑✴❚

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

qrst

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

q✉s✈t✇ 12✇tt2

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

3425 12r2t 678 3910t

❶❇ ❱✳✾✲✳ ✴❇✿✽▲ ✾❇ ◗❄✽✿ ❘ ❀✽ ◗❄✽✿ ❙ ✵✾✵ ▲❀✶ ✷✾❁✿ ✿✳✴ ❀✽✾❑✾❇❄✷ ✲✽✴✵✾✿❀✽❷

❸✤❹❋ ●●●●● ✩✣ ❺Check one)❻ ❼ ❽✦✪❾ ✬❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ❽✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀ ❿✧✦✤✫➁

❼ ❽✦✪❾ ➇❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ➈✩❹❉✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀ ❿✧✦✤✫➁

➉❄❁✿ ➊ ✵✾❑✾✿❁ ❀▼ ❄✲✲❀✶❇✿ ❇✶❈◆✴✽

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

qrst

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

q✉s✈t✇ 12✇tt2

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

3425 12r2t 678 3910t

❶❇ ❱✳✾✲✳ ✴❇✿✽▲ ✾❇ ◗❄✽✿ ❘ ❀✽ ◗❄✽✿ ❙ ✵✾✵ ▲❀✶ ✷✾❁✿ ✿✳✴ ❀✽✾❑✾❇❄✷ ✲✽✴✵✾✿❀✽❷

❸✤❹❋ ●●●●● ✩✣ ❺Check one)❻ ❼ ❽✦✪❾ ✬❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ❽✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀ ❿✧✦✤✫➁

➋ ❽✦✪❾ ➇❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ➈✩❹❉✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀

❿✧✦✤✫➁

➉❄❁✿ ➊ ✵✾❑✾✿❁ ❀▼ ❄✲✲❀✶❇✿ ❇✶❈◆✴✽

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

qrst

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

q✉s✈t✇ 12✇tt2

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

3425 12r2t 678 3910t

❶❇ ❱✳✾✲✳ ✴❇✿✽▲ ✾❇ ◗❄✽✿ ❘ ❀✽ ◗❄✽✿ ❙ ✵✾✵ ▲❀✶ ✷✾❁✿ ✿✳✴ ❀✽✾❑✾❇❄✷ ✲✽✴✵✾✿❀✽❷

❸✤❹❋ ●●●●● ✩✣ ❺Check one)❻ ❼ ❽✦✪❾ ✬❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ❽✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀ ❿✧✦✤✫➁

➋ ❽✦✪❾ ➇❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ➈✩❹❉✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀

❿✧✦✤✫➁

➉❄❁✿ ➊ ✵✾❑✾✿❁ ❀▼ ❄✲✲❀✶❇✿ ❇✶❈◆✴✽

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

qrst

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

q✉s✈t✇ 12✇tt2

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

3425 12r2t 678 3910t

❶❇ ❱✳✾✲✳ ✴❇✿✽▲ ✾❇ ◗❄✽✿ ❘ ❀✽ ◗❄✽✿ ❙ ✵✾✵ ▲❀✶ ✷✾❁✿ ✿✳✴ ❀✽✾❑✾❇❄✷ ✲✽✴✵✾✿❀✽❷

❸✤❹❋ ●●●●● ✩✣ ❺Check one)❻ ❼ ❽✦✪❾ ✬❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ❽✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀ ❿✧✦✤✫➁

➋ ❽✦✪❾ ➇❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ➈✩❹❉✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀

❿✧✦✤✫➁

➉❄❁✿ ➊ ✵✾❑✾✿❁ ❀▼ ❄✲✲❀✶❇✿ ❇✶❈◆✴✽

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

qrst

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

q✉s✈t✇ 12✇tt2

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

3425 12r2t 678 3910t

❶❇ ❱✳✾✲✳ ✴❇✿✽▲ ✾❇ ◗❄✽✿ ❘ ❀✽ ◗❄✽✿ ❙ ✵✾✵ ▲❀✶ ✷✾❁✿ ✿✳✴ ❀✽✾❑✾❇❄✷ ✲✽✴✵✾✿❀✽❷

❸✤❹❋ ●●●●● ✩✣ ❺Check one)❻ ❼ ❽✦✪❾ ✬❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ❽✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀ ❿✧✦✤✫➁

➋ ❽✦✪❾ ➇❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ➈✩❹❉✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀

❿✧✦✤✫➁

➉❄❁✿ ➊ ✵✾❑✾✿❁ ❀▼ ❄✲✲❀✶❇✿ ❇✶❈◆✴✽

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

qrst

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

q✉s✈t✇ 12✇tt2

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

3425 12r2t 678 3910t

❶❇ ❱✳✾✲✳ ✴❇✿✽▲ ✾❇ ◗❄✽✿ ❘ ❀✽ ◗❄✽✿ ❙ ✵✾✵ ▲❀✶ ✷✾❁✿ ✿✳✴ ❀✽✾❑✾❇❄✷ ✲✽✴✵✾✿❀✽❷

❸✤❹❋ ●●●●● ✩✣ ❺Check one)❻ ❼ ❽✦✪❾ ✬❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ❽✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀ ❿✧✦✤✫➁

➋ ❽✦✪❾ ➇❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ➈✩❹❉✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀

❿✧✦✤✫➁

➉❄❁✿ ➊ ✵✾❑✾✿❁ ❀▼ ❄✲✲❀✶❇✿ ❇✶❈◆✴✽

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

qrst

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

q✉s✈t✇ 12✇tt2

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

3425 12r2t 678 3910t

❶❇ ❱✳✾✲✳ ✴❇✿✽▲ ✾❇ ◗❄✽✿ ❘ ❀✽ ◗❄✽✿ ❙ ✵✾✵ ▲❀✶ ✷✾❁✿ ✿✳✴ ❀✽✾❑✾❇❄✷ ✲✽✴✵✾✿❀✽❷

❸✤❹❋ ●●●●● ✩✣ ❺Check one)❻ ❼ ❽✦✪❾ ✬❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ❽✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀ ❿✧✦✤✫➁

➋ ❽✦✪❾ ➇❻ ❿✪❋➀✤❾✩✪➁ ➂✤❾➃ ➈✩❹❉✪✤✩✪✤❾➄ ➅❹➁❋✥➆✪❋➀

❿✧✦✤✫➁

➉❄❁✿ ➊ ✵✾❑✾✿❁ ❀▼ ❄✲✲❀✶❇✿ ❇✶❈◆✴✽

300 W Butterfield

1921 S Michigan Ave

2250 E Devon Ave Ste 352

P O Box 189

P O Box 3159

3 Golf Center Ste 361

Elmhurst Orthopedica SC

Maldonado OConnell Ltd

Medical Recovery Specialists LLC

Medorizon

Nationwide Credit & Collection

The Leviton Law Firm Ltd

4.15

4.8

4.24

4.14

4.24

4.29

13

Miguel Diaz

✔

✔

✔

✔

✔

✔

12

60169

60522-3159

60544

60018-4521

60616

Elmhurst 60126

Chicago

Des Plaines

Plainfield

Oak Brook

Hoffman Estates

IL

IL

IL

IL

IL

IL

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 35 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯✰★ ✱✲✳✴✵✶✷✴ ✸✹✺✻ ✼✽✴✵✾✿❀✽❁ ❂✳❀ ❃❄❅✴ ❆❇❁✴✲✶✽✴✵ ✼✷❄✾❈❁ ❉✦❊❋ ●● ✩✣ ●●●

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

❍■ ❏❀✿❄✷ ✿✳✴ ❄❈❀✶❇✿❁ ❀❑ ✲✴✽✿❄✾❇ ✿▲▼✴❁ ❀❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈❁◆ ❏✳✾❁ ✾❇❑❀✽❈❄✿✾❀❇ ✾❁ ❑❀✽ ❁✿❄✿✾❁✿✾✲❄✷ ✽✴▼❀✽✿✾❇❖ ▼✶✽▼❀❁✴❁ ❀❇✷▲◆ P◗ ❆◆✱◆✼◆ ❘ ❙❚❯◆

❱✵✵ ✿✳✴ ❄❈❀✶❇✿❁ ❑❀✽ ✴❄✲✳ ✿▲▼✴ ❀❑ ✶❇❁✴✲✶✽✴✵ ✲✷❄✾❈◆

❏❀✿❄✷ ✲✷❄✾❈

❏❀✿❄✷ ✲✷❄✾❈❁

❑✽❀❈ ❲❄✽✿ ❙

✮✦❳ ❨❀❈✴❁✿✾✲ ❁✶▼▼❀✽✿ ❀❩✷✾❖❄✿✾❀❇❁ ✮✦❳ ❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✮❭❳ ❏❄❪✴❁ ❄❇✵ ✲✴✽✿❄✾❇ ❀✿✳✴✽ ✵✴❩✿❁ ▲❀✶ ❀❫✴ ✿✳✴

❖❀❅✴✽❇❈✴❇✿ ✮❭❳ ❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✮✥❳ ✼✷❄✾❈❁ ❑❀✽ ✵✴❄✿✳ ❀✽ ▼✴✽❁❀❇❄✷ ✾❇❴✶✽▲ ❫✳✾✷✴ ▲❀✶ ❫✴✽✴

✾❇✿❀❪✾✲❄✿✴✵ ✮✥❳ ❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✮❵❳ ❛✿✳✴✽◆ ❜❵❵ ✦✧✧ ✩❝❞❋✪ ❉✪✤✩✪✤❝❡ ❢❣❤❋✥❢✪❋❵ ✥✧✦✤✫❤❳

✐✪✤❝❋ ❝❞✦❝ ✦✫✩❢❣❝ ❞❋✪❋❳ ✮❵❳

❥ ❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✮❋❳ ❏❀✿❄✷◆ ❜❵❵ ✧✤❣❋❤ ✮✦ ❝❞✪✩❢❊❞ ✮❵❳ ✮❋❳

❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❏❀✿❄✷ ✲✷❄✾❈

❏❀✿❄✷ ✲✷❄✾❈❁

❑✽❀❈ ❲❄✽✿ P

✮✣❳ ✱✿✶✵✴❇✿ ✷❀❄❇❁ ✮✣❳

❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✮❊◆ ❛❩✷✾❖❄✿✾❀❇❁ ❄✽✾❁✾❇❖ ❀✶✿ ❀❑ ❄ ❁✴▼❄✽❄✿✾❀❇ ❄❖✽✴✴❈✴❇✿

❀✽ ✵✾❅❀✽✲✴ ✿✳❄✿ ▲❀✶ ✵✾✵ ❇❀✿ ✽✴▼❀✽✿ ❄❁ ▼✽✾❀✽✾✿▲

✲✷❄✾❈❁ ✮❊❳ ❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✮❞❳ ❨✴❩✿❁ ✿❀ ▼✴❇❁✾❀❇ ❀✽ ▼✽❀❑✾✿❦❁✳❄✽✾❇❖ ▼✷❄❇❁❧ ❄❇✵ ❀✿✳✴✽

❁✾❈✾✷❄✽ ✵✴❩✿❁ ✮❞❳

❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✮✤❳ ❛✿✳✴✽◆ ❜❵❵ ✦✧✧ ✩❝❞❋✪ ❣✩❣❉✪✤✩✪✤❝❡ ❢❣❤❋✥❢✪❋❵ ✥✧✦✤✫❤❳

✐✪✤❝❋ ❝❞✦❝ ✦✫✩❢❣❝ ❞❋✪❋❳ ✮✤❳ ❥ ❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✮♠❳ ❏❀✿❄✷◆ ❜❵❵ ✧✤❣❋❤ ✮✣ ❝❞✪✩❢❊❞ ✮✤❳ ✮♠❳

❬✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

0.00

0.00

0.00

0.00

0.00

13

0.00

Miguel Diaz

0.00

13

254,316.82

254,316.82

0.00

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 36 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌ ✍✎✏✑✒✓✔✑ ✕✖ ✗✘✑✎✓✙✚✛✜ ✢✚✣✙✛✤✎✙✥ ✤✣✒ ✦✣✑✘✧★✛✑✒ ✩✑✤✥✑✥ ✪☎✫✬ ✡ ✞✁ ✭✭✭

✮✯✯✰✱✰✲✳ ✴✵✶✷ ✸✹✺✻

Schedule G: Executory Contracts and Unexpired Leases ✼✽✾✼✿

❀✑ ✤✥ ✎✚❁✧✔✑✙✑ ✤✣✒ ✤✎✎✓✛✤✙✑ ✤✥ ✧✚✥✥★❂✔✑❃ ❄❅ ✙❆✚ ❁✤✛✛★✑✒ ✧✑✚✧✔✑ ✤✛✑ ❅★✔★✣❇ ✙✚❇✑✙✏✑✛❈ ❂✚✙✏ ✤✛✑ ✑❉✓✤✔✔✜ ✛✑✥✧✚✣✥★❂✔✑ ❅✚✛ ✥✓✧✧✔✜★✣❇ ✎✚✛✛✑✎✙

★✣❅✚✛❁✤✙★✚✣❃ ❄❅ ❁✚✛✑ ✥✧✤✎✑ ★✥ ✣✑✑✒✑✒❈ ✎✚✧✜ ✙✏✑ ✤✒✒★✙★✚✣✤✔ ✧✤❇✑❈ ❅★✔✔ ★✙ ✚✓✙❈ ✣✓❁❂✑✛ ✙✏✑ ✑✣✙✛★✑✥❈ ✤✣✒ ✤✙✙✤✎✏ ★✙ ✙✚ ✙✏★✥ ✧✤❇✑❃ ❊✣ ✙✏✑ ✙✚✧ ✚❅ ✤✣✜

✤✒✒★✙★✚✣✤✔ ✧✤❇✑✥❈ ❆✛★✙✑ ✜✚✓✛ ✣✤❁✑ ✤✣✒ ✎✤✥✑ ✣✓❁❂✑✛ ❋★❅ ●✣✚❆✣❍❃

✡■ ❏✚ ✜✚✓ ✏✤❑✑ ✤✣✜ ✑✘✑✎✓✙✚✛✜ ✎✚✣✙✛✤✎✙✥ ✚✛ ✓✣✑✘✧★✛✑✒ ✔✑✤✥✑✥▲

▼ ◆✞■ ❖P✬✄◗ ❘P✂❙ ❚✞❯ ☎❱❲ ✁✂✆✬ ❘P✂❙ ✁✞✟✠ ❳✂❘P ❘P✬ ✄✞❨✟❘ ❳✂❘P ❩✞❨✟ ✞❘P✬✟ ❙✄P✬❲❨✆✬❙■ ❬✞❨ P☎❭✬ ❱✞❘P✂❱✫ ✬✆❙✬ ❘✞ ✟✬✪✞✟❘ ✞❱ ❘P✂❙ ✁✞✟✠■

▼ ❬✬❙■ ✝✂✆✆ ✂❱ ☎✆✆ ✞✁ ❘P✬ ✂❱✁✞✟✠☎❘✂✞❱ ❚✬✆✞❳ ✬❭✬❱ ✂✁ ❘P✬ ✄✞❱❘✟☎✄❘❙ ✞✟ ✆✬☎❙✬❙ ☎✟✬ ✆✂❙❘✬❲ ✞❱ Schedule A/B: Property ❪✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞❫❴❵❛■

❜■ ✩★✥✙ ✥✑✧✤✛✤✙✑✔✜ ✑✤✎✏ ✧✑✛✥✚✣ ✚✛ ✎✚❁✧✤✣✜ ❆★✙✏ ❆✏✚❁ ✜✚✓ ✏✤❑✑ ✙✏✑ ✎✚✣✙✛✤✎✙ ✚✛ ✔✑✤✥✑❃ ❝✏✑✣ ✥✙✤✙✑ ❆✏✤✙ ✑✤✎✏ ✎✚✣✙✛✤✎✙ ✚✛ ✔✑✤✥✑ ★✥ ❅✚✛ ❋❅✚✛

✑✘✤❁✧✔✑❈ ✛✑✣✙❈ ❑✑✏★✎✔✑ ✔✑✤✥✑❈ ✎✑✔✔ ✧✏✚✣✑❍❃ ❞✬✬ ❘P✬ ✂❱❙❘✟❨✄❘✂✞❱❙ ✁✞✟ ❘P✂❙ ✁✞✟✠ ✂❱ ❘P✬ ✂❱❙❘✟❨✄❘✂✞❱ ❚✞✞◗✆✬❘ ✁✞✟ ✠✞✟✬ ✬❯☎✠✪✆✬❙ ✞✁ ✬❯✬✄❨❘✞✟❩ ✄✞❱❘✟☎✄❘❙ ☎❱❲

❨❱✬❯✪✂✟✬❲ ✆✬☎❙✬❙■

❡✑✛✥✚✣ ✚✛ ✎✚❁✧✤✣✜ ❆★✙✏ ❆✏✚❁ ✜✚✓ ✏✤❑✑ ✙✏✑ ✎✚✣✙✛✤✎✙ ✚✛ ✔✑✤✥✑ ✍✙✤✙✑ ❆✏✤✙ ✙✏✑ ✎✚✣✙✛✤✎✙ ✚✛ ✔✑✤✥✑ ★✥ ❅✚✛

❜■✡

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❣❤✐❥

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❦❧♠❥❥❧

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

♥♦❧♣ ❦❧❤❧❥ qrs ♥t✉❥

❜■❜

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❣❤✐❥

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❦❧♠❥❥❧

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

♥♦❧♣ ❦❧❤❧❥ qrs ♥t✉❥

❜■✈

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❣❤✐❥

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❦❧♠❥❥❧

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

♥♦❧♣ ❦❧❤❧❥ qrs ♥t✉❥

❜■✇

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❣❤✐❥

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❦❧♠❥❥❧

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

♥♦❧♣ ❦❧❤❧❥ qrs ♥t✉❥

❜■1

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❣❤✐❥

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❦❧♠❥❥❧

❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

♥♦❧♣ ❦❧❤❧❥ qrs ♥t✉❥

2❥3❧t♠ ❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

45678 910❶❷ ❸5❹❹❺❷ 910❶❷ ❻1078 910❶❷

2❥3❧t♠ ❼ ❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❽❾❿➀➁➂➃ ➄➅ ➅➆➇➆➈➉➊ 45678 910❶❷ ❸5❹❹❺❷ 910❶❷ ❻1078 910❶❷

➋➌♦❧❥✉ ❦❧❤❧❥➍ ➎❤➌➏♠➐➑❧➒♣ ♥t➐♠❧ ➓t♠ ❧➔❥→✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭✭ 2♦➍❧♠♦➒❧ t➓ ✭✭✭✭✭✭✭✭

❽❾➣↔➣➃➊

♥❤➍❥ ➌➐✐3❥♠ ❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢❢

❽➄➅ ↕➈➀➙➈➊

 ➛★✔✔ ★✣ ✙✏★✥ ★✣❅✚✛❁✤✙★✚✣ ✙✚ ★✒✑✣✙★❅✜ ✜✚✓✛ ✎✤✥✑✖

➜ ➝➞➟➠➡ ➢➤ ➥➞➢➦ ➢➦ ➧➨

➧➩➟➨➫➟➫ ➤➢➭➢➨➯

Northern District of Illinois

1

Miguel Diaz

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 37 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌ ✍✎✏✑✒✓✔✑ ✕✖ ✗✘✓✙ ✚✘✒✑✛✜✘✙✢ ✣☎✤✥ ✡ ✞✁ ✦✦✦

✧★★✩✪✩✫✬ ✭✮✯✰ ✱✲✳✴

Schedule H: Your Codebtors ✵✶✷✵✸

✚✘✒✑✛✜✘✙✢ ✹✙✑ ✺✑✘✺✔✑ ✘✙ ✑✻✜✼✜✼✑✢ ✽✏✘ ✹✙✑ ✹✔✢✘ ✔✼✹✛✔✑ ✾✘✙ ✹✻✿ ✒✑✛✜✢ ✿✘✓ ❀✹✿ ✏✹❁✑❂ ❃✑ ✹✢ ✎✘❀✺✔✑✜✑ ✹✻✒ ✹✎✎✓✙✹✜✑ ✹✢ ✺✘✢✢✼✛✔✑❂ ❄✾ ✜✽✘ ❀✹✙✙✼✑✒ ✺✑✘✺✔✑

✹✙✑ ✾✼✔✼✻❅ ✜✘❅✑✜✏✑✙❆ ✛✘✜✏ ✹✙✑ ✑❇✓✹✔✔✿ ✙✑✢✺✘✻✢✼✛✔✑ ✾✘✙ ✢✓✺✺✔✿✼✻❅ ✎✘✙✙✑✎✜ ✼✻✾✘✙❀✹✜✼✘✻❂ ❄✾ ❀✘✙✑ ✢✺✹✎✑ ✼✢ ✻✑✑✒✑✒❆ ✎✘✺✿ ✜✏✑ ❈✒✒✼✜✼✘✻✹✔ ❉✹❅✑❆ ✾✼✔✔ ✼✜ ✘✓✜❆

✹✻✒ ✻✓❀✛✑✙ ✜✏✑ ✑✻✜✙✼✑✢ ✼✻ ✜✏✑ ✛✘❊✑✢ ✘✻ ✜✏✑ ✔✑✾✜❂ ❈✜✜✹✎✏ ✜✏✑ ❈✒✒✼✜✼✘✻✹✔ ❉✹❅✑ ✜✘ ✜✏✼✢ ✺✹❅✑❂ ❋✻ ✜✏✑ ✜✘✺ ✘✾ ✹✻✿ ❈✒✒✼✜✼✘✻✹✔ ❉✹❅✑✢❆ ✽✙✼✜✑ ✿✘✓✙ ✻✹❀✑ ✹✻✒

✎✹✢✑ ✻✓❀✛✑✙ ●✼✾ ❍✻✘✽✻■❂ ❈✻✢✽✑✙ ✑❁✑✙✿ ❇✓✑✢✜✼✘✻❂

❏❑ ▲✘ ✿✘✓ ✏✹❁✑ ✹✻✿ ✎✘✒✑✛✜✘✙✢▼ ◆❖✁ P✞◗ ☎✟✥ ✁✂✆✂❘✤ ☎ ❙✞✂❘❚ ✄☎❯✥❱ ❲✞ ❘✞❚ ✆✂❯❚ ✥✂❚❳✥✟ ❯✣✞◗❯✥ ☎❯ ☎ ✄✞❲✥❨❚✞✟❩❬

❭ ❪✞

❭ ❫✥❯

❴❑ ❵✼✜✏✼✻ ✜✏✑ ✔✹✢✜ ❛ ✿✑✹✙✢❆ ✏✹❁✑ ✿✘✓ ✔✼❁✑✒ ✼✻ ✹ ✎✘❀❀✓✻✼✜✿ ✺✙✘✺✑✙✜✿ ✢✜✹✜✑ ✘✙ ✜✑✙✙✼✜✘✙✿▼ ◆Community property states and territories ✂❘✄✆◗❲✥

❜✟✂❝✞❘☎❱ ❞☎✆✂✁✞✟❘✂☎❱ ❖❲☎❳✞❱ ❡✞◗✂❯✂☎❘☎❱ ❪✥❢☎❲☎❱ ❪✥❣ ❤✥✐✂✄✞❱ ❥◗✥✟❚✞ ❦✂✄✞❱ ❧✥✐☎❯❱ ♠☎❯❳✂❘✤❚✞❘❱ ☎❘❲ ♠✂❯✄✞❘❯✂❘❩❬

❭ ❪✞❩ ♥✞ ❚✞ ✆✂❘✥ ♦❩

❭ ❫✥❯❩ ♣✂❲ P✞◗✟ ❯✣✞◗❯✥❱ ✁✞✟✠✥✟ ❯✣✞◗❯✥❱ ✞✟ ✆✥✤☎✆ ✥q◗✂❢☎✆✥❘❚ ✆✂❢✥ ❣✂❚❳ P✞◗ ☎❚ ❚❳✥ ❚✂✠✥r

❭ ❪✞

❭ ❫✥❯❩ ❖❘ ❣❳✂✄❳ ✄✞✠✠◗❘✂❚P ❯❚☎❚✥ ✞✟ ❚✥✟✟✂❚✞✟P ❲✂❲ P✞◗ ✆✂❢✥r ✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦❩ ✝✂✆✆ ✂❘ ❚❳✥ ❘☎✠✥ ☎❘❲ ✄◗✟✟✥❘❚ ☎❲❲✟✥❯❯ ✞✁ ❚❳☎❚ ✣✥✟❯✞❘❩

