i' nl m this mformat1on to identify the case: 

United States Bankruptcy Court for the: 

________ District of=::-:------

(State) 

Case number (If known): __________ Chapter __ 

Official Form 201 

CJ Check if this is an 

amended filing 

Voluntary Petition for Non-Individuals Filing for Bankruptcy o4/19 

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

number (if known). For more information, a separate document, Instructions for Bankruptcy Fonns for Non-Individuals, is available. 

1. Debtor's name 

2. All other names debtor used 

in the last 8 years 

Include any assumed names, 

trade names, and doing business 

as names 

3. Debtor's federal Employer 

Identification Number (EIN) 

4. Debtor's address 

s. Debtor's website (URL) 

s. Type of debtor 

Official Form 201 

Principal place of business 

Number Street 

fv.t+ lovclc--rklt.. 'fL JJJU 

City State ZIP Code 

County 

Mailing address, if different from principal place 

of business 

jo\6 A\rumb:o::L cJ <'cls:. 

Number Street 

P.O. Box 

:fL-- .J:> l3L 

State ZIP Code J 

Location of principal assets, if different from 

principal place of business 

Number Street 

City State ZIP Code 

~orporation (including Limited Liability Company (LLC) and Limited Liability Partnership (LLP)) 

0 Partnership (excluding LLP) 

0 Other. Specify:--------------------------

Voluntary Petition for Non-Individuals Filing for Bankruptcy page 1 
Debtor Name 

1. Describe debtor's business 

a. Under which chapter of the 

Bankruptcy Code is the 

debtor filing? 

9. Were prior bankruptcy cases 

filed by or against the debtor 

within the last 8 years? 

If more than 2 cases, attach a 

separate list. 

10. Are any bankruptcy cases 

pending or being filed by a 

business partner or an 

affiliate of the debtor? 

List all cases. If more than 1, 

attach a separate list. 

Official Form 201 

Case number (if known) _____________ _ 

A. Check one: 

0 Health Care Business (as defined in 11 U.S.C. § 101(27A)) 

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

0 Railroad (as defined in 11 U.S.C. § 101 (44)) 

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

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

0 _>;learing Bank (as defined in 11 U.S. C. § 781 (3)) 

13' None of the above 

B. Check all that apply: 

0 Tax-exempt entity (as described in 26 U.S.C. § 501) 

0 Investment company, including hedge fund or pooled investment vehicle (as defined in 15 U.S.C. 

§ 80a-3) 

0 Investment advisor (as defined in 15 U.S.C. § 80b-2(a)(11)) 

C. NAICS (North American Industry Classification System) 4-digit code that best describes debtor. See 

http://www.uscourts.gov/four-digit-national-association-naics-codes . 

~'l__l__j_ 

Check one: 

0 Chapter? 

0 yt"~apter 9 

'od Chapter 11. Check all that apply. 

0 Debtor's aggregate noncontingent liquidated debts (exduding debts owed to 

insiders or affiliates) are less than $2,725,625 (amount subject to adjustment on 

/4101122 and every 3 years after that). 

I!J The debtor is a small business debtor as defined in 11 U.S.C. § 101 (510). If the 

debtor is a small business debtor, attach the most recent balance sheet, statement 

of operations, cash-flow statement, and federal income tax return or if all of these 

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

0 A plan is being filed with this petition. 

0 Acceptances of the plan were solicited prepetition from one or more classes of 

creditors, in accordance with 11 U.S.C. § 1126(b). 

0 The debtor is required to file periodic reports (for example, 1 OK and 1 OQ) with the 

Securities and Exchange Commission according to§ 13 or 15(d) of the Securities 

Exchange Act of 1934. File the Attachment to Voluntary Petftion for Non-Individuals Filing 

for Bankruptcy under Chapter 11 (Official Form 201A) with this form. 

0 The debtor is a shell company as defined in the Securities Exchange Act of 1934 Rule 

12b-2. 

