Fill in this information to identify your case:

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE DIVISION

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

 Chapter 11

 Chapter 12

 Chapter 13  Check if this an amended

filing

Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 12/17

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.

Dawn

First name First name

Marie

Middle name Middle name

Chase

Last name and Suffix (Sr., Jr., II, III) Last name and Suffix (Sr., Jr., II, III)

2. All other names you have used in the last 8 years

Include your married or

maiden names.

3. Only the last 4 digits of

your Social Security number or federal

Individual Taxpayer

Identification number

(ITIN)

xxx-xx-9665

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

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 1 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

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  I have not used any business name or EINs.  I have not used any business name or EINs.

Include trade names and

doing business as names Business name(s) Business name(s)

EINs EINs

5. Where you live If Debtor 2 lives at a different address:

4945 NW 48th Way

Tamarac, FL 33319-3671

Number, Street, City, State & ZIP Code Number, Street, City, State & ZIP Code

Broward

County 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.

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, P.O. Box, Street, City, State & ZIP Code Number, P.O. Box, Street, 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.)

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

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 2 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

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. District When Case number

District When Case number

District When Case number

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 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?

 No. Go to line 12.

 Yes. Fill outInitial Statement About an Eviction Judgment Against You (Form 101A) and file it as part of this bankruptcy petition.

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

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 3 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

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

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

 No. Go to Part 4.

Yes. Name and location of business

A sole proprietorship is a

business you operate as an

individual, and is not a

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

Name of business, if any

If you have more than one

sole proprietorship, use a

separate sheet and attach it

to this petition.

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?

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).

For a definition of small

business debtor, see 11

U.S.C. § 101(51D).  No. I am not filing under Chapter 11.

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

Code.

Yes.

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

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

14. Do you own or have any

property that poses or is

alleged to pose a threat of

imminent and identifiable hazard to public health or safety? Or do you own

any property that needs

immediate attention?

 No.

Yes. What is the hazard?

If immediate attention is needed, why is it needed?

For example, do you own

perishable goods, or

livestock that must be fed, or a building that needs urgent repairs?

Where is the property?

Number, Street, City, State & Zip Code

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

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 4 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

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

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

You must check one: 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, 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 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 certify that I asked for credit counseling services

from an approved agency, but was unable to obtain

those services during the 7 days after I made my

request, and exigent circumstances merit a 30-day

temporary waiver of the requirement.

To ask for a 30-day temporary waiver of the requirement, attach a separate sheet explaining what efforts you made to

obtain the briefing, why you were unable to obtain it before

you filed for bankruptcy, and what exigent circumstances

required you to file this case. Your case may be dismissed if the court is dissatisfied with

your reasons for not receiving a briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must still

receive a briefing within 30 days after you file. You must file

a certificate from the approved agency, along with a copy of

the payment plan you developed, if any. If you do not do so, your case may be dismissed. Any extension of the 30-day deadline is granted only for cause and is limited to a maximum of 15 days.

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

 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.

 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.

 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 credit counseling with the court.

If you believe you are not required to receive a briefing about credit counseling, you must file a motion for waiver of credit counseling with the court.

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

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 5 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

Part 6: Answer These Questions for Reporting Purposes

16. What kind of debts do

you have?

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

individual primarily for a personal, family, or household purpose.”  No. Go to line 16b.

 Yes. Go to line 17.

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

for a business or investment or through the operation of the business or investment. No. Go to line 16c.

 Yes. Go to line 17.

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

17. Are you filing under Chapter 7?

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

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?

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

 5001-10,000

 10,001-25,000

 25,001-50,000

 50,001-100,000

 More than100,000

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.

/s/ Dawn Marie Chase

Dawn Marie Chase Signature of Debtor 2

Signature of Debtor 1

Executed on April 17, 2019 Executed on MM / DD / YYYY MM / DD / YYYY

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

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 6 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

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.

/s/ Chad Van Horn Date April 17, 2019

Signature of Attorney for Debtor MM / DD / YYYY

Chad Van Horn

Printed name Van Horn Law Group, P.A. Firm name

330 N Andrews Ave Ste 450

Fort Lauderdale, FL 33301-1012

Number, Street, City, State & ZIP Code

Contact phone (954) 765-3166 Email address chad@cvhlawgroup.com

64500

Bar number & State

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

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 7 of 48
 Fill in this information to identify your case and this filing: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number  Check if this is an

amended filing

Official Form 106A/B

Schedule A/B: Property 12/15

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

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

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

Answer every question.

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

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

 No. Go to Part 2.

 Yes. Where is the property?

1.1 What is the property? Check all that apply Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property . 4945 NW 48th Way 





Single-family home

Duplex or multi-unit building

Condominium or cooperative

Street address, if available, or other description

Tamarac FL 33319-3671





Manufactured or mobile home

Land

Current value of the

entire property?

Current value of the

portion you own?

City State ZIP Code  Investment property $108,900.00 $108,900.00

 Timeshare Describe the nature of your ownership interest

(such as fee simple, tenancy by the entireties, or

a life estate), if known.

 Other

Who has an interest in the property? Check one  Debtor 1 only Homestead

Broward  Debtor 2 only

County  Debtor 1 and Debtor 2 only

 Check if this is community property  At least one of the debtors and another (see instructions)

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

property identification number:

Debtor is only on the title

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...........................................................................=> $108,900.00

Part 2: Describe Your Vehicles

Do you own, lease, or have legal or equitable interest in any vehicles, whether they are registered or not? Include any vehicles you own that someone else drives. If you lease a vehicle, also report it on Schedule G: Executory Contracts and Unexpired Leases.