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

t✉✈✇ 12 3145 67146✇8 215✈✇5 67146✇8 15 9✇10✉9 ✇❶4❷❸✉9✇❹❺

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

t4✈❻✇5 ❼❺5✇✇❺

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

❽❷❺3 ❼❺✉❺✇ ❾❿➀ ❽1➁✇

➂➃ ❄✻ ✚✘✔✓❀✻ ➄❆ ✔✼✢✜ ✹✔✔ ✘✾ ✿✘✓✙ ✎✘✒✑✛✜✘✙✢❂ ▲✘ ✻✘✜ ✼✻✎✔✓✒✑ ✿✘✓✙ ✢✺✘✓✢✑ ✹✢ ✹ ✎✘✒✑✛✜✘✙ ✼✾ ✿✘✓✙ ✢✺✘✓✢✑ ✼✢ ✾✼✔✼✻❅ ✽✼✜✏ ✿✘✓❂ ➅✼✢✜ ✜✏✑ ✺✑✙✢✘✻

✢✏✘✽✻ ✼✻ ✔✼✻✑ ➆ ✹❅✹✼✻ ✹✢ ✹ ✎✘✒✑✛✜✘✙ ✘✻✔✿ ✼✾ ✜✏✹✜ ✺✑✙✢✘✻ ✼✢ ✹ ❅✓✹✙✹✻✜✘✙ ✘✙ ✎✘✢✼❅✻✑✙❂ ➇✹❍✑ ✢✓✙✑ ✿✘✓ ✏✹❁✑ ✔✼✢✜✑✒ ✜✏✑ ✎✙✑✒✼✜✘✙ ✘✻

Schedule D ●❋✾✾✼✎✼✹✔ ➈✘✙❀ ➄➉➊▲■❆ Schedule E/F ●❋✾✾✼✎✼✹✔ ➈✘✙❀ ➄➉➊➋➌➈■❆ ✘✙ Schedule G ●❋✾✾✼✎✼✹✔ ➈✘✙❀ ➄➉➊➍■❂ ➎✢✑ Schedule D,

Schedule E/F, or Schedule G ✜✘ ✾✼✔✔ ✘✓✜ ✚✘✔✓❀✻ ➆❂

Column 1: ✗✘✓✙ ✎✘✒✑✛✜✘✙ Column 2: ➏✏✑ ✎✙✑✒✼✜✘✙ ✜✘ ✽✏✘❀ ✿✘✓ ✘✽✑ ✜✏✑ ✒✑✛✜

❞❳✥✄➐ ☎✆✆ ❯✄❳✥❲◗✆✥❯ ❚❳☎❚ ☎✣✣✆P➑

➒➓➔

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

t✉✈✇

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

❼❺5✇✇❺

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

❽❷❺3 ❼❺✉❺✇ ❾❿➀ ❽1➁✇

→ ➣✄❳✥❲◗✆✥ ♣❱ ✆✂❘✥ ✦✦✦✦✦✦

→ ➣✄❳✥❲◗✆✥ ↔↕✝❱ ✆✂❘✥ ✦✦✦✦✦✦

→ ➣✄❳✥❲◗✆✥ ♥❱ ✆✂❘✥ ✦✦✦✦✦✦

➒➓➙

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

t✉✈✇

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

❼❺5✇✇❺

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

❽❷❺3 ❼❺✉❺✇ ❾❿➀ ❽1➁✇

→ ➣✄❳✥❲◗✆✥ ♣❱ ✆✂❘✥ ✦✦✦✦✦✦

→ ➣✄❳✥❲◗✆✥ ↔↕✝❱ ✆✂❘✥ ✦✦✦✦✦✦

→ ➣✄❳✥❲◗✆✥ ♥❱ ✆✂❘✥ ✦✦✦✦✦✦

➒➓➒

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

t✉✈✇

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

❼❺5✇✇❺

ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

❽❷❺3 ❼❺✉❺✇ ❾❿➀ ❽1➁✇

→ ➣✄❳✥❲◗✆✥ ♣❱ ✆✂❘✥ ✦✦✦✦✦✦

→ ➣✄❳✥❲◗✆✥ ↔↕✝❱ ✆✂❘✥ ✦✦✦✦✦✦

→ ➣✄❳✥❲◗✆✥ ♥❱ ✆✂❘✥ ✦✦✦✦✦✦

➛➜➝➞➟➠ ➡ ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

➢➤➥➦➧ ➨➩➫➭ ➯➤➲➲➳➭ ➨➩➫➭ ➵➩➦➧ ➨➩➫➭

➛➜➝➞➟➠ ➸ ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

➺❼7146✇8 ❷2 2❷9❷❹10➻ ➢➤➥➦➧ ➨➩➫➭ ➯➤➲➲➳➭ ➨➩➫➭ ➵➩➦➧ ➨➩➫➭

➼➽➾➞➜➚ ➪➞➶➞➜➹ ➘➶➽➴➠➷➬➞➮➱ ✃➟➷➠➞ ❐➟➠ ➞❒➜❮✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦✦ ➛➾➹➞➠➾➮➞ ➟❐ ✦✦✦✦✦✦✦✦

➺❼❺✉❺✇➻

✃➶➹➜ ➽➷❰➝➜➠ ssssssssssssssssssssssssssssssssssssssssssss

➺❿2 Ï❹1Ð❹➻

 ➈✼✔✔ ✼✻ ✜✏✼✢ ✼✻✾✘✙❀✹✜✼✘✻ ✜✘ ✼✒✑✻✜✼✾✿ ✿✘✓✙ ✎✹✢✑✖

Ñ ÒÓÔÕÖ ×Ø ÙÓ×Ú ×Ú ÛÜ

ÛÝÔÜÞÔÞ Ø×ß×Üà

Northern District of Illinois

✔

1

Miguel Diaz

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 38 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌ ✍✎✏✑✒✓✔✑ ✕✖ ✗✘✓✙ ✕✚✎✘✛✑ ✜☎✢✣ ✤

✥✦✦✧★✧✩✪ ✫✬✭✮ ✯✰✱✲

Schedule I: Your Income ✳✴✵✳✶

✷✑ ✸✹ ✎✘✛✺✔✑✻✑ ✸✚✒ ✸✎✎✓✙✸✻✑ ✸✹ ✺✘✹✹✼✽✔✑✾ ✕✿ ✻❀✘ ✛✸✙✙✼✑✒ ✺✑✘✺✔✑ ✸✙✑ ✿✼✔✼✚❁ ✻✘❁✑✻✏✑✙ ❂❃✑✽✻✘✙ ✤ ✸✚✒ ❃✑✽✻✘✙ ❄❅❆ ✽✘✻✏ ✸✙✑ ✑❇✓✸✔✔❈ ✙✑✹✺✘✚✹✼✽✔✑ ✿✘✙

✹✓✺✺✔❈✼✚❁ ✎✘✙✙✑✎✻ ✼✚✿✘✙✛✸✻✼✘✚✾ ✕✿ ❈✘✓ ✸✙✑ ✛✸✙✙✼✑✒ ✸✚✒ ✚✘✻ ✿✼✔✼✚❁ ❉✘✼✚✻✔❈❆ ✸✚✒ ❈✘✓✙ ✹✺✘✓✹✑ ✼✹ ✔✼❊✼✚❁ ❀✼✻✏ ❈✘✓❆ ✼✚✎✔✓✒✑ ✼✚✿✘✙✛✸✻✼✘✚ ✸✽✘✓✻ ❈✘✓✙ ✹✺✘✓✹✑✾

✕✿ ❈✘✓ ✸✙✑ ✹✑✺✸✙✸✻✑✒ ✸✚✒ ❈✘✓✙ ✹✺✘✓✹✑ ✼✹ ✚✘✻ ✿✼✔✼✚❁ ❀✼✻✏ ❈✘✓❆ ✒✘ ✚✘✻ ✼✚✎✔✓✒✑ ✼✚✿✘✙✛✸✻✼✘✚ ✸✽✘✓✻ ❈✘✓✙ ✹✺✘✓✹✑✾ ✕✿ ✛✘✙✑ ✹✺✸✎✑ ✼✹ ✚✑✑✒✑✒❆ ✸✻✻✸✎✏ ✸

✹✑✺✸✙✸✻✑ ✹✏✑✑✻ ✻✘ ✻✏✼✹ ✿✘✙✛✾ ❋✚ ✻✏✑ ✻✘✺ ✘✿ ✸✚❈ ✸✒✒✼✻✼✘✚✸✔ ✺✸❁✑✹❆ ❀✙✼✻✑ ❈✘✓✙ ✚✸✛✑ ✸✚✒ ✎✸✹✑ ✚✓✛✽✑✙ ❂✼✿ ●✚✘❀✚❅✾ ❍✚✹❀✑✙ ✑❊✑✙❈ ❇✓✑✹✻✼✘✚✾

Part 1: Describe Employment

■❏ ❑✼✔✔ ✼✚ ❈✘✓✙ ✑✛✺✔✘❈✛✑✚✻

✼✚✿✘✙✛✸✻✼✘✚✾

✌✁ ▲✞▼ ◆☎❖✣ ✠✞✟✣ P◆☎◗ ✞◗✣ ❘✞❙❚

☎PP☎✄◆ ☎ ❯✣✜☎✟☎P✣ ✜☎✢✣ ❱✂P◆

✂◗✁✞✟✠☎P✂✞◗ ☎❙✞▼P ☎❲❲✂P✂✞◗☎✆

✣✠✜✆✞▲✣✟❯❳

✌◗✄✆▼❲✣ ✜☎✟P❨P✂✠✣❚ ❯✣☎❯✞◗☎✆❚ ✞✟

❯✣✆✁❨✣✠✜✆✞▲✣❲ ❱✞✟❩❳

✄✄▼✜☎P✂✞◗ ✠☎▲ ✂◗✄✆▼❲✣ ❯P▼❲✣◗P

✞✟ ◆✞✠✣✠☎❩✣✟❚ ✂✁ ✂P ☎✜✜✆✂✣❯❳

❃✑✽✻✘✙ ✤ ❃✑✽✻✘✙ ❄ ✘✙ ✚✘✚❬✿✼✔✼✚❁ ✹✺✘✓✹✑

❭✛✺✔✘❈✛✑✚✻ ✹✻✸✻✓✹ ❪ ❫✠✜✆✞▲✣❲

❪ ❴✞P ✣✠✜✆✞▲✣❲

❪ ❫✠✜✆✞▲✣❲

❪ ❴✞P ✣✠✜✆✞▲✣❲

❋✎✎✓✺✸✻✼✘✚ ❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵ ❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵

❭✛✺✔✘❈✑✙❛✹ ✚✸✛✑ ❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵ ❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵

❭✛✺✔✘❈✑✙❛✹ ✸✒✒✙✑✹✹

❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❝❞❡❢❣❤ ✐❥❤❣❣❥

❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❦❧❥♠ ✐❥♥❥❣ ♦♣q ❦rs❣

❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❝❞❡❢❣❤ ✐❥❤❣❣❥

❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❦❧❥♠ ✐❥♥❥❣ ♦♣q ❦rs❣

t✘❀ ✔✘✚❁ ✑✛✺✔✘❈✑✒ ✻✏✑✙✑✉✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈ ✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈✈

Part 2: Give Details About Monthly Income

❭✹✻✼✛✸✻✑ ✛✘✚✻✏✔❈ ✼✚✎✘✛✑ ✸✹ ✘✿ ✻✏✑ ✒✸✻✑ ❈✘✓ ✿✼✔✑ ✻✏✼✹ ✿✘✙✛✾ ✌✁ ▲✞▼ ◆☎❖✣ ◗✞P◆✂◗✢ P✞ ✟✣✜✞✟P ✁✞✟ ☎◗▲ ✆✂◗✣❚ ❱✟✂P✣ ✇☛ ✂◗ P◆✣ ❯✜☎✄✣❳ ✌◗✄✆▼❲✣ ▲✞▼✟ ◗✞◗❨✁✂✆✂◗✢

❯✜✞▼❯✣ ▼◗✆✣❯❯ ▲✞▼ ☎✟✣ ❯✣✜☎✟☎P✣❲❳

✌✁ ▲✞▼ ✞✟ ▲✞▼✟ ◗✞◗❨✁✂✆✂◗✢ ❯✜✞▼❯✣ ◆☎❖✣ ✠✞✟✣ P◆☎◗ ✞◗✣ ✣✠✜✆✞▲✣✟❚ ✄✞✠❙✂◗✣ P◆✣ ✂◗✁✞✟✠☎P✂✞◗ ✁✞✟ ☎✆✆ ✣✠✜✆✞▲✣✟❯ ✁✞✟ P◆☎P ✜✣✟❯✞◗ ✞◗ P◆✣ ✆✂◗✣❯

❙✣✆✞❱❳ ✌✁ ▲✞▼ ◗✣✣❲ ✠✞✟✣ ❯✜☎✄✣❚ ☎PP☎✄◆ ☎ ❯✣✜☎✟☎P✣ ❯◆✣✣P P✞ P◆✂❯ ✁✞✟✠❳

❑✘✙ ❃✑✽✻✘✙ ✤ ❑✘✙ ❃✑✽✻✘✙ ❄ ✘✙

✚✘✚❬✿✼✔✼✚❁ ✹✺✘✓✹✑

1❏ 2✼✹✻ ✛✘✚✻✏✔❈ ❁✙✘✹✹ ❀✸❁✑✹❆ ✹✸✔✸✙❈❆ ✸✚✒ ✎✘✛✛✼✹✹✼✘✚✹ 3❙✣✁✞✟✣ ☎✆✆ ✜☎▲✟✞✆✆

❲✣❲▼✄P✂✞◗❯4❳ ✌✁ ◗✞P ✜☎✂❲ ✠✞◗P◆✆▲❚ ✄☎✆✄▼✆☎P✣ ❱◆☎P P◆✣ ✠✞◗P◆✆▲ ❱☎✢✣ ❱✞▼✆❲ ❙✣❳ 5❳ ✇❵❵❵❵❵❵❵❵❵❵❵ ✇❵❵❵❵❵❵❵❵❵❵❵❵

6❏ ❭✹✻✼✛✸✻✑ ✸✚✒ ✔✼✹✻ ✛✘✚✻✏✔❈ ✘❊✑✙✻✼✛✑ ✺✸❈✾ 7❳ 8 ✇❵❵❵❵❵❵❵❵❵❵❵ 8 ✇❵❵❵❵❵❵❵❵❵❵❵❵

9❏ 10✸✔✎✓✔✸✻✑ ❁✙✘✹✹ ✼✚✎✘✛✑✾ ❶❲❲ ✆✂◗✣ 5 ❷ ✆✂◗✣ 7❳ ❸❳ ✇❵❵❵❵❵❵❵❵❵❵ ✇❵❵❵❵❵❵❵❵❵❵❵❵

❹❣❢❥r❤ ■ ❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

❺❻❼❽❾ ❿➀➁➂ ➃❻➄➄➅➂ ❿➀➁➂ ➆➀❽❾ ❿➀➁➂

❹❣❢❥r❤ 1 ❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

➇➈➉➊➋➌➍➎ ➏➐ ➐➏➑➏➒➓➔ ❺❻❼❽❾ ❿➀➁➂ ➃❻➄➄➅➂ ❿➀➁➂ ➆➀❽❾ ❿➀➁➂

→➣❧❥❣s ✐❥♥❥❣↔ ↕♥➣➙❤❞➛❥➜♠ ❦r❞❤❥ ➝r❤ ❥➞❣➟ ❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵ ❹❧↔❥❤❧➜❥ r➝ ❵❵❵❵❵❵❵❵❵❵❵

➇➈➠➡➠➍➔

❦♥↔❣ ➣❞❡❢❣❤ ❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜❜

➇➢➐ ➤➒➊➥➒➔

 ❑✼✔✔ ✼✚ ✻✏✼✹ ✼✚✿✘✙✛✸✻✼✘✚ ✻✘ ✼✒✑✚✻✼✿❈ ❈✘✓✙ ✎✸✹✑✖

➦➧➨➩➫ ➭➯ ➲➧➭➳ ➭➳➵

➸ ➺➻ ➼➽➨➻➾➨➾ ➯➭➚➭➻➪

➸ ➺ ➳➶➹➹➚➨➽➨➻➲ ➳➧➘➴➭➻➪ ➹➘➳➲➹➨➲➭➲➭➘➻ ➩➧➼➹➲➨➷ ➬➮

➭➻➩➘➽➨ ➼➳ ➘➯ ➲➧➨ ➯➘➚➚➘➴➭➻➪ ➾➼➲➨➵

❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵❵

➱➱ ✃ ❹❹ ✃ ❐❐❐❐

Northern District of Illinois

Miguel Diaz

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 39 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯ ✰✱✲✳✴✵✶✳ ✷✸ ✹✺✵✻ ✷✼✱✺✽✳ ✾✦✿❀ ❁

❂✺✻ ❃✳❄❅✺✻ ❆ ❂✺✻ ❃✳❄❅✺✻ ❁ ✺✻

✼✺✼❇❈❉✶❉✼❊ ❋●✺✵❋✳

❍✺●■ ✶❉✼✳ ❏ ✲✳✻✳ ❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑▲ ▼❑ ◆❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

P◗ ❘❉❋❅ ❙✶✶ ●❙■✻✺✶✶ ✴✳✴✵✱❅❉✺✼❋✸

❚✦❑ ❯❙❱❲ ❳✳✴❉✱❙✻✳❲ ❙✼✴ ✰✺✱❉❙✶ ✰✳✱✵✻❉❅■ ✴✳✴✵✱❅❉✺✼❋ ❚✦❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❚❨❑ ❳❙✼✴❙❅✺✻■ ✱✺✼❅✻❉❄✵❅❉✺✼❋ ❈✺✻ ✻✳❅❉✻✳✽✳✼❅ ●✶❙✼❋ ❚❨❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❚✥❑ ❩✺✶✵✼❅❙✻■ ✱✺✼❅✻❉❄✵❅❉✺✼❋ ❈✺✻ ✻✳❅❉✻✳✽✳✼❅ ●✶❙✼❋ ❚✥❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❚❬❑ ❭✳❪✵❉✻✳✴ ✻✳●❙■✽✳✼❅❋ ✺❈ ✻✳❅❉✻✳✽✳✼❅ ❈✵✼✴ ✶✺❙✼❋ ❚❬❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❚❀❑ ✷✼❋✵✻❙✼✱✳ ❚❀❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❚✣❑ ❃✺✽✳❋❅❉✱ ❋✵●●✺✻❅ ✺❄✶❉❊❙❅❉✺✼❋ ❚✣❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❚✿❑ ❫✼❉✺✼ ✴✵✳❋ ❚✿❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❚❴❑ ❵❅✲✳✻ ✴✳✴✵✱❅❉✺✼❋❛ ❜✾❀✥✤✣❝❞ ❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖ ❚❴❑ ❡ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ❡ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❢◗ ❣✴✴ ❅✲✳ ●❙■✻✺✶✶ ✴✳✴✵✱❅❉✺✼❋❑ ❤❬❬ ✧✤✐❀❥ ❚✦ ❦ ❚❨ ❦ ❚✥ ❦ ❚❬ ❦ ❚❀ ❦❚✣ ❦ ❚✿ ❦ ❚❴❑ ✮❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❧◗ ❍❙✶✱✵✶❙❅✳ ❅✺❅❙✶ ✽✺✼❅✲✶■ ❅❙♠✳❇✲✺✽✳ ●❙■❛ ❜♥❨♦✪✦✥♦ ✧✤✐❀ ✮ ✣✪✩✫ ✧✤✐❀ ▼❑ ♣❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

q◗ ❘❉❋❅ ❙✶✶ ✺❅✲✳✻ ❉✼✱✺✽✳ ✻✳❊✵✶❙✻✶■ ✻✳✱✳❉r✳✴✸

s✦❑ t✳❅ ❉✼✱✺✽✳ ❈✻✺✽ ✻✳✼❅❙✶ ●✻✺●✳✻❅■ ❙✼✴ ❈✻✺✽ ✺●✳✻❙❅❉✼❊ ❙ ❄✵❋❉✼✳❋❋❲

●✻✺❈✳❋❋❉✺✼❲ ✺✻ ❈❙✻✽

❤♦♦✦✥❴ ✦ ❥♦✦♦❀✫❀✐♦ ✣✩✪ ❀✦✥❴ ✾✪✩✾❀✪♦❝ ✦✐❬ ❨♥❥✤✐❀❥❥ ❥❴✩✉✤✐✿ ✿✪✩❥❥

✪❀✥❀✤✾♦❥✈ ✩✪❬✤✐✦✪❝ ✦✐❬ ✐❀✥❀❥❥✦✪❝ ❨♥❥✤✐❀❥❥ ❀✇✾❀✐❥❀❥✈ ✦✐❬ ♦❴❀ ♦✩♦✦✧

✫✩✐♦❴✧❝ ✐❀♦ ✤✐✥✩✫❀❑ s✦❑

◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

s❨❑ ✷✼❅✳✻✳❋❅ ❙✼✴ ✴❉r❉✴✳✼✴❋ s❨❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

s✥❑ ❂❙✽❉✶■ ❋✵●●✺✻❅ ●❙■✽✳✼❅❋ ❅✲❙❅ ■✺✵❲ ❙ ✼✺✼❇❈❉✶❉✼❊ ❋●✺✵❋✳❲ ✺✻ ❙ ✴✳●✳✼✴✳✼❅

✻✳❊✵✶❙✻✶■ ✻✳✱✳❉r✳

✯✐✥✧♥❬❀ ✦✧✤✫✩✐❝✈ ❥✾✩♥❥✦✧ ❥♥✾✾✩✪♦✈ ✥❴✤✧❬ ❥♥✾✾✩✪♦✈ ✫✦✤✐♦❀✐✦✐✥❀✈ ❬✤1✩✪✥❀

❥❀♦♦✧❀✫❀✐♦✈ ✦✐❬ ✾✪✩✾❀✪♦❝ ❥❀♦♦✧❀✫❀✐♦❑ s✥❑

◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

s❬❑ ❫✼✳✽●✶✺■✽✳✼❅ ✱✺✽●✳✼❋❙❅❉✺✼ s❬❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

s❀❑ ✰✺✱❉❙✶ ✰✳✱✵✻❉❅■ s❀❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

s✣❑ ❵❅✲✳✻ ❊✺r✳✻✼✽✳✼❅ ❙❋❋❉❋❅❙✼✱✳ ❅✲❙❅ ■✺✵ ✻✳❊✵✶❙✻✶■ ✻✳✱✳❉r✳

✯✐✥✧♥❬❀ ✥✦❥❴ ✦❥❥✤❥♦✦✐✥❀ ✦✐❬ ♦❴❀ 1✦✧♥❀ 2✤✣ 3✐✩✉✐4 ✩✣ ✦✐❝ ✐✩✐5✥✦❥❴ ✦❥❥✤❥♦✦✐✥❀

♦❴✦♦ ❝✩♥ ✪❀✥❀✤1❀✈ ❥♥✥❴ ✦❥ ✣✩✩❬ ❥♦✦✫✾❥ 2❨❀✐❀✣✤♦❥ ♥✐❬❀✪ ♦❴❀ ❜♥✾✾✧❀✫❀✐♦✦✧

6♥♦✪✤♦✤✩✐ ❤❥❥✤❥♦✦✐✥❀ 7✪✩✿✪✦✫4 ✩✪ ❴✩♥❥✤✐✿ ❥♥❨❥✤❬✤❀❥❑

❜✾❀✥✤✣❝❞ ❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖ s✣❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

s✿❑ 8✳✼❋❉✺✼ ✺✻ ✻✳❅❉✻✳✽✳✼❅ ❉✼✱✺✽✳ s✿❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

s❴❑ ❵❅✲✳✻ ✽✺✼❅✲✶■ ❉✼✱✺✽✳❛ ❜✾❀✥✤✣❝❞ ❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖ s❴❑ ❡ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ❡◆❖❖❖❖❖❖❖❖❖❖❖❖❖

9◗ ❣✴✴ ❙✶✶ ✺❅✲✳✻ ❉✼✱✺✽✳❑ ❤❬❬ ✧✤✐❀❥ s✦ ❦ s❨ ❦ s✥ ❦ s❬ ❦ s❀ ❦ s✣ ❦s✿ ❦ s❴❑ 10❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

✝❶◗ ❍❙✶✱✵✶❙❅✳ ✽✺✼❅✲✶■ ❉✼✱✺✽✳❛ ❤❬❬ ✧✤✐❀ ♣ ❦ ✧✤✐❀ 10❑

❤❬❬ ♦❴❀ ❀✐♦✪✤❀❥ ✤✐ ✧✤✐❀ ✬✭ ✣✩✪ ❷❀❨♦✩✪ ✬ ✦✐❬ ❷❀❨♦✩✪ ❸ ✩✪ ✐✩✐5✣✤✧✤✐✿ ❥✾✩♥❥❀❑ ✬✭◗

◆❖❖❖❖❖❖❖❖❖❖❖ ❹ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖ ❺ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

✝✝◗ ✰❅❙❅✳ ❙✶✶ ✺❅✲✳✻ ✻✳❊✵✶❙✻ ✱✺✼❅✻❉❄✵❅❉✺✼❋ ❅✺ ❅✲✳ ✳❱●✳✼❋✳❋ ❅✲❙❅ ■✺✵ ✶❉❋❅ ❉✼ Schedule J❛

✯✐✥✧♥❬❀ ✥✩✐♦✪✤❨♥♦✤✩✐❥ ✣✪✩✫ ✦✐ ♥✐✫✦✪✪✤❀❬ ✾✦✪♦✐❀✪✈ ✫❀✫❨❀✪❥ ✩✣ ❝✩♥✪ ❴✩♥❥❀❴✩✧❬✈ ❝✩♥✪ ❬❀✾❀✐❬❀✐♦❥✈ ❝✩♥✪ ✪✩✩✫✫✦♦❀❥✈ ✦✐❬ ✩♦❴❀✪

✣✪✤❀✐❬❥ ✩✪ ✪❀✧✦♦✤1❀❥❛

❷✩ ✐✩♦ ✤✐✥✧♥❬❀ ✦✐❝ ✦✫✩♥✐♦❥ ✦✧✪❀✦❬❝ ✤✐✥✧♥❬❀❬ ✤✐ ✧✤✐❀❥ ❸5✬✭ ✩✪ ✦✫✩♥✐♦❥ ♦❴✦♦ ✦✪❀ ✐✩♦ ✦1✦✤✧✦❨✧❀ ♦✩ ✾✦❝ ❀✇✾❀✐❥❀❥ ✧✤❥♦❀❬ ✤✐ Schedule J❑

❜✾❀✥✤✣❝❞ ❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖ ✬✬❑ ❹ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

✝❻◗ ❣✴✴ ❅✲✳ ❙✽✺✵✼❅ ❉✼ ❅✲✳ ✶❙❋❅ ✱✺✶✵✽✼ ✺❈ ✶❉✼✳ ❆❼ ❅✺ ❅✲✳ ❙✽✺✵✼❅ ❉✼ ✶❉✼✳ ❆❆❛ ❽❴❀ ✪❀❥♥✧♦ ✤❥ ♦❴❀ ✥✩✫❨✤✐❀❬ ✫✩✐♦❴✧❝ ✤✐✥✩✫❀❑

❾✪✤♦❀ ♦❴✦♦ ✦✫✩♥✐♦ ✩✐ ♦❴❀ Summary of Your Assets and Liabilities and Certain Statistical Information, ✤✣ ✤♦ ✦✾✾✧✤❀❥ ✬❸❑ ◆❖❖❖❖❖❖❖❖❖❖❖❖❖

❿➀➁➂➃➄➅➆

➁➀➄➇➈➉➊ ➃➄➋➀➁➅

✝➌◗ ❃✺ ■✺✵ ✳❱●✳✱❅ ❙✼ ❉✼✱✻✳❙❋✳ ✺✻ ✴✳✱✻✳❙❋✳ ➍❉❅✲❉✼ ❅✲✳ ■✳❙✻ ❙❈❅✳✻ ■✺✵ ❈❉✶✳ ❅✲❉❋ ❈✺✻✽➎

➏ 6✩❑

➏ ➐❀❥❑ ➑✇✾✧✦✤✐❞

196.00

0.00

0.00

196.00

0.00

0.00

0.00

0.00

0.00

Food Stamps

Debtor has been unable to work since the date of his injury, March 5, 2011.