0 Jllapter 12 

0 Yes. District --------- When Case number---------

MMI DDIYYYY 

District --------- When Case number---------

MM I DD IYYYY 

@%0 

0 Yes. Debtor Relationship 

District ----------------- When 

MM I DO IYYYY 

Case number,~ known ------------

Voluntary Petition for Non-Individuals Filing for Bankruptcy page 2 
Debtor Name 

11. Why is the case filed in this 

districr? 

12. Does the debtor own or have 

possession of any real 

property or personal property 

that needs immediate 

attention? 

Case number (if known) _____________ _ 

cht/:k all that apply: 

rJ Debtor has had its domicile, principal place of business, or principal assets in this district for 180 days 

immediately preceding the date of this petition or for a longer part of such 180 days than in any other 

district. 

0 A1bankruptcy case concerning debtor's affiliate, general partner, or partnership is pending in this district. 

0 Yes. Answer below for each property that needs immediate attention. Attach additional sheets if needed. 

Why does the property need immediate attention? (Check all that appy.) 

0 It poses or is alleged to pose a threat of imminent and identifiable hazard to public health or safety. 

What is the hazard?~·-------------------------

0 It needs to be physically secured or protected from the weather. 

0 It includes perishable goods or assets that could quickly deteriorate or lose value without 

attention (for example, livestock, seasonal goods, meat, dairy, produce, or securities-related 

assets or other options). 

0 Other ____________________________________________________ __ 

Where is the property?--:-:-----------=----------------------------------- Number Street 

City 

Is the property insured? 

0 No 

State ZIP Code 

0 Yes. Insurance agency-------------------------

Contact name 

Phone 

Statistical and administrative information 

13. Debtor's estimation of 

available funds 

14. Estimated number of 

creditors 

15. Estimated assets 

Official Form 201 

Check one: 

q"Funds will be available for distribution to unsecured creditors. 

litJ After any administrative expenses are paid, no funds will be available for distribution to unsecured creditors. 

i6 1-49 

0 50-99 

0 100-199 

oro0-999 

Ell $0-$50' 000 

0 $50,001-$100,000 

0 $100,001-$500,000 

0 $500,001-$1 million 

0 1,000-5,000 

0 5,001-10,000 

0 10,001-25,000 

0 $1,000,001-$10 million 

0 $10,000,001-$50 million 

0 $50,000,001-$100 million 

0 $100,000,001-$500 million 

Voluntary Petition for Non-Individuals Filing for Bankruptcy 

0 25,001-50,000 

0 50,001-100,000 

0 More than 100,000 

0 $500,000,001-$1 billion 

0 $1,000,000,001-$10 billion 

0 $10,000,000,001-$50 billion 

0 More than $50 billion 

page 3 
Debtor Name 

1&. Estimated liabilities 

0 $0-$50' 000 

0 $50,001-$100,000 

0 $100,001-$500,000 

0 $500,001-$1 million 

Case number (if known) _____________ _ 

d$1 ,000,001-$10 million 

0 $10,000,001-$50 million 

0 $50,000,001-$100 million 

0 $100,000,001-$500 million 

0 $500,000,001-$1 billion 

0 $1,000,000,001-$10 billion 

0 $10,000,000,001-$50 billion 

0 More than $50 billion 

Request for Relief, Declaration, and Signatures 

WARNING-- Bankruptcy fraud is a serious crime. Making a false statement in connection with a bankruptcy case can result in fines up to 

$500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571. 

11. Declaration and signature of 

authorized representative of 

debtor 

18. Signature of attorney 

Official Form 201 

• The debtor requests relief in accordance with the chapter of title 11, United States Code, specified in this 

petition. 

• I have been authorized to file this petition on behalf of the debtor. 

• I have examined the information in this petition and have a reasonable belief that the information is true and 

correct. 

I declare under penalty of pe~ury that the foregoing is true and correct. 