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

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 8 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

3. Cars, vans, trucks, tractors, sport utility vehicles, motorcycles  No

Yes

3.1 Make: Jeep Who has an interest in the property? Check one Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Model: Patriot 4WD  Debtor 1 only Creditors Who Have Claims Secured by Property . Year: 2016  Debtor 2 only Current value of the

entire property?

Current value of the

Approximate mileage: 64000  Debtor 1 and Debtor 2 only portion you own?

Other information:  At least one of the debtors and another

Vin#1C4NJRFB7GD613980

Using Black Book Trade In

Average Value

Check if this is community property $12,065.00 $12,065.00

 (see instructions)

3.2 Make: Kia Who has an interest in the property? Check one Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Model: Soul  Debtor 1 only Creditors Who Have Claims Secured by Property . Year: 2017  Debtor 2 only Current value of the

entire property?

Current value of the

Approximate mileage: 40000  Debtor 1 and Debtor 2 only portion you own?

Other information:  At least one of the debtors and another

Vin# KNDJN2A24H7883587

Using Black Book Trade In

Average Value

Check if this is community property $10,070.00 $10,070.00

 (see instructions)

4. Watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories Examples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle accessories  No

Yes

5

.Add the dollar value of the portion you own for all of your entries from Part 2, including any entries for pagesyou have attached for Part 2. Write that number here.............................................................................=> $22,135.00

Part 3: Describe Your Personal and Household Items

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

Do not deduct secured

claims or exemptions.

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

Yes. Describe..... 1 sofa (4 years old) 1 Futon ( 1 year old), 1 end table (25 years

old), 2 cedar chest ( 40 years old), 1 TV stand ( 3 years old) 1

cabinet (1 year old), , 1 recliner (3 years old), 1 recliner (1 year

old), 2 full size beds ( 5 years old), 2 night stand, 2 dressers ( 5

years old), 1 dresser drawer ( 30 years old), 1 kitchen table, 2

chairs, 2 stools (5 years old).

Value: $500.00 $250.00

7. Electronics Examples: Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music collections; electronic devices

including cell phones, cameras, media players, games

 No

Yes. Describe..... 1 TV 65"( 3 years old), 1 TV 32" ( 1 year old), 1 computer, 1 printer

(1 year old)

Value: $300.00 $150.00

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

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 9 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

8. Collectibles of value Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects; stamp, coin, or baseball card collections; other collections, memorabilia, collectibles

 No

Yes. Describe.....

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

instruments

 No

Yes. Describe.....

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

 No

Yes. Describe.....

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

Yes. Describe..... Clothing of no value except to the Debtor $200.00

12. Jewelry

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

Yes. Describe..... 1 watch, silver chain $50.00

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

Yes. Describe..... 2 dogs $0.00

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 .............................................................................. $650.00

Part 4: Describe Your Financial Assets

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

Do not deduct secured

claims or exemptions.

16. Cash

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

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

Cash on hand $30.00

17. Deposits of money

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

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

 No

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

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 10 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

Yes........................

Institution name:

17.1. Checking Account

TD Bank

Account ending#6180

Balance: -$425.47 $0.00

17.2. Savings Account

TD Bank

Account ending#3997 $224.05

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

Yes..................

Institution or issuer name:

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

joint venture  No

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

Name of entity: % of ownership:

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

Yes. Give specific information about them

Issuer name:

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

 No

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

401K Thrift Retirement Account $93,255.00

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

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

Yes. .....................

Institution name or individual:

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

 No

Yes.............

Issuer name and description.

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

Yes.............

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

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

 No

 Yes. Give specific information about them...

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

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

 Yes. Give specific information about them...

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

 Yes. Give specific information about them...

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

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 11 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

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.......

29. Family support

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

 No

Yes. Give specific information......

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

unpaid loans you made to someone else

 No

Yes. Give specific information..

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

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

value:

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

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

 No

Yes. Give specific information..

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

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

 No

 Yes. Describe each claim.........

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

 Yes. Describe each claim.........

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..................................................................................................................... $93,509.05

Part 5: Describe Any Business-Related Property You Own or Have an Interest In. List any real estate in Part 1.

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

 No. Go to Part 6.

 Yes. Go to line 38.

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

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

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

 No. Go to Part 7.

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

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 12 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

 Yes. Go to line 47.

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

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

Examples: Season tickets, country club membership

 No

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

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

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

55. Part 1: Total real estate, line 2 ...................................................................................................................... $108,900.00

56. Part 2: Total vehicles, line 5 $22,135.00

57. Part 3: Total personal and household items, line 15 $650.00

58. Part 4: Total financial assets, line 36 $93,509.05

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

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

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

62. Total personal property. Add lines 56 through 61... $116,294.05 Copy personal property total $116,294.05

63. Total of all property on Schedule A/B. Add line 55 + line 62 $225,194.05

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

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 13 of 48
 Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106C

Schedule C: The Property You Claim as Exempt 4/19

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

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

known).

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

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

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

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

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

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

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

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

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

Schedule A/B that lists this property

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption.