Miguel Diaz

✔

196.00 196.00

0.00

196.00

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 40 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌ ✍✎✏✑✒✓✔✑ ✕✖ ✗✘✓✙ ✚✛✜✑✢✣✑✣ ✤☎✥✦ ✧

★✩✩✪✫✪✬✭ ✮✯✰✱ ✲✳✴✵

Schedule J: Your Expenses ✶✷✸✶✹

✺✑ ✻✣ ✎✘✼✜✔✑✽✑ ✻✢✒ ✻✎✎✓✙✻✽✑ ✻✣ ✜✘✣✣✾✿✔✑❀ ❁❂ ✽❃✘ ✼✻✙✙✾✑✒ ✜✑✘✜✔✑ ✻✙✑ ❂✾✔✾✢❄ ✽✘❄✑✽✏✑✙❅ ✿✘✽✏ ✻✙✑ ✑❆✓✻✔✔❇ ✙✑✣✜✘✢✣✾✿✔✑ ❂✘✙ ✣✓✜✜✔❇✾✢❄ ✎✘✙✙✑✎✽

✾✢❂✘✙✼✻✽✾✘✢❀ ❁❂ ✼✘✙✑ ✣✜✻✎✑ ✾✣ ✢✑✑✒✑✒❅ ✻✽✽✻✎✏ ✻✢✘✽✏✑✙ ✣✏✑✑✽ ✽✘ ✽✏✾✣ ❂✘✙✼❀ ❈✢ ✽✏✑ ✽✘✜ ✘❂ ✻✢❇ ✻✒✒✾✽✾✘✢✻✔ ✜✻❄✑✣❅ ❃✙✾✽✑ ❇✘✓✙ ✢✻✼✑ ✻✢✒ ✎✻✣✑ ✢✓✼✿✑✙

❉✾❂ ❊✢✘❃✢❋❀ ●✢✣❃✑✙ ✑❍✑✙❇ ❆✓✑✣✽✾✘✢❀

Part 1: Describe Your Household

■❏ ❁✣ ✽✏✾✣ ✻ ❑✘✾✢✽ ✎✻✣✑▲

▼ ◆✞❖ P✞ ◗✞ ✆✂❘✦ ❙❖

▼ ❚✦❯❖ ❱✘✑✣ ❱✑✿✽✘✙ ❲ ✔✾❍✑ ✾✢ ✻ ✣✑✜✻✙✻✽✑ ✏✘✓✣✑✏✘✔✒▲

▼ ◆✞

▼ ❚✦❯❖ ❳✦❨◗✞✟ ❙ ✠❩❯◗ ✁✂✆✦ ✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌❬❙❭ Expenses for Separate Household of Debtor 2❖

❪❏ ❱✘ ❇✘✓ ✏✻❍✑ ✒✑✜✑✢✒✑✢✽✣▲

❳✞ ❘✞◗ ✆✂❯◗ ❳✦❨◗✞✟ ✡ ☎❘❫

❳✦❨◗✞✟ ❙❖

❳✞ ❘✞◗ ❯◗☎◗✦ ◗❴✦ ❫✦✤✦❘❫✦❘◗❯❵

❘☎✠✦❯❖

▼ ◆✞

▼ ❚✦❯❖ ✝✂✆✆ ✞❩◗ ◗❴✂❯ ✂❘✁✞✟✠☎◗✂✞❘ ✁✞✟

✦☎✄❴ ❫✦✤✦❘❫✦❘◗❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖❖

❛❜❝❜❞❡❜❞❢❣❤ ✐❜❥❦❢❧♠❞❤♥❧❝ ❢♠

❛❜♦❢♠✐ ♣ ♠✐ ❛❜♦❢♠✐ q

❛❜❝❜❞❡❜❞❢❣❤

❦r❜

❛♠❜❤ ❡❜❝❜❞❡❜❞❢ ❥❧s❜

t❧❢♥ ✉♠✈✇

1111111111111111111111111 11111111 ▼ ◆✞

▼ ❚✦❯

1111111111111111111111111 11111111 ▼ ◆✞

▼ ❚✦❯

1111111111111111111111111 11111111 ▼ ◆✞

▼ ❚✦❯

1111111111111111111111111 11111111 ▼ ◆✞

▼ ❚✦❯

1111111111111111111111111 11111111 ▼ ◆✞

▼ ❚✦❯

2❏ ❱✘ ❇✘✓✙ ✑✛✜✑✢✣✑✣ ✾✢✎✔✓✒✑

✑✛✜✑✢✣✑✣ ✘❂ ✜✑✘✜✔✑ ✘✽✏✑✙ ✽✏✻✢

❇✘✓✙✣✑✔❂ ✻✢✒ ❇✘✓✙ ✒✑✜✑✢✒✑✢✽✣▲

▼ ◆✞

▼ ❚✦❯

Part 2: Estimate Your Ongoing Monthly Expenses

✚✣✽✾✼✻✽✑ ❇✘✓✙ ✑✛✜✑✢✣✑✣ ✻✣ ✘❂ ❇✘✓✙ ✿✻✢❊✙✓✜✽✎❇ ❂✾✔✾✢❄ ✒✻✽✑ ✓✢✔✑✣✣ ❇✘✓ ✻✙✑ ✓✣✾✢❄ ✽✏✾✣ ❂✘✙✼ ✻✣ ✻ ✣✓✜✜✔✑✼✑✢✽ ✾✢ ✻ 3✏✻✜✽✑✙ ✧4 ✎✻✣✑ ✽✘ ✙✑✜✘✙✽

✑✛✜✑✢✣✑✣ ✻✣ ✘❂ ✻ ✒✻✽✑ ✻❂✽✑✙ ✽✏✑ ✿✻✢❊✙✓✜✽✎❇ ✾✣ ❂✾✔✑✒❀ ❁❂ ✽✏✾✣ ✾✣ ✻ ✣✓✜✜✔✑✼✑✢✽✻✔ Schedule J❅ ✎✏✑✎❊ ✽✏✑ ✿✘✛ ✻✽ ✽✏✑ ✽✘✜ ✘❂ ✽✏✑ ❂✘✙✼ ✻✢✒ ❂✾✔✔ ✾✢ ✽✏✑

✻✜✜✔✾✎✻✿✔✑ ✒✻✽✑❀

❁✢✎✔✓✒✑ ✑✛✜✑✢✣✑✣ ✜✻✾✒ ❂✘✙ ❃✾✽✏ ✢✘✢5✎✻✣✏ ❄✘❍✑✙✢✼✑✢✽ ✻✣✣✾✣✽✻✢✎✑ ✾❂ ❇✘✓ ❊✢✘❃ ✽✏✑ ❍✻✔✓✑ ✘❂

✣✓✎✏ ✻✣✣✾✣✽✻✢✎✑ ✻✢✒ ✏✻❍✑ ✾✢✎✔✓✒✑✒ ✾✽ ✘✢ Schedule I: Your Income ❉❈❂❂✾✎✾✻✔ 6✘✙✼ ✧78❁❀❋ ✗✘✓✙ ✑✛✜✑✢✣✑✣

9❏ 10✏✑ ✙✑✢✽✻✔ ✘✙ ✏✘✼✑ ✘❃✢✑✙✣✏✾✜ ✑✛✜✑✢✣✑✣ ❂✘✙ ❇✘✓✙ ✙✑✣✾✒✑✢✎✑❀ ❶❘✄✆❩❫✦ ✁✂✟❯◗ ✠✞✟◗✥☎✥✦ ✤☎❷✠✦❘◗❯ ☎❘❫

☎❘❷ ✟✦❘◗ ✁✞✟ ◗❴✦ ✥✟✞❩❘❫ ✞✟ ✆✞◗❖ 9❏

❸111111111111111111111

❁❂ ✢✘✽ ✾✢✎✔✓✒✑✒ ✾✢ ✔✾✢✑ ❹✖

9❺❏ ❻✦☎✆ ✦❯◗☎◗✦ ◗☎❼✦❯ 9❺❏ ❸111111111111111111111

9❽❏ ❾✟✞✤✦✟◗❷❭ ❴✞✠✦✞❿❘✦✟❵❯❭ ✞✟ ✟✦❘◗✦✟❵❯ ✂❘❯❩✟☎❘✄✦ 9❽❏ ❸111111111111111111111

9➀❏ ➁✞✠✦ ✠☎✂❘◗✦❘☎❘✄✦❭ ✟✦✤☎✂✟❭ ☎❘❫ ❩✤➂✦✦✤ ✦❼✤✦❘❯✦❯ 9➀❏ ❸111111111111111111111

9➃❏ ➁✞✠✦✞❿❘✦✟❵❯ ☎❯❯✞✄✂☎◗✂✞❘ ✞✟ ✄✞❘❫✞✠✂❘✂❩✠ ❫❩✦❯ 9➃❏ ❸111111111111111111111

➄➅❽➆➇➈ ■ ➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉

➊➋➌➍➎ ➏➐➑➒ ➓➋➔➔→➒ ➏➐➑➒ ➣➐➍➎ ➏➐➑➒

➄➅❽➆➇➈ ❪ ➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉

↔↕➙➛➜➝➞➟ ➠➡ ➡➠➢➠➤➥➦ ➊➋➌➍➎ ➏➐➑➒ ➓➋➔➔→➒ ➏➐➑➒ ➣➐➍➎ ➏➐➑➒

➧➨➩➆➅➃ ➫➆❺➆➅➭ ➯❺➨➲➈➳➵➆➀➸ ➺➇➳➈➆ ➻➇➈ ➆➼➅➽ 1111111111111111111111 ➄➩➭➆➈➩➀➆ ➇➻ 1111111111

↔↕➾➚➾➞➦

➺❺➭➅ ➨➳➪❽➅➈ ➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉

↔➶➡ ➹➤➛➘➤➦

 6✾✔✔ ✾✢ ✽✏✾✣ ✾✢❂✘✙✼✻✽✾✘✢ ✽✘ ✾✒✑✢✽✾❂❇ ❇✘✓✙ ✎✻✣✑✖

➴➷➬➮➱ ✃❐ ❒➷✃❮ ✃❮❰

Ï ÐÑ ÒÓ➬ÑÔ➬Ô ❐✃Õ✃ÑÖ

Ï Ð ❮×ØØÕ➬Ó➬Ñ❒ ❮➷ÙÚ✃ÑÖ ØÙ❮❒Ø➬❒✃❒✃ÙÑ ➮➷ÒØ❒➬Û ÜÝ

➬ÞØ➬Ñ❮➬❮ Ò❮ Ù❐ ❒➷➬ ❐ÙÕÕÙÚ✃ÑÖ ÔÒ❒➬❰

1111111111111111

ßß à ➄➄ à áááá

0.00

0.00

0.00

0.00

0.00

Northern District of Illinois

Miguel Diaz

✔

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 41 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯ ✰✱✲✳✴✵✶✳ ✷✸ ✹✺✵✻ ✼✽✾✳✿❀✳❀ ❁✦❂❃ ❄

✹✺✵✻ ✳✽✾✳✿❀✳❀

❅❆ ❇✴✴❈❉❈✺✿❊✶ ❋✺✻❉●❊●✳ ✾❊❍❋✳✿❉❀ ■✺✻ ❍✺✵✻ ✻✳❀❈✴✳✿✱✳❏ ❑▲✥▼ ✦❑ ▼✩✫❃ ❃◆▲✤❖P ✧✩✦◗❑ ❅❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

❚❆ ❯❉❈✶❈❉❈✳❀✸

❚✠❆ ❱✧❃✥❖✪✤✥✤❖P❏ ▼❃✦❖❏ ◗✦❖▲✪✦✧ ❂✦❑ ❚✠❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

❚✂❆ ❲✦❖❃✪❏ ❑❃❳❃✪❏ ❂✦✪❨✦❂❃ ✥✩✧✧❃✥❖✤✩◗ ❚✂❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

❚❩❆ ❬❃✧❃❁▼✩◗❃❏ ✥❃✧✧ ❁▼✩◗❃❏ ❭◗❖❃✪◗❃❖❏ ❑✦❖❃✧✧✤❖❃❏ ✦◗❪ ✥✦❨✧❃ ❑❃✪❫✤✥❃❑ ❚❩❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

❚❴❆ ✢❖▼❃✪❵ ❛❁❃✥✤✣P❜ ❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙ ❚❴❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

❝❆ ❞✺✺✴ ❊✿✴ ✲✺✵❀✳❡✳✳✾❈✿● ❀✵✾✾✶❈✳❀ ❝❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

❢❆ ❣✲❈✶✴✱❊✻✳ ❊✿✴ ✱✲❈✶✴✻✳✿❤❀ ✳✴✵✱❊❉❈✺✿ ✱✺❀❉❀ ❢❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✐❆ ❣✶✺❉✲❈✿●❥ ✶❊✵✿✴✻❍❥ ❊✿✴ ✴✻❍ ✱✶✳❊✿❈✿● ✐❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❦❆ ❧✳✻❀✺✿❊✶ ✱❊✻✳ ✾✻✺✴✵✱❉❀ ❊✿✴ ❀✳✻♠❈✱✳❀ ✝❦❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝✝❆ ♥✳✴❈✱❊✶ ❊✿✴ ✴✳✿❉❊✶ ✳✽✾✳✿❀✳❀ ✝✝❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝♦❆ ♣✻❊✿❀✾✺✻❉❊❉❈✺✿q ❭◗✥✧▲❪❃ ❂✦❑❏ ✫✦✤◗❖❃◗✦◗✥❃❏ ❨▲❑ ✩✪ ❖✪✦✤◗ ✣✦✪❃❵

r✩ ◗✩❖ ✤◗✥✧▲❪❃ ✥✦✪ ❁✦P✫❃◗❖❑❵ ✝♦❆

❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝s❆ ✼✿❉✳✻❉❊❈✿❋✳✿❉❥ ✱✶✵t❀❥ ✻✳✱✻✳❊❉❈✺✿❥ ✿✳✉❀✾❊✾✳✻❀❥ ❋❊●❊✈❈✿✳❀❥ ❊✿✴ t✺✺❡❀ ✝s❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝✇❆ ❣✲❊✻❈❉❊t✶✳ ✱✺✿❉✻❈t✵❉❈✺✿❀ ❊✿✴ ✻✳✶❈●❈✺✵❀ ✴✺✿❊❉❈✺✿❀ ✝✇❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❅❆ 1✿❀✵✻❊✿✱✳q

r✩ ◗✩❖ ✤◗✥✧▲❪❃ ✤◗❑▲✪✦◗✥❃ ❪❃❪▲✥❖❃❪ ✣✪✩✫ P✩▲✪ ❁✦P ✩✪ ✤◗✥✧▲❪❃❪ ✤◗ ✧✤◗❃❑ 2 ✩✪ 3✭❵

✝

✝❅✠❆ 4✤✣❃ ✤◗❑▲✪✦◗✥❃ ✝❅✠❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❅✂❆ 5❃✦✧❖▼ ✤◗❑▲✪✦◗✥❃ ✝❅✂❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❅❩❆ 6❃▼✤✥✧❃ ✤◗❑▲✪✦◗✥❃ ✝❅❩❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❅❴❆ ✢❖▼❃✪ ✤◗❑▲✪✦◗✥❃❵ ❛❁❃✥✤✣P❜❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙ ✝❅❴❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❚❆ ♣❊✽✳❀q r✩ ◗✩❖ ✤◗✥✧▲❪❃ ❖✦7❃❑ ❪❃❪▲✥❖❃❪ ✣✪✩✫ P✩▲✪ ❁✦P ✩✪ ✤◗✥✧▲❪❃❪ ✤◗ ✧✤◗❃❑ 2 ✩✪ 3✭❵

❛❁❃✥✤✣P❜ ❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙ ✝❚❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❝❆ 1✿❀❉❊✶✶❋✳✿❉ ✺✻ ✶✳❊❀✳ ✾❊❍❋✳✿❉❀✸

✝❝✠❆ 8✦✪ ❁✦P✫❃◗❖❑ ✣✩✪ 6❃▼✤✥✧❃ ✬ ✝❝✠❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❝✂❆ 8✦✪ ❁✦P✫❃◗❖❑ ✣✩✪ 6❃▼✤✥✧❃ 3 ✝❝✂❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❝❩❆ ✢❖▼❃✪❵ ❛❁❃✥✤✣P❜❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙ ✝❝❩❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❝❴❆ ✢❖▼❃✪❵ ❛❁❃✥✤✣P❜❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙ ✝❝❴❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝❢❆ ✹✺✵✻ ✾❊❍❋✳✿❉❀ ✺■ ❊✶❈❋✺✿❍❥ ❋❊❈✿❉✳✿❊✿✱✳❥ ❊✿✴ ❀✵✾✾✺✻❉ ❉✲❊❉ ❍✺✵ ✴❈✴ ✿✺❉ ✻✳✾✺✻❉ ❊❀ ✴✳✴✵✱❉✳✴ ■✻✺❋

❍✺✵✻ ✾❊❍ ✺✿ ✶❈✿✳ 9❥ Schedule I, Your Income 10❶■■❈✱❈❊✶ ❞✺✻❋ ❷❸❹1❺q ✝❢❆

❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

✝✐❆ ❶❉✲✳✻ ✾❊❍❋✳✿❉❀ ❍✺✵ ❋❊❡✳ ❉✺ ❀✵✾✾✺✻❉ ✺❉✲✳✻❀ ✉✲✺ ✴✺ ✿✺❉ ✶❈♠✳ ✉❈❉✲ ❍✺✵q

❛❁❃✥✤✣P❜❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙ ✝✐❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

♦❦❆ ❶❉✲✳✻ ✻✳❊✶ ✾✻✺✾✳✻❉❍ ✳✽✾✳✿❀✳❀ ✿✺❉ ❈✿✱✶✵✴✳✴ ❈✿ ✶❈✿✳❀ ❻ ✺✻ 9 ✺■ ❉✲❈❀ ■✺✻❋ ✺✻ ✺✿ Schedule I✸ Your Income.