Printed name 

Title _ _,(2='-"Wl-'--'---------

Date 

Signature of attorney for debtor MM /DO /YYYY 

Printed name 

Firm name 

Number Street 

City State ZIP Code 

Contact phone Email address 

Bar number State 

Voluntary Petition for Non-Individuals Filing for Bankruptcy page4 
F1ll 1n th1s mformat1on to 1dent1fy the case: 

Debtor name ----------

United States Bankruptcy Court for the: __________ District of-:-::::--:-:--

(State) 

Case number (If knoiMl): 

Official Form 206Sum 

Summary of Assets and Liabilities for Non-Individuals 

f§!l Summary of Assets 

1. Schedule AlB: Asset:r-Rea I and Personal Property (Official Form 206A/B) 

1a. Real property: 

Copy line 88 from Schedule A/B .................................................................................................................................... . 

0 Check if this is an 

amended filing 

12/15 

1

b. ~~~ ~;:~:a:r~:~~:~uleAIB ................................................................................................................................... I 

~=========~ 

$ _____ _ 

1c. ~~~~~=~~~~~:;:~eduleAIB ..................................................................................................................................... I.__$_1._-.J_(li). __ ·tPJ __ _. 

flfj Summary of Uabilities 

2. ScheduleD: Creditors Who Have Claims Secured by Property (OffiCial Form 2060) 

Copy the total dollar amJunt listed in Colurm A, Amount of claim, from line 3 of Schedule 0 ............................................. . $ 1/ Z-S:Cao i 

I 

3. Schedule ElF: Creditors Who Have Unsecured Claims( OffiCial Form 206EIF) 

3a. Total claim amounts of priority unsecured claims: 

Copy the total claims from Part 1 from line 5a of Schedule ElF ................................................................................... . $ ______ 1 

3b. Total amount of claims of nonpriority amount of unsecured claims: 

Copy the total of the amJunt of claims from Part 2 from line 5b of Schedule ElF ........................................................ . + $ _____ _ 

4. Totalliabilities .................................................................................................................................................................. . 

Lines 2 + 3a + 3b 

Official Form 206Sum Summary of Assets and Liabilities for Non-Individuals page 1 
F1ll 1n this mformat1on to Identify the case: 

Debtor name --------------------------

United States Bankruptcy Court for the: __________ District of --;-;::=7"""""-

(State) 

Case number-{\! known): 

Official Form 206A/B 

[J Check if this is an 

amended filing 

Schedule AlB: Assets - Real and Personal Property 12/15 

Disclose all property, real and personal, which the debtor owns or in which the debtor has any other legal, equitable, or future interest Include 

all property in which the debtor holds rights and powers exercisable for the debtor's own benefit. Also include assets and properties which have 

no book value, such as fully depreciated assets or assets that were not capitalized. In Schedule AlB, list any executory contracts or unexpired 

leases. Also list them on Schedule G: Executory Contracts and Unexpired Leases (Official Form 206G). 

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

the debtor's name and case number (if known). Also identify the form and line number to which the additional information applies. If an 

additional sheet is attached, include the amounts from the attachment in the total for the pertinent part. 

For Part 1 through Part 11, list each asset under the appropriate category or attach separate supporting schedules, such as a fixed asset 

schedule or depreciation schedule, that gives the details for each asset in a particular category. List each asset only once. In valuing the 

debtor's interest, do not deduct the value of secured claims. See the instructions to understand the terms used in this form. 

Cash and cash equivalents 

1. Do~ the debtor have any cash or cash equivalents? 

8' No. Go to Part 2. 

[J Yes. Fill in the information below. 

All cash or cash equivalents owned or controlled by the debtor 

2. Cash on hand 

3. Checking, savings, money market, or financial brokerage accounts (Identify all) 

Name of institution (bank or brokerage firm) Type of account 

3.1.------------------ --------- 3.2.------------------ ---------

4. Other cash equivalents (Identify all) 

Last 4 digits of account number 

4.1. _____________________________________ _ 

4.2. _____________________________________ _ 

5. Total of Part 1 

6. 

Add lines 2 through 4 (including amounts on any additional sheets). Copy the total to line 80. 