Specific laws that allow exemption

4945 NW 48th Way

Tamarac FL, 33319-3671

County : Broward

Line from Schedule A/B: 1.1

$108,900.00  $108,900.00 Fla. Const. Art. X, §4(a)(1);

Fla. Stat.§§ 222.01, 222.02

 100% of fair market value, up to

any applicable statutory limit

1 sofa (4 years old) 1 Futon ( 1 year

old), 1 end table (25 years old), 2

cedar chest ( 40 years old), 1 TV

stand ( 3 years old) 1 cabinet (1 year

old), , 1 recliner (3 years old), 1

recliner (1 year old), 2 full size beds (

5 years old), 2 night stand, 2

Line from Schedule A/B: 6.1

$250.00  $250.00 Fla. Const. Art X, § 4(a)(2)

 100% of fair market value, up to

any applicable statutory limit

1 TV 65"( 3 years old), 1 TV 32" ( 1

year old), 1 computer, 1 printer (1

year old)

Value: $300.00

Line from Schedule A/B: 7.1

$150.00  $150.00 Fla. Const. Art X, § 4(a)(2)

 100% of fair market value, up to

any applicable statutory limit

Clothing of no value except to the

Debtor

Line from Schedule A/B: 11.1

$200.00  $200.00 Fla. Const. Art X, § 4(a)(2)

 100% of fair market value, up to

any applicable statutory limit

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

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 14 of 48
Brief description of the property and line on

Schedule A/B that lists this property

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption.

Specific laws that allow exemption

1 watch, silver chain

Line from Schedule A/B: 12.1

$50.00  $50.00 Fla. Const. Art X, § 4(a)(2)

 100% of fair market value, up to

any applicable statutory limit

Cash on hand

Line from Schedule A/B: 16.1

$30.00  $30.00 Fla. Const. Art X, § 4(a)(2)

 100% of fair market value, up to

any applicable statutory limit

TD Bank

Account ending#3997

Line from Schedule A/B: 17.2

$224.05  $224.05 Fla. Const. Art X, § 4(a)(2)

 100% of fair market value, up to

any applicable statutory limit

Thrift Retirement Account

Line from Schedule A/B: 21.1

$93,255.00  $96,874.40 Fla. Stat. § 222.21(2)

 100% of fair market value, up to

any applicable statutory limit

3. Are you claiming a homestead exemption of more than $170,350?

(Subject to adjustment on 4/01/22 and every 3 years after that for cases filed on or after the date of adjustment.)

 No

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

 No

 Yes

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

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 15 of 48
 Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106D

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

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

needed, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any additional pages, write your name and case number (if

known).

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

No. Check this box and submit this form to the court with your other schedules. You have nothing else to report on this form. Yes. Fill in all of the information below. Part 1: List All Secured Claims

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

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

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

Column A

Amount of claim

Do not deduct the

value of collateral.

Column B

Value of collateral

that supports this

claim

Column C

Unsecured

portion

If any

2.1 Regional Acceptance Co Describe the property that secures the claim: $20,290.00 $10,070.00 $10,220.00

Creditor's Name 2017 Kia Soul

Vin# KNDJN2A24H7883587 Using

Black Book Trade In Average Value

5400 W Sample Rd Ste A

Margate, FL 33073-3475

As of the date you file, the claim is: Check all that apply.  Contingent Number, Street, City, State & Zip Code  Unliquidated

 Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply.

 Debtor 1 only

 Debtor 2 only

 An agreement you made (such as mortgage or secured

car loan)

Debtor 1 and Debtor 2 only  Statutory lien (such as tax lien, mechanic's lien)

 At least one of the debtors and another  Judgment lien from a lawsuit

Check if this claim relates to a

community debt

 Other (including a right to offset) 2017 Kia Auto Loan

Date debt was incurred 2017-05 Last 4 digits of account number 4801

Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of 2

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 16 of 48
Debtor 1 Dawn Marie Chase Case number (if known) First Name Middle Name Last Name

2.2 Regional Acceptance Co Describe the property that secures the claim: $14,486.00 $12,065.00 $2,421.00

Creditor's Name 2016 Jeep Patriot 4WD

Vin#1C4NJRFB7GD613980 Using

Black Book Trade In Average Value

5400 W Sample Rd Ste A

Margate, FL 33073-3475

As of the date you file, the claim is: Check all that apply.  Contingent Number, Street, City, State & Zip Code  Unliquidated

 Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply.

 Debtor 1 only

 Debtor 2 only

 An agreement you made (such as mortgage or secured

car loan)

Debtor 1 and Debtor 2 only  Statutory lien (such as tax lien, mechanic's lien)

 At least one of the debtors and another  Judgment lien from a lawsuit

Check if this claim relates to a

community debt

 Other (including a right to offset) 2016 Jeep Auto Loan

Date debt was incurred 2017-10 Last 4 digits of account number 0601

Add the dollar value of your entries in Column A on this page. Write that number here: $34,776.00

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

Write that number here: $34,776.00

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

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

trying to collect from you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection agency here. Similarly, if you have more

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

debts in Part 1, do not fill out or submit this page.

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

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 17 of 48
Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106E/F

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

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

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

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

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

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

case number (if known).

Part 1: List All of Your PRIORITY Unsecured Claims

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

 No. Go to Part 2.

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

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

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

Yes.

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

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

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

2.