♦❦✠❆ ❼✩✪❖❂✦❂❃❑ ✩◗ ✩❖▼❃✪ ❁✪✩❁❃✪❖P ♦❦✠❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

♦❦✂❆ ❽❃✦✧ ❃❑❖✦❖❃ ❖✦7❃❑ ♦❦✂❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

♦❦❩❆ ❾✪✩❁❃✪❖P❏ ▼✩✫❃✩❳◗❃✪❿❑❏ ✩✪ ✪❃◗❖❃✪❿❑ ✤◗❑▲✪✦◗✥❃ ♦❦❩❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

♦❦❴❆ ❼✦✤◗❖❃◗✦◗✥❃❏ ✪❃❁✦✤✪❏ ✦◗❪ ▲❁➀❃❃❁ ❃7❁❃◗❑❃❑ ♦❦❴❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

♦❦✁❆ 5✩✫❃✩❳◗❃✪❿❑ ✦❑❑✩✥✤✦❖✤✩◗ ✩✪ ✥✩◗❪✩✫✤◗✤▲✫ ❪▲❃❑ ♦❦✁❆ ❘❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙❙

0.00

0.00

0.00

0.00

60.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

99.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Miguel Diaz

0.00

0.00

0.00

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 42 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯ ✰✱✲✳✴✵✶✳ ✷✸ ✹✺✵✻ ✼✽✾✳✿❀✳❀ ❁✦❂❃ ❄

❅✝❆ ❇❈✲✳✻❉ ❊❁❃✥✤✣❋● ❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍ ❅✝❆ ■❏❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍

❅❅❆ ❑▲✶✱✵✶▲❈✳ ▼✺✵✻ ◆✺✿❈✲✶▼ ✳✽✾✳✿❀✳❀❖

PP✦❉ ◗❘❘ ✧✤❙❃❚ ❯ ❱❲✪✩❳❂❲ P✬❉ ❅❅✠❆

PP❨❉ ❩✩❁❋ ✧✤❙❃ PP ❬✫✩❙❱❲✧❋ ❃❭❁❃❙❚❃❚ ✣✩✪ ❪❃❨❱✩✪ P❫❴ ✤✣ ✦❙❋❴ ✣✪✩✫ ✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮✯❵P ❅❅✂❆

PP✥❉ ◗❘❘ ✧✤❙❃ PP✦ ✦❙❘ PP❨❉ ❛❲❃ ✪❃❚❳✧❱ ✤❚ ❋✩❳✪ ✫✩❙❱❲✧❋ ❃❭❁❃❙❚❃❚❉ ❅❅❜❆

❏❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍

❏❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍

❏❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍

❅❝❆ ❑▲✶✱✵✶▲❈✳ ▼✺✵✻ ◆✺✿❈✲✶▼ ✿✳❈ ❞✿✱✺◆✳❖

P❡✦❉ ❩✩❁❋ ✧✤❙❃ ✬P ❬your combined monthly income❫ ✣✪✩✫ Schedule I. ❅❝✠❆ ❏❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍

P❡❨❉ ❩✩❁❋ ❋✩❳✪ ✫✩❙❱❲✧❋ ❃❭❁❃❙❚❃❚ ✣✪✩✫ ✧✤❙❃ PP✥ ✦❨✩❢❃❉ ❅❝✂❆ ❣ ❏❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍

P❡✥❉ ❊❳❨❱✪✦✥❱ ❋✩❳✪ ✫✩❙❱❲✧❋ ❃❭❁❃❙❚❃❚ ✣✪✩✫ ❋✩❳✪ ✫✩❙❱❲✧❋ ✤❙✥✩✫❃❉

❛❲❃ ✪❃❚❳✧❱ ✤❚ ❋✩❳✪ monthly net income❉ ❅❝❜❆ ❏❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍❍

❅❤❆ ✐✺ ▼✺✵ ✳✽✾✳✱❈ ▲✿ ❞✿✱✻✳▲❀✳ ✺✻ ✴✳✱✻✳▲❀✳ ❞✿ ▼✺✵✻ ✳✽✾✳✿❀✳❀ ❥❞❈✲❞✿ ❈✲✳ ▼✳▲✻ ▲❦❈✳✻ ▼✺✵ ❦❞✶✳ ❈✲❞❀ ❦✺✻◆❧

★✩✪ ❃❭✦✫❁✧❃❴ ❘✩ ❋✩❳ ❃❭❁❃✥❱ ❱✩ ✣✤❙✤❚❲ ❁✦❋✤❙❂ ✣✩✪ ❋✩❳✪ ✥✦✪ ✧✩✦❙ ♠✤❱❲✤❙ ❱❲❃ ❋❃✦✪ ✩✪ ❘✩ ❋✩❳ ❃❭❁❃✥❱ ❋✩❳✪

✫✩✪❱❂✦❂❃ ❁✦❋✫❃❙❱ ❱✩ ✤❙✥✪❃✦❚❃ ✩✪ ❘❃✥✪❃✦❚❃ ❨❃✥✦❳❚❃ ✩✣ ✦ ✫✩❘✤✣✤✥✦❱✤✩❙ ❱✩ ❱❲❃ ❱❃✪✫❚ ✩✣ ❋✩❳✪ ✫✩✪❱❂✦❂❃♥

♦ ♣✩❉

♦ q❃❚❉ r❭❁✧✦✤❙ ❲❃✪❃●

✔

159.00

0.00

Miguel Diaz

159.00

196.00

37.00

159.00

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 43 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞✌✍✄ ✎✏✑✒✓✔✓✕✖✗✘ ✙✚✗✛✕ ✓✘ ✜✘✢✖✣✖✢✛✓✒ ✎✏✚✕✗✔✤✥ ✦✑✧✏✢✛✒✏✥

★✩✩✪✫✪✬✭ ✮✯✰✱ ✲✳✴✵✶✫

Declaration About an Individual Debtor’s Schedules ✷✸✹✷✺

✜✻ ✕✼✗ ✽✓✔✔✖✏✢ ✾✏✗✾✒✏ ✓✔✏ ✻✖✒✖✘✿ ✕✗✿✏✕✧✏✔❀ ✚✗✕✧ ✓✔✏ ✏❁✛✓✒✒❂ ✔✏✥✾✗✘✥✖✚✒✏ ✻✗✔ ✥✛✾✾✒❂✖✘✿ ✑✗✔✔✏✑✕ ✖✘✻✗✔✽✓✕✖✗✘❃

❄✗✛ ✽✛✥✕ ✻✖✒✏ ✕✧✖✥ ✻✗✔✽ ✼✧✏✘✏✣✏✔ ❂✗✛ ✻✖✒✏ ✚✓✘❅✔✛✾✕✑❂ ✥✑✧✏✢✛✒✏✥ ✗✔ ✓✽✏✘✢✏✢ ✥✑✧✏✢✛✒✏✥❃ ❆✓❅✖✘✿ ✓ ✻✓✒✥✏ ✥✕✓✕✏✽✏✘✕❀ ✑✗✘✑✏✓✒✖✘✿ ✾✔✗✾✏✔✕❂❀ ✗✔

✗✚✕✓✖✘✖✘✿ ✽✗✘✏❂ ✗✔ ✾✔✗✾✏✔✕❂ ✚❂ ✻✔✓✛✢ ✖✘ ✑✗✘✘✏✑✕✖✗✘ ✼✖✕✧ ✓ ✚✓✘❅✔✛✾✕✑❂ ✑✓✥✏ ✑✓✘ ✔✏✥✛✒✕ ✖✘ ✻✖✘✏✥ ✛✾ ✕✗ ❇✸✺❈❀❈❈❈❀ ✗✔ ✖✽✾✔✖✥✗✘✽✏✘✕ ✻✗✔ ✛✾ ✕✗ ✸❈

❂✏✓✔✥❀ ✗✔ ✚✗✕✧❃ ✷❉ ❊❃✦❃❋❃ ●● ✷✺✸❀ ✷❍■✷❀ ✷✺✷❏❀ ✓✘✢ ❍✺❑✷❃

Sign Below

✎✖✢ ❂✗✛ ✾✓❂ ✗✔ ✓✿✔✏✏ ✕✗ ✾✓❂ ✥✗✽✏✗✘✏ ✼✧✗ ✖✥ ▲▼◆ ✓✘ ✓✕✕✗✔✘✏❂ ✕✗ ✧✏✒✾ ❂✗✛ ✻✖✒✒ ✗✛✕ ✚✓✘❅✔✛✾✕✑❂ ✻✗✔✽✥❖

P ◗✞

P ❘✍❙❚ ❯❱❲❳ ❨❩ ❬❳❭❪❨❫❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❵ ❛❜❜❱❝❞ Bankruptcy Petition Preparer’s Notice, Declaration, and 

Signature ❡❢❩❩❣❝❣❱❤ ✐❨❭❲ ❥❥❦❧❵

❊✘✢✏✔ ✾✏✘✓✒✕❂ ✗✻ ✾✏✔♠✛✔❂❀ ✜ ✢✏✑✒✓✔✏ ✕✧✓✕ ✜ ✧✓✣✏ ✔✏✓✢ ✕✧✏ ✥✛✽✽✓✔❂ ✓✘✢ ✥✑✧✏✢✛✒✏✥ ✻✖✒✏✢ ✼✖✕✧ ✕✧✖✥ ✢✏✑✒✓✔✓✕✖✗✘ ✓✘✢

✕✧✓✕ ✕✧✏❂ ✓✔✏ ✕✔✛✏ ✓✘✢ ✑✗✔✔✏✑✕❃

♥♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦ ♥ ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣

q❣r❫❱❜s❭❳ ❨❩ t❳✉❜❨❭ ❥ q❣r❫❱❜s❭❳ ❨❩ t❳✉❜❨❭ ✈

t❱❜❳ ✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇ t❱❜❳ ❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴

11 2 33 2 4444 11 2 33 2 4444

t❳✉❜❨❭ ❥ ❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴

56789 10❶❷❸ ❹6❺❺❻❸ 10❶❷❸ ❼❶89 10❶❷❸

t❳✉❜❨❭ ✈ ❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴

❽❾❿➀➁➂➃➄ ➅➆ ➆➅➇➅➈➉➊ 56789 10❶❷❸ ❹6❺❺❻❸ 10❶❷❸ ❼❶89 10❶❷❸

➋❫❣❜❳➌ q❜❱❜❳❪ ➍❱❫➎❭s❬❜❝➏ ➐❨s❭❜ ❩❨❭ ❜❞❳➑ ✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇✇ t❣❪❜❭❣❝❜ ❨❩ ✇✇✇✇✇✇✇✇✇✇

❽❾➒➓➒➃➊

➐❱❪❳ ❫s❲✉❳❭ ❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴❴

❽➔➆ →➈➀➣➈➊

 ↔✖✒✒ ✖✘ ✕✧✖✥ ✖✘✻✗✔✽✓✕✖✗✘ ✕✗ ✖✢✏✘✕✖✻❂ ❂✗✛✔ ✑✓✥✏↕

➙ ➛➜➝➞➟ ➠➡ ➢➜➠➤ ➠➤ ➥➦

➥➧➝➦➨➝➨ ➡➠➩➠➦➫

Miguel Diaz

Northern District of Illinois

✔

08/15/2016 08/15/2016

/s/ Miguel Diaz /s/

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 44 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞ ✌✍✎✍✏✑✏✒✍ ✓✔ ✕✖✒✎✒✗✖✎✘ ✙✔✔✎✖✚✛ ✔✓✚ ✜✒✢✖✣✖✢✤✎✘✛ ✕✖✘✖✒✥ ✔✓✚ ✦✎✒✧✚✤★✍✗✩ ✪☎✫✬ ✭

✮✯✯✰✱✰✲✳ ✴✵✶✷ ✸✹✺

Statement of Financial Affairs for Individuals Filing for Bankruptcy ✻✼✽✾

✦✏ ✎✛ ✗✓✑★✘✏✍✏ ✎✒✢ ✎✗✗✤✚✎✍✏ ✎✛ ★✓✛✛✖✿✘✏❀ ✜✔ ✍❁✓ ✑✎✚✚✖✏✢ ★✏✓★✘✏ ✎✚✏ ✔✖✘✖✒✥ ✍✓✥✏✍❂✏✚❃ ✿✓✍❂ ✎✚✏ ✏❄✤✎✘✘✩ ✚✏✛★✓✒✛✖✿✘✏ ✔✓✚ ✛✤★★✘✩✖✒✥ ✗✓✚✚✏✗✍

✖✒✔✓✚✑✎✍✖✓✒❀ ✜✔ ✑✓✚✏ ✛★✎✗✏ ✖✛ ✒✏✏✢✏✢❃ ✎✍✍✎✗❂ ✎ ✛✏★✎✚✎✍✏ ✛❂✏✏✍ ✍✓ ✍❂✖✛ ✔✓✚✑❀ ❅✒ ✍❂✏ ✍✓★ ✓✔ ✎✒✩ ✎✢✢✖✍✖✓✒✎✘ ★✎✥✏✛❃ ❁✚✖✍✏ ✩✓✤✚ ✒✎✑✏ ✎✒✢ ✗✎✛✏

✒✤✑✿✏✚ ❆✖✔ ✧✒✓❁✒❇❀ ✙✒✛❁✏✚ ✏✣✏✚✩ ❄✤✏✛✍✖✓✒❀

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

❈❉ ❊❂✎✍ ✖✛ ✩✓✤✚ ✗✤✚✚✏✒✍ ✑✎✚✖✍✎✘ ✛✍✎✍✤✛❋

● ❍☎✟✟✂✬■

● ❏✞❑ ✠☎✟✟✂✬■

▲▼ ◆✤✚✖✒✥ ✍❂✏ ✘✎✛✍ ❖ ✩✏✎✚✛❃ ❂✎✣✏ ✩✓✤ ✘✖✣✏✢ ✎✒✩❁❂✏✚✏ ✓✍❂✏✚ ✍❂✎✒ ❁❂✏✚✏ ✩✓✤ ✘✖✣✏ ✒✓❁❋

● ❏✞

● P✬◗❘ ❙✂◗❑ ☎✆✆ ✞✁ ❑❚✬ ✪✆☎✄✬◗ ❯✞❱ ✆✂❲✬■ ✂❳ ❑❚✬ ✆☎◗❑ ❨ ❯✬☎✟◗❘ ❩✞ ❳✞❑ ✂❳✄✆❱■✬ ❬❚✬✟✬ ❯✞❱ ✆✂❲✬ ❳✞❬❘

◆✏✿✍✓✚ ✭❭ ◆✎✍✏✛ ◆✏✿✍✓✚ ✭

✘✖✣✏✢ ✍❂✏✚✏

◆✏✿✍✓✚ ❪❭ ◆✎✍✏✛ ◆✏✿✍✓✚ ❪

✘✖✣✏✢ ✍❂✏✚✏

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❴❵❛❜❝❞ ❡❢❞❝❝❢

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❣❤❢✐ ❡❢❥❢❝ ❦❧♠ ❣♥♦❝

✝✟✞✠ ❫❫❫❫❫❫❫❫

♣✞ ❫❫qq❫❫❫❫❫❫

● ❡❥❛❝ ❥r s❝❜❢♥❞ t

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❴❵❛❜❝❞ ❡❢❞❝❝❢

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❣❤❢✐ ❡❢❥❢❝ ❦❧♠ ❣♥♦❝

✉ ❡❥❛❝ ❥r s❝❜❢♥❞ t

✝✟✞✠ ❫❫❫❫❫❫❫❫

♣✞ ✈✈✈✈✈✈✈✈

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❴❵❛❜❝❞ ❡❢❞❝❝❢

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❣❤❢✐ ❡❢❥❢❝ ❦❧♠ ❣♥♦❝

✝✟✞✠ ❫❫❫❫❫❫❫❫

♣✞ ❫❫❫❫❫❫❫❫

● ❡❥❛❝ ❥r s❝❜❢♥❞ t

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❴❵❛❜❝❞ ❡❢❞❝❝❢

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❣❤❢✐ ❡❢❥❢❝ ❦❧♠ ❣♥♦❝

✉ ❡❥❛❝ ❥r s❝❜❢♥❞ t

✝✟✞✠ ❫❫❫❫❫❫❫❫

♣✞ ✈✈✈✈✈✈✈✈

✇❉ ❊✖✍❂✖✒ ✍❂✏ ✘✎✛✍ 1 ✩✏✎✚✛❃ ✢✖✢ ✩✓✤ ✏✣✏✚ ✘✖✣✏ ❁✖✍❂ ✎ ✛★✓✤✛✏ ✓✚ ✘✏✥✎✘ ✏❄✤✖✣✎✘✏✒✍ ✖✒ ✎ ✗✓✑✑✤✒✖✍✩ ★✚✓★✏✚✍✩ ✛✍✎✍✏ ✓✚ ✍✏✚✚✖✍✓✚✩❋ 2Community property states

and territories ✂❳✄✆❱■✬ 3✟✂4✞❳☎5 6☎✆✂✁✞✟❳✂☎5 7■☎❚✞5 ❙✞❱✂◗✂☎❳☎5 ❏✬❲☎■☎5 ❏✬❬ ❍✬8✂✄✞5 9❱✬✟❑✞ 10✂✄✞5 ♣✬8☎◗5 ❶☎◗❚✂❳✫❑✞❳5 ☎❳■ ❶ ✂◗✄✞❳◗✂❳❘❷

● ❏✞

● P✬◗❘ ❍☎❸✬ ◗❱✟✬ ❯✞❱ ✁✂✆✆ ✞❱❑ Schedule H: Your Codebtors 2✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛❹❺❷❘

s❝❜❢♥❞ t ❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

❻❼❽❾❿ ➀➁➂➃ ➄❼➅➅➆➃ ➀➁➂➃ ➇➁❾❿ ➀➁➂➃

s❝❜❢♥❞ ▲ ❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

➈➉➊➋➌➍➎➏ ➐➑ ➑➐➒➐➓➔→ ❻❼❽❾❿ ➀➁➂➃ ➄❼➅➅➆➃ ➀➁➂➃ ➇➁❾❿ ➀➁➂➃

➣↔❤❢❝♦ ❡❢❥❢❝r ↕❥↔➙❞❵➛❢➜✐ ❣♥❵❞❢ ➝♥❞ ❢➞❝➟ ❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫ s❤r❢❞❤➜❢ ♥➝ ❫❫❫❫❫❫❫❫❫❫❫❫❫❫

➈➉➠➡➠➎→

❣❥r❝ ↔❵❛❜❝❞ ❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫❫

➈➢➑ ➤➓➋➥➓→

 ✕✖✘✘ ✖✒ ✍❂✖✛ ✖✒✔✓✚✑✎✍✖✓✒ ✍✓ ✖✢✏✒✍✖✔✩ ✩✓✤✚ ✗✎✛✏❭

➦ ➧➨➩➫➭ ➯➲ ➳➨➯➵ ➯➵ ➸➺

➸➻➩➺➼➩➼ ➲➯➽➯➺➾

Northern District of Illinois

✔

Miguel Diaz

✔

 

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 45 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊

❋● ❍✸✿ ❆✵❁ ■✱❀✲ ✱✴❆ ✸✴✹✵✳✲ ✶✼✵✳ ✲✳❅✺✵❆✳✲✴✰ ✵✼ ✶✼✵✳ ✵❅✲✼✱✰✸✴❂ ✱ ❏❁✽✸✴✲✽✽ ✿❁✼✸✴❂ ✰■✸✽ ❆✲✱✼ ✵✼ ✰■✲ ✰❑✵ ❅✼✲❀✸✵❁✽ ✹✱✺✲✴✿✱✼ ❆✲✱✼✽▲

★✤✧✧ ✤▼ ◆❖❉ ◆✩◆✦✧ ✦✫✩P▼◆ ✩✣ ✤▼✥✩✫❉ ◗✩P ✪❉✥❉✤❘❉❙ ✣✪✩✫ ✦✧✧ ❚✩❯❱ ✦▼❙ ✦✧✧ ❯P❱✤▼❉❱❱❉❱❲ ✤▼✥✧P❙✤▼❈ ❇✦✪◆❳◆✤✫❉ ✦✥◆✤❘✤◆✤❉❱❨

❩✣ ◗✩P ✦✪❉ ✣✤✧✤▼❈ ✦ ❚✩✤▼◆ ✥✦❱❉ ✦▼❙ ◗✩P ❖✦❘❉ ✤▼✥✩✫❉ ◆❖✦◆ ◗✩P ✪❉✥❉✤❘❉ ◆✩❈❉◆❖❉✪❲ ✧✤❱◆ ✤◆ ✩▼✧◗ ✩▼✥❉ P▼❙❉✪ ❬❉❯◆✩✪ ✬❨

❭ ❪✩

❭ ❫❉❱❨ ★✤✧✧ ✤▼ ◆❖❉ ❙❉◆✦✤✧❱❨

❴❵❛❜❝❞ ❡ ❴❵❛❜❝❞ ❢

❣❝❤❞✐❵❥ ❝❦ ❧♠✐❝♥❵

✟♦✁♣q ✠rr ✄♦✠✄ ✠ssrt●

✉❞❝❥❥ ❧♠✐❝♥❵

✈✂✁✇☎✆✁ 1✁1☞♣✄2☎☛✡ ✠☛1

✁3♣r☞✡2☎☛✡4

❣❝❤❞✐❵❥ ❝❦ ❧♠✐❝♥❵

✟♦✁♣q ✠rr ✄♦✠✄ ✠ssrt●

✉❞❝❥❥ ❧♠✐❝♥❵

✈✂✁✇☎✆✁ 1✁1☞♣✄2☎☛✡ ✠☛1

✁3♣r☞✡2☎☛✡4

✷✼✵✳ 5✱✴❁✱✼❆ 6 ✵✶ ✹❁✼✼✲✴✰ ❆✲✱✼ ❁✴✰✸✺

✰■✲ ✿✱✰✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ❏✱✴❄✼❁❅✰✹❆7

❭ 8✠9✁✡10 ♣☎✌✌2✡✡2☎☛✡10

✂☎☛☞✡✁✡10 ✄2s✡

❭ ❶s✁✆✠✄2☛9 ✠ ✂☞✡2☛✁✡✡

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❭ 8✠9✁✡10 ♣☎✌✌2✡✡2☎☛✡10

✂☎☛☞✡✁✡10 ✄2s✡

❭ ❶s✁✆✠✄2☛9 ✠ ✂☞✡2☛✁✡✡

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

✷✵✼ ✺✱✽✰ ✹✱✺✲✴✿✱✼ ❆✲✱✼7

❹❺✦▼P✦✪◗ ✬ ◆✩ ❬❉✥❉✫❯❉✪ ❻✬❲ ❸❸❸❸❸❸❸❸❸❼

❽❽❽❽

❭ 8✠9✁✡10 ♣☎✌✌2✡✡2☎☛✡10

✂☎☛☞✡✁✡10 ✄2s✡

❭ ❶s✁✆✠✄2☛9 ✠ ✂☞✡2☛✁✡✡

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❭ 8✠9✁✡10 ♣☎✌✌2✡✡2☎☛✡10

✂☎☛☞✡✁✡10 ✄2s✡

❭ ❶s✁✆✠✄2☛9 ✠ ✂☞✡2☛✁✡✡

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

✷✵✼ ✰■✲ ✹✱✺✲✴✿✱✼ ❆✲✱✼ ❏✲✶✵✼✲ ✰■✱✰7

❹❺✦▼P✦✪◗ ✬ ◆✩ ❬❉✥❉✫❯❉✪ ❻✬❲ ❸❸❸❸❸❸❸❸❸❼

❽❽❽❽

❭ 8✠9✁✡10 ♣☎✌✌2✡✡2☎☛✡10

✂☎☛☞✡✁✡10 ✄2s✡

❭ ❶s✁✆✠✄2☛9 ✠ ✂☞✡2☛✁✡✡

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❭ 8✠9✁✡10 ♣☎✌✌2✡✡2☎☛✡10

✂☎☛☞✡✁✡10 ✄2s✡

❭ ❶s✁✆✠✄2☛9 ✠ ✂☞✡2☛✁✡✡

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❾● ❍✸✿ ❆✵❁ ✼✲✹✲✸❀✲ ✱✴❆ ✵✰■✲✼ ✸✴✹✵✳✲ ✿❁✼✸✴❂ ✰■✸✽ ❆✲✱✼ ✵✼ ✰■✲ ✰❑✵ ❅✼✲❀✸✵❁✽ ✹✱✺✲✴✿✱✼ ❆✲✱✼✽▲

❩▼✥✧P❙❉ ✤▼✥✩✫❉ ✪❉❈✦✪❙✧❉❱❱ ✩✣ ❿❖❉◆❖❉✪ ◆❖✦◆ ✤▼✥✩✫❉ ✤❱ ◆✦➀✦❯✧❉❨ ➁➀✦✫❇✧❉❱ ✩✣ other income ✦✪❉ ✦✧✤✫✩▼◗➂ ✥❖✤✧❙ ❱P❇❇✩✪◆➂ ➃✩✥✤✦✧ ➃❉✥P✪✤◆◗❲ P▼❉✫❇✧✩◗✫❉▼◆❲

✦▼❙ ✩◆❖❉✪ ❇P❯✧✤✥ ❯❉▼❉✣✤◆ ❇✦◗✫❉▼◆❱➂ ❇❉▼❱✤✩▼❱➂ ✪❉▼◆✦✧ ✤▼✥✩✫❉➂ ✤▼◆❉✪❉❱◆➂ ❙✤❘✤❙❉▼❙❱➂ ✫✩▼❉◗ ✥✩✧✧❉✥◆❉❙ ✣✪✩✫ ✧✦❿❱P✤◆❱➂ ✪✩◗✦✧◆✤❉❱➂ ✦▼❙ ❈✦✫❯✧✤▼❈ ✦▼❙ ✧✩◆◆❉✪◗

❿✤▼▼✤▼❈❱❨ ❩✣ ◗✩P ✦✪❉ ✣✤✧✤▼❈ ✦ ❚✩✤▼◆ ✥✦❱❉ ✦▼❙ ◗✩P ❖✦❘❉ ✤▼✥✩✫❉ ◆❖✦◆ ◗✩P ✪❉✥❉✤❘❉❙ ◆✩❈❉◆❖❉✪❲ ✧✤❱◆ ✤◆ ✩▼✧◗ ✩▼✥❉ P▼❙❉✪ ❬❉❯◆✩✪ ✬❨