Deposits and prepayments 

the debtor have any deposits or prepayments? 

No. Go to Part 3. 

[J Yes. Fill in the information below. 

7. Deposits, including security deposits and utility deposits 

Description, including name of holder of deposit 

7.1. ______________________________________ _ 

7.2. ______________________________________ _ 

Official Form 206A/B Schedule AlB: Assets- Real and Personal Property 

Current value of debtor's 

interest 

$ ______ _ 

$ ____________ _ 

$ _______ _ 

$ ______ _ 

$ ____________ _ 

Current value of 

debtor's interest 

$ ______ _ 

$ ______________ _ 

page 1 
Debtor Case number (if known)'--------------- Name 

8. Prepayments, including prepayments on executory contracts, leases, insurance, taxes, and rent 

Description, including name of holder of prepayment 

8.1. _______________________________________ _ 

8.2. _______________________________________ _ 

9. Total of Part 2. 

Add lines 7 through 8. Copy the total to line 81. 

:F-Tii Accounts receivable 

10. Doe1 the debtor have any accounts receivable? 

l:lV"No. Go to Part 4. 

D Yes. Fill in the information below. 

11. Accounts receivable 

11a. 90 days old or less: 

face amount 

11b. Over 90 days old: 

face amount 

12. Total of Part 3 

doubtful or uncollectible accounts 

doubtful or uncollectible accounts 

Current value on lines 11 a + 11 b = line 12. Copy the total to line 82 . 

• ,,, Investments 

13. D~ the debtor own any investments? 

~No. Go to Part 5. 

D Yes. Fill in the information below. 

14. Mutual funds or publicly traded stocks not included in Part 1 

Name of fund or stock: 

14.1. _______________________________ _ 

14.2.------------------------------

........ -+ 

........ -+ 

Valuation method 

used for current value 

15. Non-publicly traded stock and interests in incorporated and unincorporated businesses, 

including any interest in an LLC, partnership, or joint venture 

Name of entity: 

15.1. _______________________ _ 

15.2. _______________________ _ 

% of ownership: 

____ % 

___ % 

16. Government bonds, corporate bonds, and other negotiable and non-negotiable 

instruments not included in Part 1 

Describe: 

16.1. _____________________________ _ 

16.2. _______________________________ _ 

17. Total of Part 4 

Add lines 14 through 16. Copy the total to line 83. 

Official Form 206A/B Schedule AlB: Assets- Real and Personal Property 

$ ______________ _ 

$, ______ _ 

Current value of debtor's 

interest 

$ ______________ _ 

$ ______________ _ 

Current value of debtor's 

interest 

$ ______ _ 

$ _______ _ 

$ ______ _ 

$, ______ _ 

$ _______ _ 

$ _______ _ 

page 2 
Debtor Case number (if known) ______________ _ 

Name 

Inventory, excluding agriculture assets 

18. ooJ'the debtor own any inventory (excluding agriculture assets)? 

uf No. Go to Part 6. 

0 Yes. Fill in the information below. 

General description 

19. Raw materials 

20. Work in progress 

Date of the last 

physical inventory 

MM /00/YYYY 

MM /00/YYYY 

21. Finished goods, including goods held for resale 

MM /00/YYYY 

22. Other inventory or supplies 

MM /00/YYYY 

23. Total of Part 5 

24. 

Add lines 19 through 22. Copy the total to line 84. 

Is t-ny of the property listed in Part 5 perishable? 

El No 

0 Yes 

Net book value of 

debtor's interest 

(Where available) 

$ _____ _ 

$ _____ _ 

$ ____ _ 

$. _____ _ 

Valuation method used 

for current value 

25. Has any of the property listed in Part 5 been purchased within 20 days before the bankruptcy was filed? 

~No 

0 Yes. Book value ------- Valuation method _________ Current value. _____ _ 

26. Has any of the property listed in Part 5 been appraised by a professional within the last year? 

Q No 

0 Yes 

Farming and fishing-related assets (other than titled motor vehicles and land) 

27. the debtor own or lease any farming and fishing-related assets (other than titled motor vehicles and land)? 