Total claim

4.1 Aqua Finance Inc Last 4 digits of account number 0050 $5,059.00

Nonpriority Creditor's Name

1 Corporate Dr

Wausau, WI 54401-1722

When was the debt incurred? 2015-01

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Installment account

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 1 of 8

Software Copyright (c) 2019 CINGroup - www.cincompass.com G2320

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 18 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

4.2 Broward Health Imperial Point Last 4 digits of account number 2591 $425.00

Nonpriority Creditor's Name

1608 SE 3rd Ave

Fort Lauderdale, FL 33316-2564

When was the debt incurred? 3/2019

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Medical

4.3 Comenity Bank/Beallsfl Last 4 digits of account number 8542 $748.00

Nonpriority Creditor's Name

PO Box 182789

Columbus, OH 43218-2789

When was the debt incurred? 2015-03

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Revolving account

4.4 Comenity Bank/Beallsol Last 4 digits of account number 1510 $506.00

Nonpriority Creditor's Name

PO Box 182789

Columbus, OH 43218-2789

When was the debt incurred? 2014-08

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Revolving account

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 2 of 8

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 19 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

4.5 Discover Fin Svcs LLC Last 4 digits of account number 1253 $154.00

Nonpriority Creditor's Name

PO Box 15316

Wilmington, DE 19850-5316

When was the debt incurred? 2019-01

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Revolving account

4.6 Elite Imaging, LLC Last 4 digits of account number 4716 $38.80

Nonpriority Creditor's Name

PO Box 826618

Philadelphia, PA 19182-6618

When was the debt incurred? 08/2017

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Medical

4.7 Enhanced Recovery Co L Last 4 digits of account number 2171 $1,314.00

Nonpriority Creditor's Name

PO Box 57547

Jacksonville, FL 32241-7547

When was the debt incurred? 2018-03

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Open account

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 3 of 8

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 20 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

4.8 Jefferson Capital Syst Last 4 digits of account number 1003 $280.00

Nonpriority Creditor's Name

16 McLeland Rd

Saint Cloud, MN 56303-2198

When was the debt incurred? 2016-06

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Open account

4.9 Jefferson Capital Systems, LLC Last 4 digits of account number 2351 $280.48

Nonpriority Creditor's Name

16 McLeland Rd

Saint Cloud, MN 56303-2198

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Collection

4.10 Portfolio Recov Assoc Last 4 digits of account number 8542 $749.00

Nonpriority Creditor's Name

120 Corporate Blvd Ste 1

Norfolk, VA 23502-4952

When was the debt incurred? 2018-09

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Open account

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 4 of 8

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 21 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

4.11 Portfolio Recovery Last 4 digits of account number 8542 $748.84

Nonpriority Creditor's Name

120 Corporate Blvd

Norfolk, VA 23502-4962

When was the debt incurred?

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Collection

4.12 Steward Financial Services, LLC Last 4 digits of account number 2048 $13,240.00

Nonpriority Creditor's Name

444 E Kings Hwy

Maple Shade, NJ 08052-3427

When was the debt incurred? 09/2014

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Lawsuit Case: COSO19002928

4.13 Tbom/Total Crd Last 4 digits of account number 0086 $304.00

Nonpriority Creditor's Name

PO Box 85710

Sioux Falls, SD 57118-5710

When was the debt incurred? 2018-09

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Revolving account

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 5 of 8

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 22 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

4.14 Tbom/Total Crd Last 4 digits of account number 4759 $267.00

Nonpriority Creditor's Name

PO Box 85710

Sioux Falls, SD 57118-5710

When was the debt incurred? 2018-12

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Revolving account

4.15 Td Bank N.A. Last 4 digits of account number 3798 $7,034.00

Nonpriority Creditor's Name

32 Chestnut St

Lewiston, ME 04240-7744

When was the debt incurred? 2014-08

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Revolving account

4.16 Verizon Wireless Last 4 digits of account number 0001 $418.37

Nonpriority Creditor's Name

PO Box 26055

Minneapolis, MN 55426-0055

When was the debt incurred? 01/2016

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

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim is for a community

debt

Is the claim subject to offset?

 No

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

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

report as priority claims

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

Yes Other. Specify Utility

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

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

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

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

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

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 6 of 8

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 23 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

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

Comenity Bank Line 4.10 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 8542

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

Comenity Bank/Bealls Florida

PO Box 182789

Columbus, OH 43218-2789

Line 4.11 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 8542

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

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

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 1003

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

Fingerhut/Webbank

6250 Ridgewood Rd

Saint Cloud, MN 56303-0820

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

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 2351

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

IC System

444 Highway 96 E

Saint Paul, MN 55127-2557

Line 4.7 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 2171

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

Jonathan Hempfling, Esq

5104 S West Shore Blvd

Tampa, FL 33611-5650

Line 4.12 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 2048

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

Marcadis Singer PA

5104 S West Shore Blvd

Tampa, FL 33611-5650

Line 4.12 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 2048

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

Sprint Line 4.7 of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 2171

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

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

type of unsecured claim.

Total Claim

6a. Domestic support obligations 6a. $ 0.00

Total claims

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

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

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

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

Total Claim

6f. Student loans 6f. $ 0.00

Total claims

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

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

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

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

here.

6i.

$ 31,566.49

Official Form 106 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 7 of 8

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 24 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

6j. Total Nonpriority. Add lines 6f through 6i. 6j. $ 31,566.49

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

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 25 of 48
 Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

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

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

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

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

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

unexpired leases.

Person or company with whom you have the contract or lease

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

2.1

Name

Number Street

City State ZIP Code

2.2

Name

Number Street

City State ZIP Code

2.3

Name

Number Street

City State ZIP Code

2.4

Name

Number Street

City State ZIP Code

2.5

Name

Number Street

City State ZIP Code

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

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 26 of 48
 Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106H

Schedule H: Your Codebtors 12/15

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

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

case number (if known). Answer every question.

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

Yes

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

 No. Go to line 3.

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

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

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

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

Column 2.