➄✤❱◆ ❉✦✥❖ ❱✩P✪✥❉ ✦▼❙ ◆❖❉ ❈✪✩❱❱ ✤▼✥✩✫❉ ✣✪✩✫ ❉✦✥❖ ❱✩P✪✥❉ ❱❉❇✦✪✦◆❉✧◗❨ ❬✩ ▼✩◆ ✤▼✥✧P❙❉ ✤▼✥✩✫❉ ◆❖✦◆ ◗✩P ✧✤❱◆❉❙ ✤▼ ✧✤▼❉ ➅❨

❭ ❪✩

❭ ❫❉❱❨ ★✤✧✧ ✤▼ ◆❖❉ ❙❉◆✦✤✧❱❨

❴❵❛❜❝❞ ❡ ❴❵❛❜❝❞ ❢

❣❝❤❞✐❵❥ ❝❦ ❧♠✐❝♥❵

✁✡♣✆2✂✁ ✂✁r☎➆●

✉❞❝❥❥ ❧♠✐❝♥❵ ❦❞❝♥

❵➇✐➈ ❥❝❤❞✐❵

✈✂✁✇☎✆✁ 1✁1☞♣✄2☎☛✡ ✠☛1

✁3♣r☞✡2☎☛✡4

❣❝❤❞✐❵❥ ❝❦ ❧♠✐❝♥❵

✁✡♣✆2✂✁ ✂✁r☎➆●

✉❞❝❥❥ ❧♠✐❝♥❵ ❦❞❝♥

❵➇✐➈ ❥❝❤❞✐❵

✈✂✁✇☎✆✁ 1✁1☞♣✄2☎☛✡ ✠☛1

✁3♣r☞✡2☎☛✡4

✷✼✵✳ 5✱✴❁✱✼❆ 6 ✵✶ ✹❁✼✼✲✴✰ ❆✲✱✼ ❁✴✰✸✺

✰■✲ ✿✱✰✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ❏✱✴❄✼❁❅✰✹❆7

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➉➉

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉

✷✵✼ ✺✱✽✰ ✹✱✺✲✴✿✱✼ ❆✲✱✼7

❹❺✦▼P✦✪◗ ✬ ◆✩ ❬❉✥❉✫❯❉✪ ❻✬❲ ❸❸❸❸❸❸❼

❽❽❽❽

✷✵✼ ✰■✲ ✹✱✺✲✴✿✱✼ ❆✲✱✼ ❏✲✶✵✼✲ ✰■✱✰7

❹❺✦▼P✦✪◗ ✬ ◆✩ ❬❉✥❉✫❯❉✪ ❻✬❲ ❸❸❸❸❸❸❼

❽❽❽❽

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➊

❷➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

Part 2: Explain the Sources of Your Income 

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➉

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➉

❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉➉

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➊

❷➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➊

❷➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➊

❷➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➊

❷➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸➊

❷➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊➊

❷❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸❸

1,568.00

1,568.00

1,568.00

5,000.00

Miguel Diaz

✔

✔

2014

2015

Food Stamps

Food Stamps

Food Stamps

Relocation Asst due to Foreclosure

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 46 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊

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

❋● ✻✼✲ ✲✸✰❍✲✼ ■✲❏✰✵✼ ❑▲✽ ✵✼ ■✲❏✰✵✼ ▼▲✽ ✿✲❏✰✽ ❅✼✸✳✱✼✸✺❆ ✹✵✴✽❁✳✲✼ ✿✲❏✰✽◆

❖ P✩◗ ❘✲✸✰❍✲✼ ■✲❏✰✵✼ ❑ ✴✵✼ ■✲❏✰✵✼ ▼ ❍✱✽ ❅✼✸✳✱✼✸✺❆ ✹✵✴✽❁✳✲✼ ✿✲❏✰✽❙ Consumer debts ✦✪❉ ❚❉✣✤❯❉❚ ✤❯ ✬✬ ❱◗❲◗❳◗ ❨ ✬✭✬❩❬❭ ✦❪

❫✤❯✥❴✪✪❉❚ ❵❛ ✦❯ ✤❯❚✤❜✤❚❴✦✧ ❇✪✤✫✦✪✤✧❛ ✣✩✪ ✦ ❇❉✪❪✩❯✦✧❝ ✣✦✫✤✧❛❝ ✩✪ ❞✩❴❪❉❞✩✧❚ ❇❴✪❇✩❪❉◗❡

❢❴✪✤❯❈ ❣❞❉ ❤✭ ❚✦❛❪ ❵❉✣✩✪❉ ❛✩❴ ✣✤✧❉❚ ✣✩✪ ❵✦❯✐✪❴❇❣✥❛❝ ❚✤❚ ❛✩❴ ❇✦❛ ✦❯❛ ✥✪❉❚✤❣✩✪ ✦ ❣✩❣✦✧ ✩✣ ❥❦❝❧♠♥♦ ✩✪ ✫✩✪❉♣

q P✩◗ r✩ ❣✩ ✧✤❯❉ ✮◗

q s❉❪◗ t✤❪❣ ❵❉✧✩✉ ❉✦✥❞ ✥✪❉❚✤❣✩✪ ❣✩ ✉❞✩✫ ❛✩❴ ❇✦✤❚ ✦ ❣✩❣✦✧ ✩✣ ❥❦❝❧♠♥♦ ✩✪ ✫✩✪❉ ✤❯ ✩❯❉ ✩✪ ✫✩✪❉ ❇✦❛✫❉❯❣❪ ✦❯❚

❣❞❉ ❣✩❣✦✧ ✦✫✩❴❯❣ ❛✩❴ ❇✦✤❚ ❣❞✦❣ ✥✪❉❚✤❣✩✪◗ ❢✩ ❯✩❣ ✤❯✥✧❴❚❉ ❇✦❛✫❉❯❣❪ ✣✩✪ ❚✩✫❉❪❣✤✥ ❪❴❇❇✩✪❣ ✩❵✧✤❈✦❣✤✩❯❪❝ ❪❴✥❞ ✦❪

✥❞✤✧❚ ❪❴❇❇✩✪❣ ✦❯❚ ✦✧✤✫✩❯❛◗ ✈✧❪✩❝ ❚✩ ❯✩❣ ✤❯✥✧❴❚❉ ❇✦❛✫❉❯❣❪ ❣✩ ✦❯ ✦❣❣✩✪❯❉❛ ✣✩✪ ❣❞✤❪ ❵✦❯✐✪❴❇❣✥❛ ✥✦❪❉◗

♦ ❲❴❵✇❉✥❣ ❣✩ ✦❚✇❴❪❣✫❉❯❣ ✩❯ 12✭✬2✬3 ✦❯❚ ❉❜❉✪❛ 4 ❛❉✦✪❪ ✦✣❣❉✪ ❣❞✦❣ ✣✩✪ ✥✦❪❉❪ ✣✤✧❉❚ ✩❯ ✩✪ ✦✣❣❉✪ ❣❞❉ ❚✦❣❉ ✩✣ ✦❚✇❴❪❣✫❉❯❣◗

❖ s❉❪◗ ■✲❏✰✵✼ ❑ ✵✼ ■✲❏✰✵✼ ▼ ✵✼ ❏✵✰❍ ❍✱❀✲ ❅✼✸✳✱✼✸✺❆ ✹✵✴✽❁✳✲✼ ✿✲❏✰✽❙

❢❴✪✤❯❈ ❣❞❉ ❤✭ ❚✦❛❪ ❵❉✣✩✪❉ ❛✩❴ ✣✤✧❉❚ ✣✩✪ ❵✦❯✐✪❴❇❣✥❛❝ ❚✤❚ ❛✩❴ ❇✦❛ ✦❯❛ ✥✪❉❚✤❣✩✪ ✦ ❣✩❣✦✧ ✩✣ ❥❦✭✭ ✩✪ ✫✩✪❉♣

❖ P✩◗ r✩ ❣✩ ✧✤❯❉ ✮◗

❖ s❉❪◗ t✤❪❣ ❵❉✧✩✉ ❉✦✥❞ ✥✪❉❚✤❣✩✪ ❣✩ ✉❞✩✫ ❛✩❴ ❇✦✤❚ ✦ ❣✩❣✦✧ ✩✣ ❥❦✭✭ ✩✪ ✫✩✪❉ ✦❯❚ ❣❞❉ ❣✩❣✦✧ ✦✫✩❴❯❣ ❛✩❴ ❇✦✤❚ ❣❞✦❣

✥✪❉❚✤❣✩✪◗ ❢✩ ❯✩❣ ✤❯✥✧❴❚❉ ❇✦❛✫❉❯❣❪ ✣✩✪ ❚✩✫❉❪❣✤✥ ❪❴❇❇✩✪❣ ✩❵✧✤❈✦❣✤✩❯❪❝ ❪❴✥❞ ✦❪ ✥❞✤✧❚ ❪❴❇❇✩✪❣ ✦❯❚

✦✧✤✫✩❯❛◗ ✈✧❪✩❝ ❚✩ ❯✩❣ ✤❯✥✧❴❚❉ ❇✦❛✫❉❯❣❪ ❣✩ ✦❯ ✦❣❣✩✪❯❉❛ ✣✩✪ ❣❞✤❪ ❵✦❯✐✪❴❇❣✥❛ ✥✦❪❉◗

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

5678910❶6❷❸ ❹❺❻7

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❼❻❽76 ❾1067710

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

5910❿ ❾10❺107 ➀➁➂ 5❶87

➃➄➅➆➇ ➈➉

➊➄➋➌➆➍➅

➎➈➅➄➏ ➄➌➈➐➍➅ ➊➄➑➒ ➓➌➈➐➍➅ ➋➈➐ ➇➅➑➏➏ ➈➔➆ →➄➇ ➅➣➑➇ ➊➄➋➌➆➍➅ ➉➈↔↕

➙➙➙➙➙➙➙➙➙

➙➙➙➙➙➙➙➙➙

➙➙➙➙➙➙➙➙➙

❥➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙ ❥➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙ ❖ ➛☎✆✄➜✠➜✁

➝ ✟✠✆

➝ ✟✆✁➞➟✄ ➠✠✆➞

➝ ➡☎✠☛ ✆✁➢✠➤✌✁☛✄

➝ ➥☞➢➢➦➟✁✆✡ ☎✆ ➧✁☛➞☎✆✡

➝ ➨✄➩✁✆ ✞✞✞✞✞✞✞➫➫✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

5678910❶6❷❸ ❹❺❻7

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❼❻❽76 ❾1067710

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

5910❿ ❾10❺107 ➀➁➂ 5❶87

➙➙➙➙➙➙➙➙➙

➙➙➙➙➙➙➙➙➙

➙➙➙➙➙➙➙➙➙

❥➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙ ❥➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙ ❖ ➛☎✆✄➜✠➜✁

➝ ✟✠✆

➝ ✟✆✁➞➟✄ ➠✠✆➞

➝ ➡☎✠☛ ✆✁➢✠➤✌✁☛✄

➝ ➥☞➢➢➦➟✁✆✡ ☎✆ ➧✁☛➞☎✆✡

➝ ➨✄➩✁✆ ✞✞✞✞✞✞✞✞➫➫✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

5678910❶6❷❸ ❹❺❻7

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❹❼❻❽76 ❾1067710

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

5910❿ ❾10❺107 ➀➁➂ 5❶87

➙➙➙➙➙➙➙➙➙

➙➙➙➙➙➙➙➙➙

➙➙➙➙➙➙➙➙➙

❥➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙ ❥➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙➙ ❖ ➛☎✆✄➜✠➜✁

➝ ✟✠✆

➝ ✟✆✁➞➟✄ ➠✠✆➞

➝ ➡☎✠☛ ✆✁➢✠➤✌✁☛✄

➝ ➥☞➢➢➦➟✁✆✡ ☎✆ ➧✁☛➞☎✆✡

➝ ➨✄➩✁✆ ✞✞✞✞✞✞➫➫➫✞✞✞✞✞✞

Miguel Diaz

✔

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 47 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊

❋● ❍✸✰■✸✴ ❏ ❆✲✱✼ ❑✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ❑✱✴❄✼❁❅✰✹❆▲ ✿✸✿ ❆✵❁ ✳✱❄✲ ✱ ❅✱❆✳✲✴✰ ✵✴ ✱ ✿✲❑✰ ❆✵❁ ✵▼✲✿ ✱✴❆✵✴✲ ▼■✵ ▼✱✽ ✱✴ ✸✴✽✸✿✲✼◆

Insiders ✤❖✥✧P◗❉ ❘✩P✪ ✪❉✧✦❙✤❚❉❯❱ ✦❖❘ ❈❉❖❉✪✦✧ ❇✦✪❙❖❉✪❯❱ ✪❉✧✦❙✤❚❉❯ ✩✣ ✦❖❘ ❈❉❖❉✪✦✧ ❇✦✪❙❖❉✪❯❱ ❇✦✪❙❖❉✪❯❲✤❇❯ ✩✣ ❳❲✤✥❲ ❘✩P ✦✪❉ ✦ ❈❉❖❉✪✦✧ ❇✦✪❙❖❉✪❱

✥✩✪❇✩✪✦❙✤✩❖❯ ✩✣ ❳❲✤✥❲ ❘✩P ✦✪❉ ✦❖ ✩✣✣✤✥❉✪❨ ◗✤✪❉✥❙✩✪❨ ❇❉✪❯✩❖ ✤❖ ✥✩❖❙✪✩✧❨ ✩✪ ✩❳❖❉✪ ✩✣ ❩✭❬ ✩✪ ✫✩✪❉ ✩✣ ❙❲❉✤✪ ❚✩❙✤❖❈ ❯❉✥P✪✤❙✤❉❯❱ ✦❖◗ ✦❖❘ ✫✦❖✦❈✤❖❈

✦❈❉❖❙❨ ✤❖✥✧P◗✤❖❈ ✩❖❉ ✣✩✪ ✦ ❭P❯✤❖❉❯❯ ❘✩P ✩❇❉✪✦❙❉ ✦❯ ✦ ❯✩✧❉ ❇✪✩❇✪✤❉❙✩✪❪ ✬✬ ❫❪❴❪❵❪ ❛ ✬✭✬❪ ❜❖✥✧P◗❉ ❇✦❘✫❉❖❙❯ ✣✩✪ ◗✩✫❉❯❙✤✥ ❯P❇❇✩✪❙ ✩❭✧✤❈✦❙✤✩❖❯❨

❯P✥❲ ✦❯ ✥❲✤✧◗ ❯P❇❇✩✪❙ ✦❖◗ ✦✧✤✫✩❖❘❪

❝ ❞✩

❝ ❡❉❯❪ ❢✤❯❙ ✦✧✧ ❇✦❘✫❉❖❙❯ ❙✩ ✦❖ ✤❖❯✤◗❉✪❪

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❣❤✐❥❦❧♠♥✐ ♦♣q❧

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♦rqs❧♠ t✉♠❧❧✉

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✈❥✉✇ t✉♣✉❧ 1❣2 ✈3❦❧

45678 910

❶5❷❸7❹6

❺965❻ 5❸9❼❹6

❶5❽❾

❿❸9❼❹6 ❷9❼ 86❽❻❻

9➀7

➁7589❹ 109➂ 6➃❽8 ❶5❷❸7❹6

➄➄➄➄➄➄➄➄➄

➄➄➄➄➄➄➄➄➄

➄➄➄➄➄➄➄➄➄

➅➄➄➄➄➄➄➄➄➄➄➄➄ ➅➄➄➄➄➄➄➄➄➄➄➄➄

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❣❤✐❥❦❧♠♥✐ ♦♣q❧

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♦rqs❧♠ t✉♠❧❧✉

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✈❥✉✇ t✉♣✉❧ 1❣2 ✈3❦❧

➄➄➄➄➄➄➄➄➄

➄➄➄➄➄➄➄➄➄

➄➄➄➄➄➄➄➄➄

➅➄➄➄➄➄➄➄➄➄➄➄➄ ➅➄➄➄➄➄➄➄➄➄➄➄➄

➆● ❍✸✰■✸✴ ❏ ❆✲✱✼ ❑✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ❑✱✴❄✼❁❅✰✹❆▲ ✿✸✿ ❆✵❁ ✳✱❄✲ ✱✴❆ ❅✱❆✳✲✴✰✽ ✵✼ ✰✼✱✴✽✶✲✼ ✱✴❆ ❅✼✵❅✲✼✰❆ ✵✴ ✱✹✹✵❁✴✰ ✵✶ ✱ ✿✲❑✰ ✰■✱✰ ❑✲✴✲✶✸✰✲✿

✱✴ ✸✴✽✸✿✲✼◆

❜❖✥✧P◗❉ ❇✦❘✫❉❖❙❯ ✩❖ ◗❉❭❙❯ ❈P✦✪✦❖❙❉❉◗ ✩✪ ✥✩❯✤❈❖❉◗ ❭❘ ✦❖ ✤❖❯✤◗❉✪❪

❝ ❞✩

❝ ❡❉❯❪ ❢✤❯❙ ✦✧✧ ❇✦❘✫❉❖❙❯ ❙❲✦❙ ❭❉❖❉✣✤❙❉◗ ✦❖ ✤❖❯✤◗❉✪❪

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❣❤✐❥❦❧♠♥✐ ♦♣q❧

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♦rqs❧♠ t✉♠❧❧✉

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✈❥✉✇ t✉♣✉❧ 1❣2 ✈3❦❧

45678 910

❶5❷❸7❹6

❺965❻ 5❸9❼❹6

❶5❽❾

❿❸9❼❹6 ❷9❼ 86❽❻❻

9➀7

➁7589❹ 109➂ 6➃❽8 ❶5❷❸7❹6

➇☛➈➉☞➊✁ ➈✆✁➊➋✄☎✆➌✡ ☛✠✌✁

➄➄➄➄➄➄➄➄➄

➄➄➄➄➄➄➄➄➄

➄➄➄➄➄➄➄➄➄

➅➄➄➄➄➄➄➄➄➄➄➄➄ ➅➄➄➄➄➄➄➄➄➄➄➄➄

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❣❤✐❥❦❧♠♥✐ ♦♣q❧

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

♦rqs❧♠ t✉♠❧❧✉

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✈❥✉✇ t✉♣✉❧ 1❣2 ✈3❦❧

➄➄➄➄➄➄➄➄➄

➄➄➄➄➄➄➄➄➄

➄➄➄➄➄➄➄➄➄

➅➄➄➄➄➄➄➄➄➄➄➄➄ ➅➄➄➄➄➄➄➄➄➄➄➄➄

✔

Miguel Diaz

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 48 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊

 Part 4: Identify Legal Actions, Repossessions, and Foreclosures

❋● ❍✸✰■✸✴ ❏ ❆✲✱✼ ❑✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ❑✱✴❄✼❁❅✰✹❆▲ ▼✲✼✲ ❆✵❁ ✱ ❅✱✼✰❆ ✸✴ ✱✴❆ ✺✱▼✽❁✸✰▲ ✹✵❁✼✰ ✱✹✰✸✵✴▲ ✵✼ ✱✿✳✸✴✸✽✰✼✱✰✸❀✲ ❅✼✵✹✲✲✿✸✴❂◆

❖✤P◗ ✦✧✧ P❘✥❙ ✫✦◗◗❉✪P❚ ✤❯✥✧❘❱✤❯❈ ❇❉✪P✩❯✦✧ ✤❯❲❘✪❳ ✥✦P❉P❚ P✫✦✧✧ ✥✧✦✤✫P ✦✥◗✤✩❯P❚ ❱✤❨✩✪✥❉P❚ ✥✩✧✧❉✥◗✤✩❯ P❘✤◗P❚ ❇✦◗❉✪❯✤◗❳ ✦✥◗✤✩❯P❚ P❘❇❇✩✪◗ ✩✪ ✥❘P◗✩❱❳ ✫✩❱✤✣✤✥✦◗✤✩❯P❚

✦❯❱ ✥✩❯◗✪✦✥◗ ❱✤P❇❘◗❉P❩

❬ ❭✩

❬ ❪❉P❩ ★✤✧✧ ✤❯ ◗❙❉ ❱❉◗✦✤✧P❩

✟✠✡✁ ❫❴❫❵❛❜

✟✠✡✁ ☛☞✌✂✁✆ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❝❞❡❢❣❤ ✐❥ ❡❦❤ ❧❞♠❤ ♥✐❢❣❡ ✐❣ ❞♦❤♣❧q r❡❞❡❢♠ ✐❥ ❡❦❤ ❧❞♠❤

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

st✉✈✇ 1234

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

1✉354✈ 6✇✈44✇

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

s7✇8 6✇2✇4 910❶ st❷4

❬ ❸✁☛❹❺☛❻

❬ ❼☛ ✠❽❽✁✠❾

❬ ✟☎☛❿❾☞❹✁❹

✟✠✡✁ ❫❴❫❵❛❜

✟✠✡✁ ☛☞✌✂✁✆ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

st✉✈✇ 1234

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

1✉354✈ 6✇✈44✇

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

s7✇8 6✇2✇4 910❶ st❷4

❬ ❸✁☛❹❺☛❻

❬ ❼☛ ✠❽❽✁✠❾

❬ ✟☎☛❿❾☞❹✁❹

➀➁➂ ❍✸✰■✸✴ ❏ ❆✲✱✼ ❑✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ❑✱✴❄✼❁❅✰✹❆▲ ▼✱✽ ✱✴❆ ✵✶ ❆✵❁✼ ❅✼✵❅✲✼✰❆ ✼✲❅✵✽✽✲✽✽✲✿▲ ✶✵✼✲✹✺✵✽✲✿▲ ❂✱✼✴✸✽■✲✿▲ ✱✰✰✱✹■✲✿▲ ✽✲✸➃✲✿▲ ✵✼ ✺✲❀✸✲✿◆

➄❙❉✥➅ ✦✧✧ ◗❙✦◗ ✦❇❇✧❳ ✦❯❱ ✣✤✧✧ ✤❯ ◗❙❉ ❱❉◗✦✤✧P ➆❉✧✩➇❩

❬ ❭✩❩ ➈✩ ◗✩ ✧✤❯❉ ✬✬❩

❬ ❪❉P❩ ★✤✧✧ ✤❯ ◗❙❉ ✤❯✣✩✪✫✦◗✤✩❯ ➆❉✧✩➇❩

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

s✈4❷7✇t✈➉➊ 1234

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

1✉354✈ 6✇✈44✇

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

s7✇8 6✇2✇4 910❶ st❷4

➋❤♠❧❣➌➍❤ ❡❦❤ ➎❣✐➎❤❣❡q ➋❞❡❤ ➏❞➐❢❤ ✐❥ ❡❦❤ ➎❣✐➎❤❣❡q

➑➑➑➑➑➑➑➑➑➑ ➒➑➑➑➑➑➑➑➑➑➑➑➑➑➑

➓➔➎➐❞➌♣ →❦❞❡ ❦❞➎➎❤♣❤➣

❬ ↔✪✩❇❉✪◗❳ ➇✦P ✪❉❇✩PP❉PP❉❱❩

❬ ↔✪✩❇❉✪◗❳ ➇✦P ✣✩✪❉✥✧✩P❉❱❩

❬ ↔✪✩❇❉✪◗❳ ➇✦P ❈✦✪❯✤P❙❉❱❩

❬ ↔✪✩❇❉✪◗❳ ➇✦P ✦◗◗✦✥❙❉❱❚ P❉✤↕❉❱❚ ✩✪ ✧❉❨✤❉❱❩

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

s✈4❷7✇t✈➉➊ 1234

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

1✉354✈ 6✇✈44✇

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

s7✇8 6✇2✇4 910❶ st❷4

➋❤♠❧❣➌➍❤ ❡❦❤ ➎❣✐➎❤❣❡q ➋❞❡❤ ➏❞➐❢❤ ✐❥ ❡❦❤ ➎❣✐➎❤❣❡q

➑➑➑➑➑➑➑➑➑➑ ➒➑➑➑➑➑➑➑➑➑➑➑➑➑➑

➓➔➎➐❞➌♣ →❦❞❡ ❦❞➎➎❤♣❤➣

❬ ↔✪✩❇❉✪◗❳ ➇✦P ✪❉❇✩PP❉PP❉❱❩

❬ ↔✪✩❇❉✪◗❳ ➇✦P ✣✩✪❉✥✧✩P❉❱❩

❬ ↔✪✩❇❉✪◗❳ ➇✦P ❈✦✪❯✤P❙❉❱❩

❬ ↔✪✩❇❉✪◗❳ ➇✦P ✦◗◗✦✥❙❉❱❚ P❉✤↕❉❱❚ ✩✪ ✧❉❨✤❉❱❩

Miguel Diaz v A&R Janitorial

Chicago

100 W Randolph

Workers Compensation; Date filed:

10/18/2011

✔

Miguel Diaz

Workers Compensation Commission

✔

11 WC 040137

60601

✔

IL

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 49 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊

❋❋● ❍✸✰■✸✴ ❏❑ ✿✱❆✽ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ✿✸✿ ✱✴❆ ✹✼✲✿✸✰✵✼▼ ✸✴✹✺❁✿✸✴❂ ✱ ▲✱✴❄ ✵✼ ✶✸✴✱✴✹✸✱✺ ✸✴✽✰✸✰❁✰✸✵✴▼ ✽✲✰ ✵✶✶ ✱✴❆ ✱✳✵❁✴✰✽ ✶✼✵✳ ❆✵❁✼

✱✹✹✵❁✴✰✽ ✵✼ ✼✲✶❁✽✲ ✰✵ ✳✱❄✲ ✱ ❅✱❆✳✲✴✰ ▲✲✹✱❁✽✲ ❆✵❁ ✵◆✲✿ ✱ ✿✲▲✰❖

P ◗✩

P ❘❉❙❚ ★✤✧✧ ✤❯ ❱❲❉ ❳❉❱✦✤✧❙❚

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❨❩❬❭❪❫❴❩❵❛ ❜❝❞❬

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❜❡❞❢❬❩ ❣❫❩❬❬❫

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❨❪❫❤ ❣❫❝❫❬ ✐❥❦ ❨❴❭❬

❧♠♥♦♣qr♠ st♠ ✉♦sq✈✇ st♠ ♦♣♠1qs✈♣ s✈✈2 ❧✉s♠ ✉♦sq✈✇

3✉♥ s✉2♠✇

45✈6✇s

777777777777 87777777777777777

9✦❙❱ 10 ❳✤❈✤❱❙ ✩✣ ✦✥✥✩❶❯❱ ❯❶✫❷❉✪❸ ❹❹❹❹❺

✝❻❼ ❍✸✰■✸✴ ❽ ❆✲✱✼ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ◆✱✽ ✱✴❆ ✵✶ ❆✵❁✼ ❅✼✵❅✲✼✰❆ ✸✴ ✰■✲ ❅✵✽✽✲✽✽✸✵✴ ✵✶ ✱✴ ✱✽✽✸❂✴✲✲ ✶✵✼ ✰■✲ ▲✲✴✲✶✸✰ ✵✶

✹✼✲✿✸✰✵✼✽▼ ✱ ✹✵❁✼✰❾✱❅❅✵✸✴✰✲✿ ✼✲✹✲✸❀✲✼▼ ✱ ✹❁✽✰✵✿✸✱✴▼ ✵✼ ✱✴✵✰■✲✼ ✵✶✶✸✹✸✱✺❖

P ◗✩

P ❘❉❙

Part 5: List Certain Gifts and Contributions 

✝❿❼ ❍✸✰■✸✴ ➀ ❆✲✱✼✽ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ✿✸✿ ❆✵❁ ❂✸❀✲ ✱✴❆ ❂✸✶✰✽ ◆✸✰■ ✱ ✰✵✰✱✺ ❀✱✺❁✲ ✵✶ ✳✵✼✲ ✰■✱✴ ➁❊❑❑ ❅✲✼ ❅✲✼✽✵✴❖

P ◗✩

P ❘❉❙❚ ★✤✧✧ ✤❯ ❱❲❉ ❳❉❱✦✤✧❙ ✣✩✪ ❉✦✥❲ ❈✤✣❱❚

➂q➃s♥ 3qst ✉ s✈s✉➄ ➅✉➄6♠ ✈➃ 5✈♣♠ st✉✇ ➆➇➈➈

➉♠♣ ➉♠♣♥✈✇

❧♠♥♦♣qr♠ st♠ ➊q➃s♥ ❧✉s♠♥ ➋✈6 ➊✉➅♠

st♠ ➊q➃s♥

➌✉➄6♠

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❦❬❩❛❴➍ ❫❴ ➎➏❴❞ ➐❴❡ ➑❝➒❬ ❫➏❬ ➑❪➓❫

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❜❡❞❢❬❩ ❣❫❩❬❬❫

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❨❪❫❤ ❣❫❝❫❬ ✐❥❦ ❨❴❭❬

➔✁✆✡☎☛→✡ ✆✁➣✠✄↔☎☛✡↕↔➙ ✄☎ ➛☎☞ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞

777777777

777777777

87777777777777

87777777777777

➂q➃s♥ 3qst ✉ s✈s✉➄ ➅✉➄6♠ ✈➃ 5✈♣♠ st✉✇ ➆➇➈➈

➉♠♣ ➉♠♣♥✈✇

❧♠♥♦♣qr♠ st♠ ➊q➃s♥ ❧✉s♠♥ ➋✈6 ➊✉➅♠

st♠ ➊q➃s♥

➌✉➄6♠

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❦❬❩❛❴➍ ❫❴ ➎➏❴❞ ➐❴❡ ➑❝➒❬ ❫➏❬ ➑❪➓❫

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❜❡❞❢❬❩ ❣❫❩❬❬❫

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❨❪❫❤ ❣❫❝❫❬ ✐❥❦ ❨❴❭❬

➔✁✆✡☎☛→✡ ✆✁➣✠✄↔☎☛✡↕↔➙ ✄☎ ➛☎☞ ➜➜➜➜➜➜➜➜➜➜➜➜➜➜

777777777

777777777

87777777777777

87777777777777

Miguel Diaz

✔

✔

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 50 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊

❋●❍ ■✸✰❏✸✴ ❑ ❆✲✱✼✽ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ✿✸✿ ❆✵❁ ❂✸❀✲ ✱✴❆ ❂✸✶✰✽ ✵✼ ✹✵✴✰✼✸▲❁✰✸✵✴✽ ◆✸✰❏ ✱ ✰✵✰✱✺ ❀✱✺❁✲ ✵✶ ✳✵✼✲ ✰❏✱✴ ❖P◗◗ ✰✵ ✱✴❆ ✹❏✱✼✸✰❆❘

❙ ❚✩

❙ ❯❉❱❲ ★✤✧✧ ✤❳ ❨❩❉ ❬❉❨✦✤✧❱ ✣✩✪ ❉✦✥❩ ❈✤✣❨ ✩✪ ✥✩❳❨✪✤❭❪❨✤✩❳❲

❫❴❵❛❜ ❝❞ ❡❝❢❛❞❴❣❤❛❴❝❢❜ ❛❝ ❡✐❥❞❴❛❴❦❜

❛✐❥❛ ❛❝❛❥❧ ♠❝❞❦ ❛✐❥❢ ♥♦♣♣

q❦❜❡❞❴❣❦ r✐❥❛ s❝❤ ❡❝❢❛❞❴❣❤❛❦t q❥❛❦ s❝❤

❡❝❢❛❞❴❣❤❛❦t

✉❥❧❤❦

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✈✇1234567 81910

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

8❶9❷102 ❸4210104

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✈345 ❸41410 ❹❺❻ ✈❼❽10

❾❾❾❾❾❾❾❾❾

❾❾❾❾❾❾❾❾❾

❿❾❾❾❾❾❾❾❾❾❾❾❾❾

❿❾❾❾❾❾❾❾❾❾❾❾❾❾

Part 6: List Certain Losses 

✝➀➁ ■✸✰❏✸✴ ➂ ❆✲✱✼ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆ ✵✼ ✽✸✴✹✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ✿✸✿ ❆✵❁ ✺✵✽✲ ✱✴❆✰❏✸✴❂ ▲✲✹✱❁✽✲ ✵✶ ✰❏✲✶✰▼ ✶✸✼✲▼ ✵✰❏✲✼ ✿✸✽✱✽✰✲✼▼

✵✼ ❂✱✳▲✺✸✴❂❘

❙ ❚✩

❙ ❯❉❱❲ ★✤✧✧ ✤❳ ❨❩❉ ❬❉❨✦✤✧❱❲

q❦❜❡❞❴❣❦ ❛✐❦ ➃❞❝➃❦❞❛s s❝❤ ❧❝❜❛ ❥❢t ✐❝r

❛✐❦ ❧❝❜❜ ❝❡❡❤❞❞❦t

q❦❜❡❞❴❣❦ ❥❢s ❴❢❜❤❞❥❢❡❦ ❡❝➄❦❞❥➅❦ ❵❝❞ ❛✐❦ ❧❝❜❜

➆☛➇➈☞➉✁ ✄➊✁ ✠✌☎☞☛✄ ✄➊✠✄ ➋☛✡☞✆✠☛➇✁ ➊✠✡ ➌✠➋➉➁ ➍➋✡✄ ➌✁☛➉➋☛➎ ➋☛✡☞✆✠☛➇✁

➇➈✠➋✌✡ ☎☛ ➈➋☛✁ ➏➏ ☎➐ Schedule A/B: Property.

q❥❛❦ ❝❵ s❝❤❞ ❧❝❜❜ ✉❥❧❤❦ ❝❵ ➃❞❝➃❦❞❛s

❧❝❜❛

❾❾❾❾❾❾❾❾❾ ❿❾❾❾❾❾❾❾❾❾❾❾❾❾

Part 7: List Certain Payments or Transfers 

✝➑➁ ■✸✰❏✸✴ ➂ ❆✲✱✼ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ✿✸✿ ❆✵❁ ✵✼ ✱✴❆✵✴✲ ✲✺✽✲ ✱✹✰✸✴❂ ✵✴ ❆✵❁✼ ▲✲❏✱✺✶ ❅✱❆ ✵✼ ✰✼✱✴✽✶✲✼ ✱✴❆ ❅✼✵❅✲✼✰❆ ✰✵ ✱✴❆✵✴✲ ❆✵❁

✹✵✴✽❁✺✰✲✿ ✱▲✵❁✰ ✽✲✲❄✸✴❂ ▲✱✴❄✼❁❅✰✹❆ ✵✼ ❅✼✲❅✱✼✸✴❂ ✱ ▲✱✴❄✼❁❅✰✹❆ ❅✲✰✸✰✸✵✴❘

➒❳✥✧❪❬❉ ✦❳➓ ✦❨❨✩✪❳❉➓❱➔ ❭✦❳→✪❪❇❨✥➓ ❇❉❨✤❨✤✩❳ ❇✪❉❇✦✪❉✪❱➔ ✩✪ ✥✪❉❬✤❨ ✥✩❪❳❱❉✧✤❳❈ ✦❈❉❳✥✤❉❱ ✣✩✪ ❱❉✪➣✤✥❉❱ ✪❉↔❪✤✪❉❬ ✤❳ ➓✩❪✪ ❭✦❳→✪❪❇❨✥➓❲

❙ ❚✩

❙ ❯❉❱❲ ★✤✧✧ ✤❳ ❨❩❉ ❬❉❨✦✤✧❱❲

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❻1027❼↕ ➙✇❼ ➙17 ❻13❽

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

8❶9❷102 ❸4210104

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✈345 ❸41410 ❹❺❻ ✈❼❽10

____________________________________________ 

➛913➜ ❼2 ➝10❷73410 1❽❽21077

q❦❜❡❞❴➃❛❴❝❢ ❥❢t ➄❥❧❤❦ ❝❵ ❥❢s ➃❞❝➃❦❞❛s ❛❞❥❢❜❵❦❞❞❦t q❥❛❦ ➃❥s♠❦❢❛ ❝❞

❛❞❥❢❜❵❦❞ r❥❜ ♠❥t❦

➞♠❝❤❢❛ ❝❵ ➃❥s♠❦❢❛

❾❾❾❾❾❾❾❾❾

❾❾❾❾❾❾❾❾❾

❿❾❾❾❾❾❾❾❾❾❾❾❾❾

❿❾❾❾❾❾❾❾❾❾❾❾❾❾

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❻1027❼↕ ➙✇❼ ➟1❽10 4✇10 ❻15910↕4➠ 3➡ 8❼4 ➢❼❶

Miguel Diaz

✔

✔

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 51 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❋●❍■❏❑ ▲▼❏ ▲◆■ ❋◆❖P

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

◗❘❙❚●❍ ❯❱❍●●❱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❲❖❱❳ ❯❱◆❱● ❨❩❋ ❲❏P●

________________________________________________ 

❬❙◆❖❭ ❏❍ ❪●❚■❖❱● ◆PP❍●■■

❫❴❵❛❜❝❞❡❝❢❣ ❤❣✐ ❥❤❦❧❴ ❢♠ ❤❣♥ ❞❜❢❞❴❜❡♥ ❡❜❤❣❵♠❴❜❜❴✐ ❫❤❡❴ ❞❤♥♦❴❣❡ ❢❜

❡❜❤❣❵♠❴❜ ♣❤❵ ♦❤✐❴

q♦❢❧❣❡ ❢♠

❞❤♥♦❴❣❡

rrrrrrrrr

rrrrrrrrr

srrrrrrrrrrrrr

srrrrrrrrrrrrr

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❋●❍■❏❑ ▲▼❏ t◆P● ❱▼● ❋◆❳❙●❑❱✉ ❖✈ ◗❏❱ ✇❏❘

123 4✸✰5✸✴ 6 ❆✲✱✼ 7✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ 7✱✴❄✼❁❅✰✹❆8 ✿✸✿ ❆✵❁ ✵✼ ✱✴❆✵✴✲ ✲✺✽✲ ✱✹✰✸✴❂ ✵✴ ❆✵❁✼ 7✲5✱✺✶ ❅✱❆ ✵✼ ✰✼✱✴✽✶✲✼ ✱✴❆ ❅✼✵❅✲✼✰❆ ✰✵ ✱✴❆✵✴✲ 95✵

❅✼✵✳✸✽✲✿ ✰✵ 5✲✺❅ ❆✵❁ ✿✲✱✺ 9✸✰5 ❆✵❁✼ ✹✼✲✿✸✰✵✼✽ ✵✼ ✰✵ ✳✱❄✲ ❅✱❆✳✲✴✰✽ ✰✵ ❆✵❁✼ ✹✼✲✿✸✰✵✼✽10

❶✩ ❷✩❸ ✤❷✥✧❹❺❉ ✦❷❻ ❇✦❻✫❉❷❸ ✩✪ ❸✪✦❷❼✣❉✪ ❸❽✦❸ ❻✩❹ ✧✤❼❸❉❺ ✩❷ ✧✤❷❉ ✬❾❿

➀ ➁✩

➀ ➂❉❼❿ ★✤✧✧ ✤❷ ❸❽❉ ❺❉❸✦✤✧❼❿

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❋●❍■❏❑ ▲▼❏ ▲◆■ ❋◆❖P

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

◗❘❙❚●❍ ❯❱❍●●❱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❲❖❱❳ ❯❱◆❱● ❨❩❋ ❲❏P●

❫❴❵❛❜❝❞❡❝❢❣ ❤❣✐ ❥❤❦❧❴ ❢♠ ❤❣♥ ❞❜❢❞❴❜❡♥ ❡❜❤❣❵♠❴❜❜❴✐ ❫❤❡❴ ❞❤♥♦❴❣❡ ❢❜

❡❜❤❣❵♠❴❜ ♣❤❵ ♦❤✐❴

q♦❢❧❣❡ ❢♠ ❞❤♥♦❴❣❡

rrrrrrrrr

rrrrrrrrr

srrrrrrrrrrrr

srrrrrrrrrrrr

✝➃➄ 4✸✰5✸✴ ➅ ❆✲✱✼✽ 7✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ 7✱✴❄✼❁❅✰✹❆8 ✿✸✿ ❆✵❁ ✽✲✺✺8 ✰✼✱✿✲8 ✵✼ ✵✰5✲✼9✸✽✲ ✰✼✱✴✽✶✲✼ ✱✴❆ ❅✼✵❅✲✼✰❆ ✰✵ ✱✴❆✵✴✲8 ✵✰5✲✼ ✰5✱✴ ❅✼✵❅✲✼✰❆

✰✼✱✴✽✶✲✼✼✲✿ ✸✴ ✰5✲ ✵✼✿✸✴✱✼❆ ✹✵❁✼✽✲ ✵✶ ❆✵❁✼ 7❁✽✸✴✲✽✽ ✵✼ ✶✸✴✱✴✹✸✱✺ ✱✶✶✱✸✼✽10

➆❷✥✧❹❺❉ ➇✩❸❽ ✩❹❸✪✤❈❽❸ ❸✪✦❷❼✣❉✪❼ ✦❷❺ ❸✪✦❷❼✣❉✪❼ ✫✦❺❉ ✦❼ ❼❉✥❹✪✤❸❻ ➈❼❹✥❽ ✦❼ ❸❽❉ ❈✪✦❷❸✤❷❈ ✩✣ ✦ ❼❉✥❹✪✤❸❻ ✤❷❸❉✪❉❼❸ ✩✪ ✫✩✪❸❈✦❈❉ ✩❷ ❻✩❹✪ ❇✪✩❇❉✪❸❻➉❿

❶✩ ❷✩❸ ✤❷✥✧❹❺❉ ❈✤✣❸❼ ✦❷❺ ❸✪✦❷❼✣❉✪❼ ❸❽✦❸ ❻✩❹ ❽✦➊❉ ✦✧✪❉✦❺❻ ✧✤❼❸❉❺ ✩❷ ❸❽✤❼ ❼❸✦❸❉✫❉❷❸❿

➀ ➁✩

➀ ➂❉❼❿ ★✤✧✧ ✤❷ ❸❽❉ ❺❉❸✦✤✧❼❿

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❋●❍■❏❑ ▲▼❏ ➋●➌●❖➍●P ➎❍◆❑■✈●❍

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

◗❘❙❚●❍ ❯❱❍●●❱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❲❖❱❳ ❯❱◆❱● ❨❩❋ ❲❏P●

❫❴❵❛❜❝❞❡❝❢❣ ❤❣✐ ❥❤❦❧❴ ❢♠ ❞❜❢❞❴❜❡♥

❡❜❤❣❵♠❴❜❜❴✐

❫❴❵❛❜❝➏❴ ❤❣♥ ❞❜❢❞❴❜❡♥ ❢❜ ❞❤♥♦❴❣❡❵ ❜❴❛❴❝❥❴✐

❢❜ ✐❴➏❡❵ ❞❤❝✐ ❝❣ ❴➐❛➑❤❣➒❴

❫❤❡❴ ❡❜❤❣❵♠❴❜

♣❤❵ ♦❤✐❴

rrrrrrrrr

➓✁✆✡☎☛➔✡ ✆✁→✠✄➣☎☛✡↔➣↕ ✄☎ ➙☎☞ ✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❋●❍■❏❑ ▲▼❏ ➋●➌●❖➍●P ➎❍◆❑■✈●❍

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

◗❘❙❚●❍ ❯❱❍●●❱

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

❲❖❱❳ ❯❱◆❱● ❨❩❋ ❲❏P●

rrrrrrrrr

➓✁✆✡☎☛➔✡ ✆✁→✠✄➣☎☛✡↔➣↕ ✄☎ ➙☎☞ ✞✞✞✞✞✞✞✞✞✞✞✞✞

Miguel Diaz

✔

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 52 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊

✝❋● ❍✸✰■✸✴ ❏❑ ❆✲✱✼✽ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ✿✸✿ ❆✵❁ ✰✼✱✴✽✶✲✼ ✱✴❆ ❅✼✵❅✲✼✰❆ ✰✵ ✱ ✽✲✺✶◆✽✲✰✰✺✲✿ ✰✼❁✽✰ ✵✼ ✽✸✳✸✺✱✼ ✿✲❀✸✹✲ ✵✶ ❖■✸✹■ ❆✵❁

✱✼✲ ✱ ▲✲✴✲✶✸✹✸✱✼❆P ◗❘❙❉❚❉ ✦✪❉ ✩✣❯❉❱ ✥✦✧✧❉❲ asset-protection devices❳❨

❩ ❬✩

❩ ❭❉❚❳ ★✤✧✧ ✤❱ ❯❙❉ ❲❉❯✦✤✧❚❳

❪✠✌✁ ☎❫ ✄✆☞✡✄

❴❵❛❜❝❞❡❢❞❣❤ ✐❤❥ ❦✐❧♠❵ ❣♥ ❢♦❵ ❡❝❣❡❵❝❢♣ ❢❝✐❤❛♥❵❝❝❵❥ ❴✐❢❵ ❢❝✐❤❛♥❵❝

q✐❛ r✐❥❵

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

t✉✈ ❍✸✰■✸✴ ❏ ❆✲✱✼ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ❖✲✼✲ ✱✴❆ ✶✸✴✱✴✹✸✱✺ ✱✹✹✵❁✴✰✽ ✵✼ ✸✴✽✰✼❁✳✲✴✰✽ ■✲✺✿ ✸✴ ❆✵❁✼ ✴✱✳✲▼ ✵✼ ✶✵✼ ❆✵❁✼ ▲✲✴✲✶✸✰▼

✹✺✵✽✲✿▼ ✽✵✺✿▼ ✳✵❀✲✿▼ ✵✼ ✰✼✱✴✽✶✲✼✼✲✿P

✾✴✹✺❁✿✲ ✹■✲✹❄✸✴❂▼ ✽✱❀✸✴❂✽▼ ✳✵✴✲❆ ✳✱✼❄✲✰▼ ✵✼ ✵✰■✲✼ ✶✸✴✱✴✹✸✱✺ ✱✹✹✵❁✴✰✽✇ ✹✲✼✰✸✶✸✹✱✰✲✽ ✵✶ ✿✲❅✵✽✸✰✇ ✽■✱✼✲✽ ✸✴ ▲✱✴❄✽▼ ✹✼✲✿✸✰ ❁✴✸✵✴✽▼

▲✼✵❄✲✼✱❂✲ ■✵❁✽✲✽▼ ❅✲✴✽✸✵✴ ✶❁✴✿✽▼ ✹✵✵❅✲✼✱✰✸❀✲✽▼ ✱✽✽✵✹✸✱✰✸✵✴✽▼ ✱✴✿ ✵✰■✲✼ ✶✸✴✱✴✹✸✱✺ ✸✴✽✰✸✰❁✰✸✵✴✽1

2✵

3✲✽1 ✷✸✺✺ ✸✴ ✰■✲ ✿✲✰✱✸✺✽1

444444444444444444444444444444444444

5678 910 ❶❷❸6❸❹❷6❺ ❻❸❼❽❷❽❾❽❷9❸

444444444444444444444444444444444444

5❾7❿8➀ ➁❽➀88❽

444444444444444444444444444444444444

444444444444444444444444444444444444

➂❷❽➃ ➁❽6❽8 ➄❻➅ ➂9➆8

➇✐❛❢ ➈ ❥❞➉❞❢❛ ❣♥ ✐❜❜❣♠❤❢ ❤♠r➊❵❝ ➋♣❡❵ ❣♥ ✐❜❜❣♠❤❢ ❣❝

❞❤❛❢❝♠r❵❤❢

❴✐❢❵ ✐❜❜❣♠❤❢ q✐❛

❜❧❣❛❵❥➌ ❛❣❧❥➌ r❣❦❵❥➌

❣❝ ❢❝✐❤❛♥❵❝❝❵❥

➇✐❛❢ ➊✐❧✐❤❜❵ ➊❵♥❣❝❵

❜❧❣❛❞❤➉ ❣❝ ❢❝✐❤❛♥❵❝

➍➍➍➍➎➏➏➏ ➏➏➏ ➏➏➏ ➏➏➏ ➐♦❵❜➑❞❤➉

➒✐❦❞❤➉❛

➓❣❤❵♣ r✐❝➑❵❢

➔❝❣➑❵❝✐➉❵

→❢♦❵❝4444444444

➏➏➏➏➏➏➏➏➏ ➣➏➏➏➏➏➏➏➏➏➏➏

444444444444444444444444444444444444

5678 910 ❶❷❸6❸❹❷6❺ ❻❸❼❽❷❽❾❽❷9❸

444444444444444444444444444444444444

5❾7❿8➀ ➁❽➀88❽

444444444444444444444444444444444444

444444444444444444444444444444444444

➂❷❽➃ ➁❽6❽8 ➄❻➅ ➂9➆8

➍➍➍➍➎➏➏➏ ➏➏➏ ➏➏➏ ➏➏➏ ➐♦❵❜➑❞❤➉

➒✐❦❞❤➉❛

➓❣❤❵♣ r✐❝➑❵❢

➔❝❣➑❵❝✐➉❵

→❢♦❵❝4444444444

➏➏➏➏➏➏➏➏➏ ➣➏➏➏➏➏➏➏➏➏➏➏

t↔✈ ↕✵ ❆✵❁ ✴✵❖ ■✱❀✲▼ ✵✼ ✿✸✿ ❆✵❁ ■✱❀✲ ❖✸✰■✸✴ ❏ ❆✲✱✼ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼ ✱✴❆ ✽✱✶✲ ✿✲❅✵✽✸✰ ▲✵➙ ✵✼ ✵✰■✲✼ ✿✲❅✵✽✸✰✵✼❆ ✶✵✼

✽✲✹❁✼✸✰✸✲✽▼ ✹✱✽■▼ ✵✼ ✵✰■✲✼ ❀✱✺❁✱▲✺✲✽P

2✵

3✲✽1 ✷✸✺✺ ✸✴ ✰■✲ ✿✲✰✱✸✺✽1

444444444444444444444444444444444444

5678 910 ❶❷❸6❸❹❷6❺ ❻❸❼❽❷❽❾❽❷9❸

444444444444444444444444444444444444

5❾7❿8➀ ➁❽➀88❽

444444444444444444444444444444444444

444444444444444444444444444444444444

➂❷❽➃ ➁❽6❽8 ➄❻➅ ➂9➆8

➛♦❣ ❵❧❛❵ ♦✐❥ ✐❜❜❵❛❛ ❢❣ ❞❢➜ ❴❵❛❜❝❞➊❵ ❢♦❵ ❜❣❤❢❵❤❢❛ ❴❣ ♣❣♠ ❛❢❞❧❧

♦✐❦❵ ❞❢➜

444444444444444444444444444444444444444

5678

444444444444444444444444444444444444444

5❾7❿8➀ ➁❽➀88❽

444444444444444444444444444444444444444

➂❷❽➃ ➁❽6❽8 ➄❻➅ ➂9➆8

2✵

3✲✽

✔

✔

Miguel Diaz

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 53 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊❋