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

Check all schedules that apply:

3.1 Amilia Chase  Schedule D, line 2.1

 Schedule E/F, line 

Schedule G 

Regional Acceptance Co

3.2 Amilia Chase  Schedule D, line 2.2

 Schedule E/F, line 

Schedule G 

Regional Acceptance Co

3.3 Amilia Chase  Schedule D, line 

 Schedule E/F, line 4.12

Schedule G 

Steward Financial Services, LLC

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

Software Copyright (c) 2019 CINGroup - www.cincompass.com

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 27 of 48
Fill in this information to identify your case:

Debtor 1 Dawn Marie Chase

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA, FORT

LAUDERDALE DIVISION

Case number Check if this is:

(If known)  An amended filing

 A supplement showing postpetition chapter 13

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

Schedule I: Your Income 12/15

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

Part 1: Describe Employment

1. Fill in your employment

information. Debtor 1 Debtor 2 or non-filing spouse

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

information about additional employers.

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

homemaker, if it applies.

Employment status  Employed

 Not employed

 Employed

 Not employed

Occupation Postal Clerk

Employer's name Post Office

Employer's address 3255 NW 94th Ave

Coral Springs, FL 33065-4134

How long employed there? 24 years

Part 2: Give Details About Monthly Income

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

unless you are separated.

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

space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or non-filing spouse

2.

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

deductions). If not paid monthly, calculate what the monthly wage would be. 2. $ 5,341.69 $ N/A

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

4. Calculate gross Income. Add line 2 + line 3. 4. $ 5,341.69 $ N/A

Official Form 106I Schedule I: Your Income page 1

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 28 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

For Debtor 1 For Debtor 2 or non-filing spouse Copy line 4 here 4. $ 5,341.69 $ N/A

5. List all payroll deductions: 5a. Tax, Medicare, and Social Security deductions 5a. $ 1,162.30 $ N/A

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

5c. Voluntary contributions for retirement plans 5c. $ 0.00 $ N/A

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

5e. Insurance 5e. $ 0.00 $ N/A

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

5g. Union dues 5g. $ 113.48 $ N/A

5h. Other deductions. Specify: Health Plan 5h.+ $ 137.26 + $ N/A

Vision $ 11.12 $ N/A

Fers $ 37.32 $ N/A

6. Add the payroll deductions. Add lines 5a+5b+5c+5d+5e+5f+5g+5h. 6. $ 1,461.48 $ N/A

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $ 3,880.21 $ N/A

8. List all other income regularly received: 8a. Net income from rental property and from operating a business, profession, or farm

Attach a statement for each property and business showing gross

receipts, ordinary and necessary business expenses, and the total

monthly net income. 8a. $ 0.00 $ N/A

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

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

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

settlement, and property settlement. 8c. $ 0.00 $ N/A

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

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

8f. Other government assistance that you regularly receive

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

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

Nutrition Assistance Program) or housing subsidies.

Specify: 8f. $ 0.00 $ N/A

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

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

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

10. Calculate monthly income. Add line 7 + line 9. 10. $ 3,880.21 + $ N/A = $ 3,880.21

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

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

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

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

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

Write that amount on the Summary of Schedules 12. $ 3,880.21 and Statistical Summary of Certain Liabilities and Related Data, if it applies

Combined monthly income

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

 No.

 Yes. Explain:

Official Form 106I Schedule I: Your Income page 2

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 29 of 48
Fill in this information to identify your case:

Debtor 1 Dawn Marie Chase Check if this is:

 An amended filing

Debtor 2  A supplement showing postpetition chapter 13

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

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA, FORT

LAUDERDALE DIVISION

MM / DD / YYYY

Case number

(If known)

Official Form 106J

Schedule J: Your Expenses 12/15

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

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

(if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

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

 No

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

2. Do you have dependents?  No

Do not list Debtor 1 and

Debtor 2.

Yes. Fill out this information for

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

Dependent’s relationship to

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent

live with you?

Do not state the

dependents names.

 No

Yes  No

Yes  No

Yes  No

Yes 3. Do your expenses include

expenses of people other than

yourself and your dependents?

 No

Yes

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

applicable date.

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

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

(Official Form 106I.) Your expenses

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

payments and any rent for the ground or lot. 4. $ 1,092.00

If not included in line 4:

4a. Real estate taxes 4a. $ 0.00

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

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

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

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

Official Form 106J Schedule J: Your Expenses page 1

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 30 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

6. Utilities: 6a. Electricity, heat, natural gas 6a. $ 200.00

6b. Water, sewer, garbage collection 6b. $ 70.00

6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $ 181.00

6d. Other. Specify: Cable 6d. $ 130.00

7. Food and housekeeping supplies 7. $ 300.00

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

9. Clothing, laundry, and dry cleaning 9. $ 150.00

10. Personal care products and services 10. $ 150.00

11. Medical and dental expenses 11. $ 400.00

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

Do not include car payments. 12. $ 200.00

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $ 100.00

14. Charitable contributions and religious donations 14. $ 0.00

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

15a. Life insurance 15a. $ 168.00

15b. Health insurance 15b. $ 0.00

15c. Vehicle insurance 15c. $ 280.00

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

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

17. Installment or lease payments: 17a. Car payments for Vehicle 1 17a. $ 364.00

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

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

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

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

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

Specify: 19.

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

20b. Real estate taxes 20b. $ 0.00

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

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

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

21. Other: Specify: Animal Food/Grooming/Vet 21. +$ 125.00

Miami Herald +$ 13.90

Planet Fit Club +$ 36.00

22. Calculate your monthly expenses

22a. Add lines 4 through 21. $ 3,959.90

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

22c. Add line 22a and 22b. The result is your monthly expenses. $ 3,959.90

23. Calculate your monthly net income. 23a. Copy line 12(your combined monthly income) from Schedule I. 23a. $ 3,880.21

23b. Copy your monthly expenses from line 22c above. 23b. -$ 3,959.90

23c. Subtract your monthly expenses from your monthly income. The result is your monthly net income. 23c. $ -79.69

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

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

modification to the terms of your mortgage?