●●❍ ■✱❀✲ ❆✵❁ ✽✰✵✼✲✿ ❅✼✵❅✲✼✰❆ ✸✴ ✱ ✽✰✵✼✱❂✲ ❁✴✸✰ ✵✼ ❅✺✱✹✲ ✵✰❏✲✼ ✰❏✱✴ ❆✵❁✼ ❏✵✳✲ ❑✸✰❏✸✴ ❊ ❆✲✱✼ ▲✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ ▲✱✴❄✼❁❅✰✹❆▼

◆✵

❖✲✽P ✷✸✺✺ ✸✴ ✰❏✲ ✿✲✰✱✸✺✽P

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❙❚❯ ❱❲ ❳❨❱❩❙❬❯ ❭❙❪❫❴❫❨❵

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❛❚❜❯❩ ❳❨❩❯❯❨

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❝❫❨❵ ❳❨❙❨❯ ❞❡❢ ❝❱❣❯

❤✐❥ ❦❧♠❦ ✐♥♠ ❥♦ ✐♥♣ ♥qq❦♠♠ r❥ srt ✉❦♠q♦s✈❦ r✐❦ q❥✇r❦✇r♠ ✉❥ 1❥2 ♠rs❧❧

✐♥3❦ srt

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❙❚❯

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❛❚❜❯❩ ❳❨❩❯❯❨

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❝❫❨❵❳❨❙❨❯ ❞❡❢ ❝❱❣❯

◆✵

❖✲✽

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

●4❍ 5✵ ❆✵❁ ❏✵✺✿ ✵✼ ✹✵✴✰✼✵✺ ✱✴❆ ❅✼✵❅✲✼✰❆ ✰❏✱✰ ✽✵✳✲✵✴✲ ✲✺✽✲ ✵❑✴✽▼ ✾✴✹✺❁✿✲ ✱✴❆ ❅✼✵❅✲✼✰❆ ❆✵❁ ▲✵✼✼✵❑✲✿ ✶✼✵✳6 ✱✼✲ ✽✰✵✼✸✴❂ ✶✵✼6

✵✼ ❏✵✺✿ ✸✴ ✰✼❁✽✰ ✶✵✼ ✽✵✳✲✵✴✲P

◆✵

❖✲✽P ✷✸✺✺ ✸✴ ✰❏✲ ✿✲✰✱✸✺✽P

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

789❯❩10❶ ❘❙❚❯

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❛❚❜❯❩ ❳❨❩❯❯❨

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❝❫❨❵ ❳❨❙❨❯ ❞❡❢ ❝❱❣❯

❤✐❦♦❦ s♠ r✐❦ ❷♦❥❷❦♦r1t ✉❦♠q♦s✈❦ r✐❦ ❷♦❥❷❦♦r1 ❸♥❧2❦

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❛❚❜❯❩ ❳❨❩❯❯❨

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❝❫❨❵ ❳❨❙❨❯ ❞❡❢ ❝❱❣❯

❹❺❺❺❺❺❺❺❺❺❺

Part 10: Give Details About Environmental Information

✷✵✼ ✰❏✲ ❅❁✼❅✵✽✲ ✵✶ ❻✱✼✰ ❊❋6 ✰❏✲ ✶✵✺✺✵❑✸✴❂ ✿✲✶✸✴✸✰✸✵✴✽ ✱❅❅✺❆❼

❽ Environmental law ✳✲✱✴✽ ✱✴❆ ✶✲✿✲✼✱✺6 ✽✰✱✰✲6 ✵✼ ✺✵✹✱✺ ✽✰✱✰❁✰✲ ✵✼ ✼✲❂❁✺✱✰✸✵✴ ✹✵✴✹✲✼✴✸✴❂ ❅✵✺✺❁✰✸✵✴6 ✹✵✴✰✱✳✸✴✱✰✸✵✴6 ✼✲✺✲✱✽✲✽ ✵✶

❏✱❾✱✼✿✵❁✽ ✵✼ ✰✵❿✸✹ ✽❁▲✽✰✱✴✹✲✽6 ❑✱✽✰✲✽6 ✵✼ ✳✱✰✲✼✸✱✺ ✸✴✰✵ ✰❏✲ ✱✸✼6 ✺✱✴✿6 ✽✵✸✺6 ✽❁✼✶✱✹✲ ❑✱✰✲✼6 ❂✼✵❁✴✿❑✱✰✲✼6 ✵✼ ✵✰❏✲✼ ✳✲✿✸❁✳6

✸✴✹✺❁✿✸✴❂ ✽✰✱✰❁✰✲✽ ✵✼ ✼✲❂❁✺✱✰✸✵✴✽ ✹✵✴✰✼✵✺✺✸✴❂ ✰❏✲ ✹✺✲✱✴❁❅ ✵✶ ✰❏✲✽✲ ✽❁▲✽✰✱✴✹✲✽6 ❑✱✽✰✲✽6 ✵✼ ✳✱✰✲✼✸✱✺P

❽ Site ✳✲✱✴✽ ✱✴❆ ✺✵✹✱✰✸✵✴6 ✶✱✹✸✺✸✰❆6 ✵✼ ❅✼✵❅✲✼✰❆ ✱✽ ✿✲✶✸✴✲✿ ❁✴✿✲✼ ✱✴❆ ✲✴❀✸✼✵✴✳✲✴✰✱✺ ✺✱❑6 ❑❏✲✰❏✲✼ ❆✵❁ ✴✵❑ ✵❑✴6 ✵❅✲✼✱✰✲6 ✵✼ ❁✰✸✺✸❾✲

✸✰ ✵✼ ❁✽✲✿ ✰✵ ✵❑✴6 ✵❅✲✼✱✰✲6 ✵✼ ❁✰✸✺✸❾✲ ✸✰6 ✸✴✹✺❁✿✸✴❂ ✿✸✽❅✵✽✱✺ ✽✸✰✲✽P

❽ Hazardous material ✳✲✱✴✽ ✱✴❆✰❏✸✴❂ ✱✴ ✲✴❀✸✼✵✴✳✲✴✰✱✺ ✺✱❑ ✿✲✶✸✴✲✽ ✱✽ ✱ ❏✱❾✱✼✿✵❁✽ ❑✱✽✰✲6 ❏✱❾✱✼✿✵❁✽ ✽❁▲✽✰✱✴✹✲6 ✰✵❿✸✹

✽❁▲✽✰✱✴✹✲6 ❏✱❾✱✼✿✵❁✽ ✳✱✰✲✼✸✱✺6 ❅✵✺✺❁✰✱✴✰6 ✹✵✴✰✱✳✸✴✱✴✰6 ✵✼ ✽✸✳✸✺✱✼ ✰✲✼✳P

➀✲❅✵✼✰ ✱✺✺ ✴✵✰✸✹✲✽6 ✼✲✺✲✱✽✲✽6 ✱✴✿ ❅✼✵✹✲✲✿✸✴❂✽ ✰❏✱✰ ❆✵❁ ❄✴✵❑ ✱▲✵❁✰6 ✼✲❂✱✼✿✺✲✽✽ ✵✶ ❑❏✲✴ ✰❏✲❆ ✵✹✹❁✼✼✲✿P

●➁❍ ■✱✽ ✱✴❆ ❂✵❀✲✼✴✳✲✴✰✱✺ ❁✴✸✰ ✴✵✰✸✶✸✲✿ ❆✵❁ ✰❏✱✰ ❆✵❁ ✳✱❆ ▲✲ ✺✸✱▲✺✲ ✵✼ ❅✵✰✲✴✰✸✱✺✺❆ ✺✸✱▲✺✲ ❁✴✿✲✼ ✵✼ ✸✴ ❀✸✵✺✱✰✸✵✴ ✵✶ ✱✴ ✲✴❀✸✼✵✴✳✲✴✰✱✺ ✺✱❑▼

◆✵

❖✲✽P ✷✸✺✺ ✸✴ ✰❏✲ ✿✲✰✱✸✺✽P

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❙❚❯ ❱❲ ❶❫❨❯

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❛❚❜❯❩ ❳❨❩❯❯❨

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❝❫❨❵ ❳❨❙❨❯ ❞❡❢ ❝❱❣❯

➂❥3❦♦✇➃❦✇r♥❧ 2✇sr ➄✇3s♦❥✇➃❦✇r♥❧ ❧♥➅➆ s➇ 1❥2 ➈✇❥➅ sr ✉♥r❦ ❥➇ ✇❥rsq❦

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

➉❱➊❯❩9❚❯9❨❙❴ ❛9❫❨

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❘❛❚❜❯❩ ❳❨❩❯❯❨

◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗◗

❝❫❨❵ ❳❨❙❨❯ ❞❡❢ ❝❱❣❯

❺❺❺❺❺❺❺❺❺

✔

Miguel Diaz

✔

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 54 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊❊

❋●❍ ■✱❀✲ ❆✵❁ ✴✵✰✸✶✸✲✿ ✱✴❆ ❂✵❀✲✼✴✳✲✴✰✱✺ ❁✴✸✰ ✵✶ ✱✴❆ ✼✲✺✲✱✽✲ ✵✶ ❏✱❑✱✼✿✵❁✽ ✳✱✰✲✼✸✱✺▲

▼✵

◆✲✽❖ ✷✸✺✺ ✸✴ ✰❏✲ ✿✲✰✱✸✺✽❖

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

◗❘❙❚ ❯❱ ❲❳❨❚

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

◗❩❙❬❚❭ ❪❨❭❚❚❨

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

❫❳❨❴ ❪❨❘❨❚ ❵❛❜ ❫❯❝❚

❞❡❢❣❤✐❥❣✐❦❧♠ ♥✐♦❦ ♣✐❢♦❤❡✐❥❣✐❦❧♠ ♠❧qr ♦s t❡♥ ✉✐❡q ♦❦ ✈❧❦❣ ❡s ✐❡❦♦✇❣

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

1❯2❚❭3❙❚3❨❘4 ❩3❳❨

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

◗❩❙❬❚❭ ❪❨❭❚❚❨

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

❫❳❨❴ ❪❨❘❨❚ ❵❛❜ ❫❯❝❚

555555555

❋6❍ ■✱❀✲ ❆✵❁ 7✲✲✴ ✱ ❅✱✼✰❆ ✸✴ ✱✴❆ 8❁✿✸✹✸✱✺ ✵✼ ✱✿✳✸✴✸✽✰✼✱✰✸❀✲ ❅✼✵✹✲✲✿✸✴❂ ❁✴✿✲✼ ✱✴❆ ✲✴❀✸✼✵✴✳✲✴✰✱✺ ✺✱9▲ ✾✴✹✺❁✿✲ ✽✲✰✰✺✲✳✲✴✰✽ ✱✴✿ ✵✼✿✲✼✽❖

▼✵

◆✲✽❖ ✷✸✺✺ ✸✴ ✰❏✲ ✿✲✰✱✸✺✽❖

10❧❶❣ ❦♦❦♠❣

10❧❶❣ ✐♥❥❷❣❤

10❡♥❤❦ ❡❤ ❧❸❣✐✇t ❹❧❦♥❤❣ ❡s ❦❺❣ ✇❧❶❣

❻❦❧❦♥❶ ❡s ❦❺❣

✇❧❶❣

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

❫❯❩❭❨ ◗❘❙❚

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

◗❩❙❬❚❭ ❪❨❭❚❚❨

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

❫❳❨❴ ❪❨❘❨❚ ❵❛❜ ❫❯❝❚

❼❣✐❽♦✐❸

❾✐ ❧❿❿❣❧♠

10❡✐✇♠♥❽❣❽

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

❋➀❍ ➁✸✰❏✸✴ ➂ ❆✲✱✼✽ 7✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ 7✱✴❄✼❁❅✰✹❆➃ ✿✸✿ ❆✵❁ ✵9✴ ✱ 7❁✽✸✴✲✽✽ ✵✼ ❏✱❀✲ ✱✴❆ ✵✶ ✰❏✲ ✶✵✺✺✵9✸✴❂ ✹✵✴✴✲✹✰✸✵✴✽ ✰✵ ✱✴❆ 7❁✽✸✴✲✽✽▲

✻ ✽✵✺✲ ❅✼✵❅✼✸✲✰✵✼ ✵✼ ✽✲✺✶➄✲✳❅✺✵❆✲✿ ✸✴ ✱ ✰✼✱✿✲➃ ❅✼✵✶✲✽✽✸✵✴➃ ✵✼ ✵✰❏✲✼ ✱✹✰✸❀✸✰❆➃ ✲✸✰❏✲✼ ✶❁✺✺➄✰✸✳✲ ✵✼ ❅✱✼✰➄✰✸✳✲

✻ ✳✲✳7✲✼ ✵✶ ✱ ✺✸✳✸✰✲✿ ✺✸✱7✸✺✸✰❆ ✹✵✳❅✱✴❆ ➅➆➆➇➈ ✵✼ ✺✸✳✸✰✲✿ ✺✸✱7✸✺✸✰❆ ❅✱✼✰✴✲✼✽❏✸❅ ➅➆➆➉➈

✻ ❅✱✼✰✴✲✼ ✸✴ ✱ ❅✱✼✰✴✲✼✽❏✸❅

✻✴ ✵✶✶✸✹✲✼➃ ✿✸✼✲✹✰✵✼➃ ✵✼ ✳✱✴✱❂✸✴❂ ✲➊✲✹❁✰✸❀✲ ✵✶ ✱ ✹✵✼❅✵✼✱✰✸✵✴

✻✴ ✵9✴✲✼ ✵✶ ✱✰ ✺✲✱✽✰ ➋➌ ✵✶ ✰❏✲ ❀✵✰✸✴❂ ✵✼ ✲➍❁✸✰❆ ✽✲✹❁✼✸✰✸✲✽ ✵✶ ✱ ✹✵✼❅✵✼✱✰✸✵✴

▼✵❖ ▼✵✴✲ ✵✶ ✰❏✲ ✱7✵❀✲ ✱❅❅✺✸✲✽❖ ➎✵ ✰✵ ➉✱✼✰ ❊➏❖

◆✲✽❖ ➇❏✲✹❄ ✱✺✺ ✰❏✱✰ ✱❅❅✺❆ ✱7✵❀✲ ✱✴✿ ✶✸✺✺ ✸✴ ✰❏✲ ✿✲✰✱✸✺✽ 7✲✺✵9 ✶✵✼ ✲✱✹❏ 7❁✽✸✴✲✽✽❖

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

➐❩❲❳3❚❲❲ ◗❘❙❚

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

◗❩❙❬❚❭ ❪❨❭❚❚❨

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

❫❳❨❴ ❪❨❘❨❚ ❵❛❜ ❫❯❝❚

✈❣❶✇❤♦❷❣ ❦❺❣ ✐❧❦♥❤❣ ❡s ❦❺❣ ❷♥❶♦✐❣❶❶ ♣❥❿♠❡t❣❤ ➑❽❣✐❦♦s♦✇❧❦♦❡✐ ✐♥❥❷❣❤

✈❡ ✐❡❦ ♦✐✇♠♥❽❣ ❻❡✇♦❧♠ ❻❣✇♥❤♦❦t ✐♥❥❷❣❤ ❡❤ ➑➒➑❹❍

➓✾▼➔ PPP PPP → PPP PPP PPP PPP PPP PPP PPP

❹❧❥❣ ❡s ❧✇✇❡♥✐❦❧✐❦ ❡❤ ❷❡❡✉✉❣❣❿❣❤ ✈❧❦❣❶ ❷♥❶♦✐❣❶❶ ❣➣♦❶❦❣❽

✷✼✵✳ 5555555 ↔✵ 5555555

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

➐❩❲❳3❚❲❲ ◗❘❙❚

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

◗❩❙❬❚❭ ❪❨❭❚❚❨

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

❫❳❨❴ ❪❨❘❨❚ ❵❛❜ ❫❯❝❚

✈❣❶✇❤♦❷❣ ❦❺❣ ✐❧❦♥❤❣ ❡s ❦❺❣ ❷♥❶♦✐❣❶❶ ♣❥❿♠❡t❣❤ ➑❽❣✐❦♦s♦✇❧❦♦❡✐ ✐♥❥❷❣❤

✈❡ ✐❡❦ ♦✐✇♠♥❽❣ ❻❡✇♦❧♠ ❻❣✇♥❤♦❦t ✐♥❥❷❣❤ ❡❤ ➑➒➑❹❍

➓✾▼➔ PPP PPP → PPP PPP PPP PPP PPP PPP PPP

❹❧❥❣ ❡s ❧✇✇❡♥✐❦❧✐❦ ❡❤ ❷❡❡✉✉❣❣❿❣❤ ✈❧❦❣❶ ❷♥❶♦✐❣❶❶ ❣➣♦❶❦❣❽

✷✼✵✳ 5555555 ↔✵ 5555555

Miguel Diaz

✔

✔

✔

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 55 of 70
✁✂✄☎✆ ✝ ✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞ ✟✠✡✁ ☛☞✌✂✁✆ ✍if known✎✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞

✏✑✒✓✔ ✕✖✗✘ ✙✑✚✚✛✘ ✕✖✗✘ ✜✖✓✔ ✕✖✗✘

✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✭✮ ✯✰✱✰✲✳✲✴✰ ✵✶ ✷✸✴✱✴✹✸✱✺ ✻✶✶✱✸✼✽ ✶✵✼ ✾✴✿✸❀✸✿❁✱✺✽ ✷✸✺✸✴❂ ✶✵✼ ❃✱✴❄✼❁❅✰✹❆ ❇✦❈❉ ❊❋

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

❍■❏❑▲▼❏❏ ◆❖P▼

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

◆■P◗▼❘ ❙❚❘▼▼❚

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

❯❑❚❱ ❙❚❖❚▼ ❲❳❨ ❯❩❬▼

❭❪❫❴❵❛❜❪ ❝❞❪ ❡❢❝❣❵❪ ❤✐ ❝❞❪ ❜❣❫❛❡❪❫❫ ❥❦❧♠❤♥❪❵ ♦♣❪❡❝❛✐❛❴❢❝❛❤❡ ❡❣❦❜❪❵

❭❤ ❡❤❝ ❛❡❴♠❣♣❪ q❤❴❛❢♠ q❪❴❣❵❛❝♥ ❡❣❦❜❪❵ ❤❵ ♦r♦st

✉✾✈✇ ●●● ●●● 1 ●●● ●●● ●●● ●●● ●●● ●●● ●●●

s❢❦❪ ❤✐ ❢❴❴❤❣❡❝❢❡❝ ❤❵ ❜❤❤22❪❪❧❪❵ ❭❢❝❪❫ ❜❣❫❛❡❪❫❫ ❪3❛❫❝❪♣

✷✼✵✳ 4444444 5✵ 4444444

67t 8✸✰9✸✴ ❋ ❆✲✱✼✽ 10✲✶✵✼✲ ❆✵❁ ✶✸✺✲✿ ✶✵✼ 10✱✴❄✼❁❅✰✹❆❶ ✿✸✿ ❆✵❁ ❂✸❀✲ ✱ ✶✸✴✱✴✹✸✱✺ ✽✰✱✰✲✳✲✴✰ ✰✵ ✱✴❆✵✴✲ ✱10✵❁✰ ❆✵❁✼ 10❁✽✸✴✲✽✽❷ ✾✴✹✺❁✿✲ ✱✺✺ ✶✸✴✱✴✹✸✱✺

✸✴✽✰✸✰❁✰✸✵✴✽❶ ✹✼✲✿✸✰✵✼✽❶ ✵✼ ✵✰9✲✼ ❅✱✼✰✸✲✽❸

❹ ✈✵

❹ ❺✲✽❸ ✷✸✺✺ ✸✴ ✰9✲ ✿✲✰✱✸✺✽ 10✲✺✵❻❸

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

◆❖P▼

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

◆■P◗▼❘ ❙❚❘▼▼❚

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

❯❑❚❱ ❙❚❖❚▼ ❲❳❨ ❯❩❬▼

❭❢❝❪ ❛❫❫❣❪♣

444444444444

❼❼ ❽ ❾❾ ❽ ❿❿❿❿

Part 12: Sign Below

✾ 9✱❀✲ ✼✲✱✿ ✰9✲ ✱✴✽❻✲✼✽ ✵✴ ✰9✸✽ Statement of Financial Affairs ✱✴✿ ✱✴❆ ✱✰✰✱✹9✳✲✴✰✽❶ ✱✴✿ ✾ ✿✲✹✺✱✼✲ ❁✴✿✲✼ ❅✲✴✱✺✰❆ ✵✶ ❅✲✼➀❁✼❆ ✰9✱✰ ✰9✲

✱✴✽❻✲✼✽ ✱✼✲ ✰✼❁✲ ✱✴✿ ✹✵✼✼✲✹✰❸ ✾ ❁✴✿✲✼✽✰✱✴✿ ✰9✱✰ ✳✱❄✸✴❂ ✱ ✶✱✺✽✲ ✽✰✱✰✲✳✲✴✰❶ ✹✵✴✹✲✱✺✸✴❂ ❅✼✵❅✲✼✰❆❶ ✵✼ ✵10✰✱✸✴✸✴❂ ✳✵✴✲❆ ✵✼ ❅✼✵❅✲✼✰❆ 10❆ ✶✼✱❁✿

✸✴ ✹✵✴✴✲✹✰✸✵✴ ❻✸✰9 ✱ 10✱✴❄✼❁❅✰✹❆ ✹✱✽✲ ✹✱✴ ✼✲✽❁✺✰ ✸✴ ✶✸✴✲✽ ❁❅ ✰✵ ➁❋➂➃❶➃➃➃❶ ✵✼ ✸✳❅✼✸✽✵✴✳✲✴✰ ✶✵✼ ❁❅ ✰✵ ❋➃ ❆✲✱✼✽❶ ✵✼ 10✵✰9❸

❊➄ ➅❸✯❸➆❸ ➇➇ ❊➂❋❶ ❊➈➉❊❶ ❊➂❊➊❶ ✱✴✿ ➈➂➋❊❸

______________________________________________ _____________________________

q❛➌❡❢❝❣❵❪ ❤✐ ❭❪❜❝❤❵ ➍ q❛➌❡❢❝❣❵❪ ❤✐ ❭❪❜❝❤❵ 6

❭❢❝❪ ________________ ❭❢❝❪ _________________

➎✸✿ ❆✵❁ ✱✰✰✱✹9 ✱✿✿✸✰✸✵✴✱✺ ❅✱❂✲✽ ✰✵ Your Statement of Financial Affairs for Individuals Filing for Bankruptcy ➏➐✶✶✸✹✸✱✺ ✷✵✼✳ ❊➃➋➑❷

❹ ➒✩

❹ ➓❉➔

➎✸✿ ❆✵❁ ❅✱❆ ✵✼ ✱❂✼✲✲ ✰✵ ❅✱❆ ✽✵✳✲✵✴✲ ❻9✵ ✸✽ ✴✵✰ ✱✴ ✱✰✰✵✼✴✲❆ ✰✵ 9✲✺❅ ❆✵❁ ✶✸✺✺ ✵❁✰ 10✱✴❄✼❁❅✰✹❆ ✶✵✼✳✽❷

❹ ➒✩

❹ ➓❉➔→ ➒✦✫❉ ✩✣ ❇❉✪➔✩➣✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞✞↔ ↕➙➙✦✥➛ ➙➛❉ Bankruptcy Petition Preparer’s Notice,

Declaration, and Signature ➜✢✣✣✤✥✤✦✧ ★✩✪✫ ✬✬➝➞→

08/15/2016

✔

Miguel Diaz

✔

08/15/2016

/s/ Miguel Diaz /s/

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 56 of 70
✁✁✂✄✂☎✆ ✝✞✟✠ ✡☛☞ ✌✍✎✍✏✑✏✒✍ ✓✔ ✕✒✍✏✒✍✖✓✒ ✔✓✗ ✕✒✘✖✙✖✘✚✎✛✜ ✢✖✛✖✒✣ ✤✒✘✏✗ ✥✦✎✧✍✏✗ ★ ✩☎✪✫ ✡