 No.

Yes. Explain here:

Official Form 106J Schedule J: Your Expenses page 2

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 31 of 48
 Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106Dec

Declaration About an Individual Debtor's Schedules 12/15

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

You must file this form whenever you file bankruptcy schedules or amended schedules. Making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20

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

Sign Below

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

 No

 Yes. Name of person Attach Bankruptcy Petition Preparer’s Notice, Declaration, and Signature (Official Form 119)

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

that they are true and correct.

X /s/ Dawn Marie Chase X

Dawn Marie Chase Signature of Debtor 2

Signature of Debtor 1

Date April 17, 2019 Date

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 32 of 48
 Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 106Sum

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

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

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

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

Part 1: Summarize Your Assets

Your assets Value of what you own

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

1a. Copy line 55, Total real estate, from Schedule A/B................................................................................................ $ 108,900.00

1b. Copy line 62, Total personal property, from Schedule A/B..................................................................................... $ 116,294.05

1c. Copy line 63, Total of all property on Schedule A/B............................................................................................... $ 225,194.05

Part 2: Summarize Your Liabilities

Your liabilities Amount you owe

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

2a. Copy the total you listed in Column A, Amount of claim, at the bottom of the last page of Part 1 of Schedule D... $ 34,776.00

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

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

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F............................ $ 31,566.49

Your total liabilities $ 66,342.49

Part 3: Summarize Your Income and Expenses

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

Copy your combined monthly income from line 12 of Schedule I................................................................................ $ 3,880.21

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

Copy your monthly expenses from line 22c of Schedule J.......................................................................... $ 3,959.90

Part 4: Answer These Questions for Administrative and Statistical Records

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

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

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

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

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

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

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Debtor 1 Chase, Dawn Marie Case number (if known)

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

122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14. $ 5,341.69

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

Total claim

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

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

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

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

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

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

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

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

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

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 34 of 48
 Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy 4/19

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

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

(if known). Answer every question.

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

1. What is your current marital status?

 Married

 Not married

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

 No

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

Debtor 1 Prior Address: Dates Debtor 1 lived

there Debtor 2 Prior Address: Dates Debtor 2lived there

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

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

 No

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

Part 2 Explain the Sources of Your Income

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

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

If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.  No

 Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income Check all that apply.Gross income

(before deductions and

exclusions)

Sources of income Check all that apply.Gross income

(before deductions and exclusions)

From January 1 of current year until

the date you filed for bankruptcy:  Wages, commissions,

bonuses, tips  Operating a business

$16,245.98  Wages, commissions,

bonuses, tips  Operating a business

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

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Debtor 1 Chase, Dawn Marie Case number (if known)

Debtor 1 Debtor 2

Sources of income Check all that apply.Gross income

(before deductions and

exclusions)

Sources of income Check all that apply.Gross income

(before deductions and exclusions)

For last calendar year:

(January 1 to December 31, 2018 )

 Wages, commissions,

bonuses, tips  Operating a business

$64,452.00  Wages, commissions,

bonuses, tips  Operating a business

For the calendar year before that:

(January 1 to December 31, 2017 )

 Wages, commissions,

bonuses, tips  Operating a business

$62,858.00  Wages, commissions,

bonuses, tips  Operating a business

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

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

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

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

List each source and the gross income from each source separately. Do not include income that you listed in line 4.  No

 Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income Describe below. Gross income from

each source

(before deductions and

exclusions)

Sources of income Describe below. Gross income

(before deductions and exclusions)

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

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

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

individual primarily for a personal, family, or household purpose.”

During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,825* or more?

 No. Go to line 7.

 Yes List below each creditor to whom you paid a total of $6,825* or more in one or more payments and the total amount you paid that

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

payments to an attorney for this bankruptcy case. * Subject to adjustment on 4/01/22 and every 3 years after that for cases filed on or after the date of adjustment.  Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts. During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more?

 No. Go to line 7.

Yes List below each creditor to whom you paid a total of $600 or more and the total amount you paid that creditor. Do not include

payments for domestic support obligations, such as child support and alimony. Also, do not include payments to an attorney for

this bankruptcy case.

Creditor's Name and Address Dates of payment Total amount

paid

Amount you

still owe Was this payment for ...

Regional Acceptance Corporation

1901 W Cypress Creek Rd Ste 415

Fort Lauderdale, FL 33309-1857

03/2019 - $364.00

02/2019 - $364.00

01/2019 - $364.00

$1,092.00 $0.00  Mortgage

 Car

 Credit Card

 Loan Repayment

Suppliers or vendors  Other

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

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

Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing agent, including one for a

business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations, such as child support and alimony.  No

 Yes. List all payments to an insider.

Insider's Name and Address Dates of payment Total amount

paid

Amount you

still owe Reason for this payment

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

insider?

Include payments on debts guaranteed or cosigned by an insider.  No

 Yes. List all payments to an insider

Insider's Name and Address Dates of payment Total amount

paid

Amount you

still owe Reason for this paymentInclude creditor's name

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

List all such matters, including personal injury cases, small claims actions, divorces, collection suits, paternity actions, support or custody modifications, and contract disputes.  No

 Yes. Fill in the details.

Case title Case number Nature of the case Court or agency Status of the case

Steward Financial Services LLC

Plaintiff

vs.

Dawn M Chase, et al

 Defendant

COSO19002928

CC Credit Card

Debt

Broward County Circuit

Court

201 SE 6th St Ste 136

Fort Lauderdale, FL

33301-3389

 Pending

 On appeal

 Concluded

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

Check all that apply and fill in the details below.

 No. Go to line 11.

 Yes. Fill in the information below. Creditor Name and Address Describe the Property

Explain what happened

Date Value of the property

11. Within 90 days before you filed for bankruptcy, did any creditor, including a bank or financial institution, set off any amounts from your accounts or refuse to make a payment because you owed a debt?

 No

 Yes. Fill in the details.

Creditor Name and Address Describe the action the creditor took Date action was

taken Amount

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

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

 No

 Yes

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

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Debtor 1 Chase, Dawn Marie Case number (if known)

Part 5: List Certain Gifts and Contributions

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

 No

 Yes. Fill in the details for each gift. Gifts with a total value of more than $600 per person

Person to Whom You Gave the Gift and

Address:

Describe the gifts Dates you gave

the gifts Value

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

 No

 Yes. Fill in the details for each gift or contribution. Gifts or contributions to charities that total more than $600

Charity's Name Address (Number, Street, City, State and ZIP Code)

Describe what you contributed Dates you

contributed

Value

Part 6: List Certain Losses

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

 No

 Yes. Fill in the details.

Describe the property you lost and

how the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending

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

Date of your

loss Value of propertylost

Part 7: List Certain Payments or Transfers

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

consulted about seeking bankruptcy or preparing a bankruptcy petition?

Include any attorneys, bankruptcy petition preparers, or credit counseling agencies for services required in your bankruptcy.  No

 Yes. Fill in the details.

Person Who Was Paid

Address Email or website address Person Who Made the Payment, if Not You

Description and value of any property

transferred

Date payment or

transfer was made

Amount of

payment

Van Horn Law Group, P.A.

330 N Andrews Ave Ste 450

Fort Lauderdale, FL 33301-1012

$500.00 3/21/2019 $500.00

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

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

Do not include any payment or transfer that you listed on line 16.  No

 Yes. Fill in the details.

Person Who Was Paid

Address Description and value of any propertytransferred

Date payment or

transfer was made

Amount of

payment

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

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

Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property). Do not include

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

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Debtor 1 Chase, Dawn Marie Case number (if known)

gifts and transfers that you have already listed on this statement.  No

 Yes. Fill in the details.

Person Who Received Transfer Address

Person's relationship to you

Description and value of

property transferred

Describe any property or payments received or debts paid in exchangeDate transfer was made

19. Within 10 years before you filed for bankruptcy, did you transfer any property to a self-settled trust or similar device of which you are a beneficiary? (These are often called asset-protection devices.)

 No

 Yes. Fill in the details.

Name of trust Description and value of the property transferred Date Transfer was made

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

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

Include checking, savings, money market, or other financial accounts; certificates of deposit; shares in banks, credit unions, brokerage houses, pension funds, cooperatives, associations, and other financial institutions.  No

 Yes. Fill in the details. Name of Financial Institution and

Address (Number, Street, City, State and ZIP

Code)

Last 4 digits of account number Type of account or

instrument

Date account was

closed, sold, moved, or

transferred

Last balance before

closing or transfer

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

 No

 Yes. Fill in the details. Name of Financial Institution Address (Number, Street, City, State and ZIP Code)

Who else had access to it?

Address (Number, Street, City, State

and ZIP Code)

Describe the contents Do you still

have it?

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

 No

 Yes. Fill in the details. Name of Storage Facility

Address (Number, Street, City, State and ZIP Code)

Who else has or had access

to it?

Address (Number, Street, City, State

and ZIP Code)

Describe the contents Do you still

have it?

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

23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for, or hold in trust for someone.  No

 Yes. Fill in the details. Owner's Name Address (Number, Street, City, State and ZIP Code)

Where is the property?

(Number, Street, City, State and ZIP

Code)

Describe the property Value

Part 10: Give Details About Environmental Information

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

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

controlling the cleanup of these substances, wastes, or material.  Site means any location, facility, or property as defined under any environmental law, whether you now own, operate, or utilize it or used to Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 5

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 39 of 48
Debtor 1 Chase, Dawn Marie Case number (if known)

own, operate, or utilize it, including disposal sites.  Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, contaminant, or similar term.

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

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

 No

 Yes. Fill in the details. Name of site Address (Number, Street, City, State and ZIP Code)

Governmental unit

Address (Number, Street, City, State and

ZIP Code)

Environmental law, if you

know it

Date of notice

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

 No

 Yes. Fill in the details. Name of site Address (Number, Street, City, State and ZIP Code)

Governmental unit

Address (Number, Street, City, State and

ZIP Code)

Environmental law, if you

know it

Date of notice

26. Have you been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders.  No

 Yes. Fill in the details. Case Title Case Number Court or agency

Name Address (Number, Street, City, State

and ZIP Code)

Nature of the case Status of the

case

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

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

A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time A member of a limited liability company (LLC) or limited liability partnership (LLP)

A partner in a partnership

An officer, director, or managing executive of a corporation An owner of at least 5% of the voting or equity securities of a corporation  No. None of the above applies. Go to Part 12.  Yes. Check all that apply above and fill in the details below for each business. Business Name Address

(Number, Street, City, State and ZIP Code)

Describe the nature of the business

Name of accountant or bookkeeper

Employer Identification number Do not include Social Security number or ITIN.

Dates business existed

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

institutions, creditors, or other parties.  No

 Yes. Fill in the details below. Name Address

(Number, Street, City, State and ZIP Code)

Date Issued

Part 12: Sign Below

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

true and correct. I understand that making a false statement, concealing property, or obtaining money or property by fraud in connection with a

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

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Debtor 1 Chase, Dawn Marie Case number (if known)

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.