✬✭✭✮✯✮✰✱ ✲✳✴✵ ✶✷✸

Statement of Intention for Individuals Filing Under Chapter 7 ✹✺✻✹✼

✕✔ ✽✓✚ ✎✗✏ ✎✒ ✖✒✘✖✙✖✘✚✎✛ ✔✖✛✖✒✣ ✚✒✘✏✗ ✾✦✎✧✍✏✗ ★✿ ✽✓✚ ✑✚✜✍ ✔✖✛✛ ✓✚✍ ✍✦✖✜ ✔✓✗✑ ✖✔❀

✾✗✏✘✖✍✓✗✜ ✦✎✙✏ ✾✛✎✖✑✜ ✜✏✾✚✗✏✘ ❁✽ ✽✓✚✗ ✧✗✓✧✏✗✍✽✿ ✓✗

✽✓✚ ✦✎✙✏ ✛✏✎✜✏✘ ✧✏✗✜✓✒✎✛ ✧✗✓✧✏✗✍✽ ✎✒✘ ✍✦✏ ✛✏✎✜✏ ✦✎✜ ✒✓✍ ✏❂✧✖✗✏✘❃

❄✓✚ ✑✚✜✍ ✔✖✛✏ ✍✦✖✜ ✔✓✗✑ ❅✖✍✦ ✍✦✏ ✾✓✚✗✍ ❅✖✍✦✖✒ ❆❇ ✘✎✽✜ ✎✔✍✏✗ ✽✓✚ ✔✖✛✏ ✽✓✚✗ ❁✎✒❈✗✚✧✍✾✽ ✧✏✍✖✍✖✓✒ ✓✗ ❁✽ ✍✦✏ ✘✎✍✏ ✜✏✍ ✔✓✗ ✍✦✏ ✑✏✏✍✖✒✣ ✓✔ ✾✗✏✘✖✍✓✗✜✿

❅✦✖✾✦✏✙✏✗ ✖✜ ✏✎✗✛✖✏✗✿ ✚✒✛✏✜✜ ✍✦✏ ✾✓✚✗✍ ✏❂✍✏✒✘✜ ✍✦✏ ✍✖✑✏ ✔✓✗ ✾✎✚✜✏❃ ❄✓✚ ✑✚✜✍ ✎✛✜✓ ✜✏✒✘ ✾✓✧✖✏✜ ✍✓ ✍✦✏ ✾✗✏✘✖✍✓✗✜ ✎✒✘ ✛✏✜✜✓✗✜ ✽✓✚ ✛✖✜✍ ✓✒ ✍✦✏ ✔✓✗✑❃

✕✔ ✍❅✓ ✑✎✗✗✖✏✘ ✧✏✓✧✛✏ ✎✗✏ ✔✖✛✖✒✣ ✍✓✣✏✍✦✏✗ ✖✒ ✎ ❉✓✖✒✍ ✾✎✜✏✿ ❁✓✍✦ ✎✗✏ ✏❊✚✎✛✛✽ ✗✏✜✧✓✒✜✖❁✛✏ ✔✓✗ ✜✚✧✧✛✽✖✒✣ ✾✓✗✗✏✾✍ ✖✒✔✓✗✑✎✍✖✓✒❃

❋✓✍✦ ✘✏❁✍✓✗✜ ✑✚✜✍ ✜✖✣✒ ✎✒✘ ✘✎✍✏ ✍✦✏ ✔✓✗✑❃

❋✏ ✎✜ ✾✓✑✧✛✏✍✏ ✎✒✘ ✎✾✾✚✗✎✍✏ ✎✜ ✧✓✜✜✖❁✛✏❃ ✕✔ ✑✓✗✏ ✜✧✎✾✏ ✖✜ ✒✏✏✘✏✘✿ ✎✍✍✎✾✦ ✎ ✜✏✧✎✗✎✍✏ ✜✦✏✏✍ ✍✓ ✍✦✖✜ ✔✓✗✑❃ ●✒ ✍✦✏ ✍✓✧ ✓✔ ✎✒✽ ✎✘✘✖✍✖✓✒✎✛ ✧✎✣✏✜✿

❅✗✖✍✏ ✽✓✚✗ ✒✎✑✏ ✎✒✘ ✾✎✜✏ ✒✚✑❁✏✗ ❍✖✔ ❈✒✓❅✒■❃

Part 1: List Your Creditors Who Have Secured Claims

✡❏ ✢✓✗ ✎✒✽ ✾✗✏✘✖✍✓✗✜ ✍✦✎✍ ✽✓✚ ✛✖✜✍✏✘ ✖✒ ❑✎✗✍ ✹ ✓✔ Schedule D: Creditors Who Have Claims Secured by Property ❍●✔✔✖✾✖✎✛ ✢✓✗✑ ✹❇▲▼■✿ ✔✖✛✛ ✖✒ ✍✦✏

✖✒✔✓✗✑✎✍✖✓✒ ❁✏✛✓❅❃

◆❖P◗❘❙❚❯ ❘❱P ❲❳P❖❙❘❨❳ ❩◗❖ ❘❱P ❬❳❨❬P❳❘❯ ❘❱❩❘ ❙❭ ❲❨❪❪❩❘P❳❩❪ ❫❱❩❘ ❖❨ ❯❨❴ ❙◗❘P◗❖ ❘❨ ❖❨ ❵❙❘❱ ❘❱P ❬❳❨❬P❳❘❯ ❘❱❩❘

❭P❲❴❳P❭ ❩ ❖P❛❘❜

❝❙❖ ❯❨❴ ❲❪❩❙❞ ❘❱P ❬❳❨❬P❳❘❯

❩❭ P❡P❞❬❘ ❨◗ ❢❲❱P❖❴❪P ❣❜

❤✟✫✐✂❥✞✟❦❧

♠☎✠✫♥ ♦ ♣q✟✟✫♠✐✫✟ ❥r✫ ✩✟✞✩✫✟❥s❏

♦ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✟✫✐✫✫✠ ✂❥❏

✉ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✫♠❥✫✟ ✂♠❥✞ ☎

Reaffirmation Agreement❏

✉ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✈✫✇✩✆☎✂♠1♥

22222222222222222222222222222222222222

♦ 3✞

♦ 4✫❧

5✫❧✄✟✂✩❥✂✞♠ ✞✁

✩✟✞✩✫✟❥s

❧✫✄q✟✂♠✪ ✐✫6❥♥

❤✟✫✐✂❥✞✟❦❧

♠☎✠✫♥ ♦ ♣q✟✟✫♠✐✫✟ ❥r✫ ✩✟✞✩✫✟❥s❏

♦ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✟✫✐✫✫✠ ✂❥❏

✉ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✫♠❥✫✟ ✂♠❥✞ ☎

Reaffirmation Agreement❏

✉ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✈✫✇✩✆☎✂♠1♥

22222222222222222222222222222222222222

♦ 3✞

♦ 4✫❧

5✫❧✄✟✂✩❥✂✞♠ ✞✁

✩✟✞✩✫✟❥s

❧✫✄q✟✂♠✪ ✐✫6❥♥

❤✟✫✐✂❥✞✟❦❧

♠☎✠✫♥ ♦ ♣q✟✟✫♠✐✫✟ ❥r✫ ✩✟✞✩✫✟❥s❏

♦ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✟✫✐✫✫✠ ✂❥❏

✉ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✫♠❥✫✟ ✂♠❥✞ ☎

Reaffirmation Agreement❏

✉ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✈✫✇✩✆☎✂♠1♥

22222222222222222222222222222222222222

♦ 3✞

♦ 4✫❧

5✫❧✄✟✂✩❥✂✞♠ ✞✁

✩✟✞✩✫✟❥s

❧✫✄q✟✂♠✪ ✐✫6❥♥

❤✟✫✐✂❥✞✟❦❧

♠☎✠✫♥ ♦ ♣q✟✟✫♠✐✫✟ ❥r✫ ✩✟✞✩✫✟❥s❏

♦ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✟✫✐✫✫✠ ✂❥❏

✉ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✫♠❥✫✟ ✂♠❥✞ ☎

Reaffirmation Agreement❏

✉ t✫❥☎✂♠ ❥r✫ ✩✟✞✩✫✟❥s ☎♠✐ ✈✫✇✩✆☎✂♠1♥

22222222222222222222222222222222222222

♦ 3✞

♦ 4✫❧

5✫❧✄✟✂✩❥✂✞♠ ✞✁

✩✟✞✩✫✟❥s

❧✫✄q✟✂♠✪ ✐✫6❥♥

78910❶❷ ❸ ❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹

❺❻❼❽❾ ❿➀➁➂ ➃❻➄➄➅➂ ❿➀➁➂ ➆➀❽❾ ❿➀➁➂

78910❶❷ ➇ ❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹

➈➉➊➋➌➍➎➏ ➐➑ ➑➐➒➐➓➔→ ❺❻❼❽❾ ❿➀➁➂ ➃❻➄➄➅➂ ❿➀➁➂ ➆➀❽❾ ❿➀➁➂

➣↔↕108➙ ➛10➜108➝ ➞➜↔➟❷➠➡10➢➤ ➥❶➠❷10 ➦❶❷ 10➧8➨ 2222222222222222222222 7↕➝10❷↕➢10 ❶➦ 2222222222

➈➉➩➫➩➎→

➥➜➝8 ↔➠➭98❷ ❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹❹

➈➯➑ ➲➓➋➳➓→

✢✖✛✛ ✖✒ ✍✦✖✜ ✖✒✔✓✗✑✎✍✖✓✒ ✍✓ ✖✘✏✒✍✖✔✽ ✽✓✚✗ ✾✎✜✏❀

➵ ➸➺➻➼➽ ➾➚ ➪➺➾➶ ➾➶ ➹➘

➹➴➻➘➷➻➷ ➚➾➬➾➘➮

Northern District of Illinois

Miguel Diaz

Case 16-26996 Doc 1 Filed 08/23/16 Entered 08/23/16 10:59:19 Desc Main

 Document Page 57 of 70
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Part 2: List Your Unexpired Personal Property Leases

✴✪✮ ✦✩✿ ✱✩✧❀✹✭✮✧✯ ✹✧✮✳✪✩✦✲ ✹✮✪✹✧✮✥✿ ✲✧✦✳✧ ✥✸✦✥ ✿✪✱ ✲✭✳✥✧✯ ✭✩ Schedule G: Executory Contracts and Unexpired Leases ❁❂✫✫✭❃✭✦✲ ✴✪✮★ ❄❅❆❇❈❉

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✻✚✙✻✽✚♠♦❤

Part 3: Sign Below

✶✩✯✧✮ ✹✧✩✦✲✥✿ ✪✫ ✹✧✮♣✱✮✿❉ ✬ ✯✧❃✲✦✮✧ ✥✸✦✥ ✬ ✸✦✰✧ ✭✩✯✭❃✦✥✧✯ ★✿ ✭✩✥✧✩✥✭✪✩ ✦❊✪✱✥ ✦✩✿ ✹✮✪✹✧✮✥✿ ✪✫ ★✿ ✧✳✥✦✥✧ ✥✸✦✥ ✳✧❃✱✮✧✳ ✦ ✯✧❊✥ ✦✩✯ ✦✩✿

✹✧✮✳✪✩✦✲ ✹✮✪✹✧✮✥✿ ✥✸✦✥ ✭✳ ✳✱❊♣✧❃✥ ✥✪ ✦✩ ✱✩✧❀✹✭✮✧✯ ✲✧✦✳✧●

qrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr qrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr

st✉☛✟✈☞✎✡ ✇1 2✡✍✈✇✎ 3 st✉☛✟✈☞✎✡ ✇1 2✡✍✈✇✎ 4

2✟✈✡ 55555555555555555 2✟✈✡ 55555555555555555

66 7  7 8888 66 7  7 8888

Miguel Diaz

/s/ Miguel Diaz

08/15/2016

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ACCREDITED AMBULATORY CARE

DEPT 4668

CAROL STREAM, IL 60122-4668

AFFILIATED RADIOLOGISTS SC

DEPT 4104

CAROL STREAM, IL 60122-4104

ARCHER OPEN MRI

4365 S ARCHER AVE

CHICAGO, IL 60632-2826

BMO HARRIS BANK NA C/O CODILIS & ASSOC

15W030 N FRONTAGE RD

BURR RIDGE, IL 60527

CARDIAC BILLING SERVICES

9410 COMPUBILL DRIVE

ORLAND PARK, IL 60462

CHICAGO PAIN & ORTHOPEDIC

DEPT 4664

CAROL STREAM, IL 60122-4664

EQMD INC

BILLING DEPT

P O BOX 337

MCHENRY, IL 60051-0337

ELITE PHYSICAL THERAPY

1921 S MICHIGAN AVE

SUITE A

CHICAGO, IL 60616

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ELMHURST ORTHOPEDICA SC

300 W BUTTERFIELD

ELMHURST, IL 60126

G&U ORTHOPEDIC LLC

106 W CALENDAR AVE

LAGRANGE, IL 60525

GRAY MEDICAL INC

1626 W LAKE STREET

CHICAGO, IL 60612

GREGORY G MARKARIAN MD

P O BOX 3098

OAK BROOK, IL 60522

HOLY CROSS HOSPITAL

ATTN PATIENT FINANCIAL SERV DEPT

P O BOX 2166

BEDFORD PARK, IL 60499

IWP

P O BOX 338

METHUEN, MA 01844

ILLINOIS MEDI-CAR INC

P O BOX 499

ELMHURST, IL 60126

INTEGRITY BILLING SOLUTIONS

6635 W HAPPY VALLEY RD A104

GLENDALE, AZ 85310

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LA CLINICA SC

P O BOX 4782

CHICAGO, IL 60680-4782

M&M ORTHOPAEDICS LTD

4300 COMMERCE CT

SUITE 230

LISLE, IL 60532-3698

MRI LINCOLN IMAGING CTR

P O BOX 2957

CAROL STREAM, IL 60132-0001

MALDONADO OCONNELL LTD

1921 S MICHIGAN AVE

CHICAGO, IL 60616

MEDICAL RECOVERY SPECIALISTS LLC

2250 E DEVON AVE STE 352

DES PLAINES, IL 60018-4521

MEDORIZON

P O BOX 189

PLAINFIELD, IL 60544

MONTANARI MEDICAL INC

1626 W LAKE STREET

CHICAGO, IL 60612

NATIONWIDE CREDIT & COLLECTION

P O BOX 3159

OAK BROOK, IL 60522-3159

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PREFERRED OPEN MRI

4200 W 63RD STREET

SUITE A

CHICAGO, IL 60629-5010

PRESCRIPTION PARTNERS LLC

P O BOX 166363

MIAMI, FL 33116-6363

RX DEVELOPMENT ASSOCIATES

P O BOX 844624

DALLAS, TX 75284

RADADVANTAGE APC

44000 GARFIELD ROAD

CLINTON TWP, MI 48038

RUSH UNIVERSITY MEDICAL CENTER

1653 W CONGRESS PARKWAY

ATTN BILLING DEPT

CHICAGO, IL 60612-3833

RUSH UNIVERSITY MEDICAL GROUP

75 REMITTANCE DR DEPT 1611

CHICAGO, IL 60675-1611

RUSH UNIVERSITY MEDICAL GROUP

75 REMITTANCE DR

SUITE 1611

CHICAGO, IL 60675-1611

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SPECIALIZED RADIOLOGY CONSULTANTS

1039 COLLEGE AVE STE A

WHEATON, IL 60187

SUBURBAN PAINCARE CENTER

535 S WASHINGTON ST

SUITE 22

NAPERVILLE, IL 60540-6695

THE LEVITON LAW FIRM LTD

3 GOLF CENTER STE 361

HOFFMAN ESTATES, IL 60169

WINDY CITY ANESTHESIA PC

21120 WASHINGTON PARKWAY

FRANKFORT, IL 60423-3112

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United States Bankruptcy Court

In re: Case No.

Chapter

Debtor(s)

Verification of Creditor Matrix

The above-named Debtor(s) hereby verify that the attached list of creditors is

true and correct to the best of their knowledge.

Date:

Signature of Debtor

Signature of Joint Debtor

Miguel Diaz

Northern District of Illinois

/s/

7

08/15/2016 /s/ Miguel Diaz

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

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

Individuals Filing for Bankruptcy (Form 2010)

This notice is for you if:

 You are an individual filing for bankruptcy, 

and 

 Your debts are primarily consumer debts.

Consumer debts are defined in 11 U.S.C. 

§ 101(8) as “incurred by an individual 

primarily for a personal, family, or 

household purpose.” 

The types of bankruptcy that are 

available to individuals

Individuals who meet the qualifications may file 

under one of four different chapters of the 

Bankruptcy Code: 

✁ Chapter 7 — Liquidation 

✁ Chapter 11 — Reorganization 

✁ Chapter 12 — Voluntary repayment plan 

for family farmers or 

fishermen

✁ Chapter 13 — Voluntary repayment plan 

for individuals with regular 

income 

You should have an attorney review your 

decision to file for bankruptcy and the choice of 

chapter. 

Chapter 7: Liquidation 

$245 filing fee

 $75 administrative fee

+ $15 trustee surcharge

$335 total fee

Chapter 7 is for individuals who have financial 

difficulty preventing them from paying their 

debts and who are willing to allow their nonexempt property to be used to pay their 

creditors. The primary purpose of filing under 

chapter 7 is to have your debts discharged. The 

bankruptcy discharge relieves you after 

bankruptcy from having to pay many of your 

pre-bankruptcy debts. Exceptions exist for 

particular debts, and liens on property may still 

be enforced after discharge. For example, a 

creditor may have the right to foreclose a home 

mortgage or repossess an automobile. 

However, if the court finds that you have 

committed certain kinds of improper conduct 

described in the Bankruptcy Code, the court 

may deny your discharge. 

You should know that even if you file 

chapter 7 and you receive a discharge, some 

debts are not discharged under the law. 

Therefore, you may still be responsible to pay: 

✁ most taxes; 

✁ most student loans; 

✁ domestic support and property settlement 

obligations; 

 

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

 most fines, penalties, forfeitures, and 

criminal restitution obligations; and 

 certain debts that are not listed in your 

bankruptcy papers. 

You may also be required to pay debts arising 

from:

 fraud or theft;

 fraud or defalcation while acting in breach 

of fiduciary capacity; 

 intentional injuries that you inflicted; and 

 death or personal injury caused by 

operating a motor vehicle, vessel, or 

aircraft while intoxicated from alcohol or 

drugs. 

If your debts are primarily consumer debts, the 

court can dismiss your chapter 7 case if it finds 

that you have enough income to repay 

creditors a certain amount. You must file 

Chapter 7 Statement of Your Current Monthly 

Income (Official Form 122A–1) if you are an 

individual filing for bankruptcy under 

chapter 7. This form will determine your 

current monthly income and compare whether 

your income is more than the median income 

that applies in your state. 

If your income is not above the median for 

your state, you will not have to complete the 

other chapter 7 form, the Chapter 7 Means 

Test Calculation (Official Form 122A–2). 

If your income is above the median for your 

state, you must file a second form —the 

Chapter 7 Means Test Calculation (Official 

Form 122A–2). The calculations on the form—

sometimes called the Means Test—deduct 

from your income living expenses and 

payments on certain debts to determine any 

amount available to pay unsecured creditors. If

your income is more than the median income 

for your state of residence and family size, 

depending on the results of the Means Test, the 

U.S. trustee, bankruptcy administrator, or 

creditors can file a motion to dismiss your case 

under § 707(b) of the Bankruptcy Code. If a 

motion is filed, the court will decide if your 

case should be dismissed. To avoid dismissal, 

you may choose to proceed under another 

chapter of the Bankruptcy Code.

If you are an individual filing for chapter 7 

bankruptcy, the trustee may sell your property 

to pay your debts, subject to your right to 

exempt the property or a portion of the 

proceeds from the sale of the property. The 

property, and the proceeds from property that 

your bankruptcy trustee sells or liquidates that 

you are entitled to, is called exempt property. 

Exemptions may enable you to keep your 

home, a car, clothing, and household items or 

to receive some of the proceeds if the property 

is sold. 

Exemptions are not automatic. To exempt 

property, you must list it on Schedule C: The 

Property You Claim as Exempt (Official Form 

106C). If you do not list the property, the 

trustee may sell it and pay all of the proceeds 

to your creditors.

Chapter 11: Reorganization 

$1,167 filing fee

+ $550 administrative fee

$1,717 total fee

Chapter 11 is often used for reorganizing a 

business, but is also available to individuals. 

The provisions of chapter 11 are too 

complicated to summarize briefly. 

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

Chapter 12: Repayment plan for family 

farmers or fishermen

$200 filing fee

+ $75 administrative fee

$275 total fee

Similar to chapter 13, chapter 12 permits 

family farmers and fishermen to repay their 

debts over a period of time using future 

earnings and to discharge some debts that are 

not paid. 

Chapter 13: Repayment plan for 

individuals with regular 

income

$235 filing fee

+ $75 administrative fee

$310 total fee

Chapter 13 is for individuals who have regular 

income and would like to pay all or part of 

their debts in installments over a period of time

and to discharge some debts that are not paid. 

You are eligible for chapter 13 only if your 

debts are not more than certain dollar amounts 

set forth in 11 U.S.C. § 109. 

Under chapter 13, you must file with the court 

a plan to repay your creditors all or part of the 

money that you owe them, usually using your 

future earnings. If the court approves your 

plan, the court will allow you to repay your 

debts, as adjusted by the plan, within 3 years or 

5 years, depending on your income and other 

factors.

After you make all the payments under your 

plan, many of your debts are discharged. The

debts that are not discharged and that you may 

still be responsible to pay include: 

 domestic support obligations, 

 most student loans, 

 certain taxes, 

 debts for fraud or theft,

 debts for fraud or defalcation while acting 

in a fiduciary capacity,

 most criminal fines and restitution 

obligations, 

 certain debts that are not listed in your 

bankruptcy papers, 

 certain debts for acts that caused death or 

personal injury, and 

 certain long-term secured debts. 

Read These Important Warnings 

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

your property, you should hire an attorney and carefully consider all of your options before you file. 

Only an attorney can give you legal advice about what can happen as a result of filing for bankruptcy 

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

properly and protect you, your family, your home, and your possessions. 

Although the law allows you to represent yourself in bankruptcy court, you should understand that 

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

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

and following all of the legal requirements. 

You should not file for bankruptcy if you are not eligible to file or if you do not intend to file the 

necessary documents.

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

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

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

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

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

Bankruptcy crimes have serious 

consequences

 If you knowingly and fraudulently conceal 

assets or make a false oath or statement 

under penalty of perjury—either orally or 

in writing—in connection with a 

bankruptcy case, you may be fined, 

imprisoned, or both. 

 All information you supply in connection 

with a bankruptcy case is subject to 

examination by the Attorney General acting 

through the Office of the U.S. Trustee, the 

Office of the U.S. Attorney, and other 

offices and employees of the U.S. 

Department of Justice.

Make sure the court has your 

mailing address

The bankruptcy court sends notices to the 

mailing address you list on Voluntary Petition 

for Individuals Filing for Bankruptcy (Official 

Form 101). To ensure that you receive 

information about your case, Bankruptcy 

Rule 4002 requires that you notify the court of 

any changes in your address. 

A married couple may file a bankruptcy case 

together—called a joint case. If you file a joint 

case and each spouse lists the same mailing 

address on the bankruptcy petition, the 

bankruptcy court generally will mail you and 

your spouse one copy of each notice, unless 

you file a statement with the court asking that 

each spouse receive separate copies.

Understand w hich services you 

could receive from credit 

counseling agencies

The law generally requires that you receive a 

credit counseling briefing from an approved 

credit counseling agency. 11 U.S.C. § 109(h). 

If you are filing a joint case, both spouses must 

receive the briefing. With limited exceptions, 

you must receive it within the 180 days before

you file your bankruptcy petition. This briefing 

is usually conducted by telephone or on the 

Internet. 

In addition, after filing a bankruptcy case, you 

generally must complete a financial 

management instructional course before you 

can receive a discharge. If you are filing a joint 

case, both spouses must complete the course. 

You can obtain the list of agencies approved to 

provide both the briefing and the instructional 

course from: 

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

In Alabama and North Carolina, go to: 

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

BankruptcyResources/ApprovedCredit 

AndDebtCounselors.aspx. 

If you do not have access to a computer, the 

clerk of the bankruptcy court may be able to 

help you obtain the list.

Warning: File Your Forms on Time

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

requires that you promptly file detailed information 

about your creditors, assets, liabilities, income, 

expenses and general financial condition. The 

court may dismiss your bankruptcy case if you do 

not file this information within the deadlines set by 

the Bankruptcy Code, the Bankruptcy Rules, and 

the local rules of the court. 

For more information about the documents and 

their deadlines, go to: 

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

s.html#procedure. 

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B2030 (Form 2030) (12/15)

✁ [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

08/15/2016 /s/ Robert Perlstein

Robert L. Perlstein

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