/s/ Dawn Marie Chase

Dawn Marie Chase Signature of Debtor 2

Signature of Debtor 1

Date April 17, 2019 Date

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

 No

Yes

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

 No

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

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

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Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 41 of 48
 Fill in this information to identify your case: Debtor 1 Dawn Marie Chase

First Name Middle Name Last Name Debtor 2

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

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA, FORT LAUDERDALE

DIVISION

Case number

(if known)  Check if this is an

amended filing

Official Form 108

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

If you are an individual filing under chapter 7, you must fill out this form if: creditors have claims secured by your property, or you have leased personal property and the lease has not expired. You must file this form with the court within 30 days after you file your bankruptcy petition or by the date set for the meeting of creditors, whichever is earlier, unless the court extends the time for cause. You must also send copies to the creditors and lessors you list on

the form

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

and date the form.

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

Part 1: List Your Creditors Who Have Secured Claims

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

information below.

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

Did you claim the property

as exempt on Schedule C?

Creditor's Regional Acceptance Co Surrender the property.  No

Yes

name:  Retain the property and redeem it.

Retain the property and enter into a Reaffirmation Agreement. Description of 2017 Kia Soul

property Retain the property and [explain]: securing debt:

Creditor's Regional Acceptance Co Surrender the property.  No

Yes

name:  Retain the property and redeem it.

Retain the property and enter into a Reaffirmation Agreement. Description of 2016 Jeep Patriot 4WD

property Retain the property and [explain]: securing debt:

Part 2: List Your Unexpired Personal Property Leases For any unexpired personal property lease that you listed in Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G), fill in

the information below. Do not list real estate leases. Unexpired leases are leases that are still in effect; the lease period has not yet ended. You may assume an unexpired personal property lease if the trustee does not assume it. 11 U.S.C. § 365(p)(2).

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

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

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Debtor 1 Chase, Dawn Marie Case number (if known)

Lessor's name:  No

 Yes Description of leased

Property:

Lessor's name:  No

 Yes Description of leased

Property:

Lessor's name:  No

 Yes Description of leased

Property:

Lessor's name:  No

 Yes Description of leased

Property:

Lessor's name:  No

 Yes Description of leased

Property:

Lessor's name:  No

 Yes Description of leased

Property:

Lessor's name:  No

 Yes Description of leased

Property:

Part 3: Sign Below

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

property that is subject to an unexpired lease. X /s/ Dawn Marie Chase X

Dawn Marie Chase Signature of Debtor 2

Signature of Debtor 1

Date April 17, 2019 Date

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

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© 2019 CINgroup 1.866.218.1003 – CINcompass (www.cincompass.com)

United States Bankruptcy Court

IN RE: Case No. 

Debtor(s)

Chapter 

The above named debtor(s) hereby verify(ies) that the attached matrix listing creditorsistrue to the best of my(our) knowledge.

Date: Signature: 

Debtor

Date: Signature: 

Joint Debtor, if any

Southern District of Florida, Fort Lauderdale Division

VERIFICATION OF CREDITOR MATRIX

Chase, Dawn Marie 7

April 17, 2019 /s/ Dawn Marie Chase

Dawn Marie Chase

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 44 of 48
Aqua Finance Inc

1 Corporate Dr

Wausau, WI 54401-1722

Broward Health Imperial Point

1608 SE 3rd Ave

Fort Lauderdale, FL 33316-2564

Caliber Home Loans

PO Box 619063

Dallas, TX 75261-9063

Comenity Bank/Bealls Florida

PO Box 182789

Columbus, OH 43218-2789

Comenity Bank/Beallsfl

PO Box 182789

Columbus, OH 43218-2789

Comenity Bank/Beallsol

PO Box 182789

Columbus, OH 43218-2789

Discover Fin Svcs LLC

PO Box 15316

Wilmington, DE 19850-5316

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 45 of 48
Elite Imaging, LLC

PO Box 826618

Philadelphia, PA 19182-6618

Enhanced Recovery Co L

PO Box 57547

Jacksonville, FL 32241-7547

Fingerhut/Webbank

6250 Ridgewood Rd

Saint Cloud, MN 56303-0820

IC System

444 Highway 96 E

Saint Paul, MN 55127-2557

Internal Revenue Services

PO Box 7346

Philadelphia, PA 19101-7346

Jefferson Capital Syst

16 McLeland Rd

Saint Cloud, MN 56303-2198

Jefferson Capital Systems, LLC

16 McLeland Rd

Saint Cloud, MN 56303-2198

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 46 of 48
Jonathan Hempfling, Esq

5104 S West Shore Blvd

Tampa, FL 33611-5650

Marcadis Singer PA

5104 S West Shore Blvd

Tampa, FL 33611-5650

Portfolio Recov Assoc

120 Corporate Blvd Ste 1

Norfolk, VA 23502-4952

Portfolio Recovery

120 Corporate Blvd

Norfolk, VA 23502-4962

Regional Acceptance Co

5400 W Sample Rd Ste A

Margate, FL 33073-3475

Steward Financial Services, LLC

444 E Kings Hwy

Maple Shade, NJ 08052-3427

Tbom/Total Crd

PO Box 85710

Sioux Falls, SD 57118-5710

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 47 of 48
Td Bank N.A.

32 Chestnut St

Lewiston, ME 04240-7744

US Attorney's Office Southern District o

99 NE 4th St

Miami, FL 33132-2131

Verizon Wireless

PO Box 26055

Minneapolis, MN 55426-0055

Case 19-14957-RBR Doc 1 Filed 04/17/19 Page 48 of 48