No. Go to Part 7. 

0 Yes. Fill in the information below. 

General description 

28. Crops--either planted or harvested 

29. Farm animals Examples: Livestock, poultry, farm-raised fish 

30. Farm machinery and equipment (Other than titled motor vehicles) 

31. Farm and fishing supplies, chemicals, and feed 

Net book value of 

debtor's interest 

(Where available) 

$. _________ __ 

$. _________ __ 

$. _________ __ 

$. _________ __ 

32. Other farming and fishing-related property not already listed in Part 6 

$. _________ __ 

Valuation method used 

for current value 

Official Form 206AIB Schedule AlB: Assets- Real and Personal Property 

Current value of 

debtor's interest 

$ ______ _ 

$. ________ _ 

$. ______ _ 

$. ________ _ 

Current value of debtor's 

interest 

$ ______ _ 

$ ______ _ 

$ ______ _ 

$ ______ _ 

$. ______ _ 

page 3 
Debtor Case number (it known), ______________ _ 

Name 

33. Total of Part 6. 

Add lines 28 through 32. Copy the total to line 85. 

34. Is the debtor a member of an agricultural cooperative? 

0 No 

0 Yes. Is any of the debtor's property stored at the cooperative? 

0 No 

0 Yes 

35. Has any of the property listed in Part 6 been purchased within 20 days before the bankruptcy was filed? 

0 No 

0 Yes. Book value $. ______ Valuation method-------- Current value$. _____ _ 

36. Is a depreciation schedule available for any of the property listed in Part 6? 

0 No 

0 Yes 

37. Has any of the property listed in Part 6 been appraised by a professional within the last year? 

0 No 

0 Yes 

Office furniture, fixtures, and equipment; and collectibles 

the debtor own or lease any office furniture, fixtures, equipment, or collectibles? 

0 Yes. Fill in the information below. 

General description 

39. Office furniture 

40. Office fixtures 

41. Office equipment, including all computer equipment and 

communication systems equipment and software 

Net book value of 

debtor's interest 

(Where available) 

$. _____ _ 

$. _____ _ 

$. _____ _ 

42. Collectibles Examples: Antiques and figurines; paintings, prints, or other 

artwork; books, pictures, or other art objects; china and crystal; stamp, coin, 

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

42.1 $ 

42.2 $ 

42.3 $ 

43. Total of Part 7. 

Add lines 39 through 42. Copy the total to line 86. 

44. Is a depreciation schedule available for any of the property listed in Part 7? 

0 No 

0 Yes 

Valuation method 

used for current value 

45. Has any of the property listed in Part 7 been appraised by a professional within the last year? 

0 No 

0 Yes 

Official Form 206A/B Schedule AlB: Assets- Real and Personal Property 

,$. __ 

Current value of debtor's 

interest 

$ _______ _ 

$. _______ _ 

$. ______ _ 

$ 

$ 

$ 

Is 

page4 
Debtor Case number (if known)•--------------- Name 

·Machinery, equipment, and vehicles 

46. Does the debtor own or lease any machinery, equipment, or vehicles? 

1:1 No. Go to Part 9. 

1:1 Yes. Fill in the information below. 

General description 

Include year, make, model, and identification numbers (i.e., VIN, 

HIN, or N-number) 

Net book value of 

debtor's interest 

(Where available) 

47. Automobiles, vans, trucks, motorcycles, trailers, and titled farm vehicles 

47.1 ______________________ _ $. _____ _ 

47.2 _____________________ _ $. _____ _ 

47.3 ______________________ _ $. _____ _ 

47.4 ______________________ _ $. _____ _ 

48. Watercraft, trailers, motors, and related accessories Examples: Boats, 

trailers, motors, floating homes, personal watercraft, and fishing vessels 

48.1 _____________________ _ 

48.2 _____________________ _ 

49. Aircraft and accessories 

49.1 _____________________ _ 

49.2 _____________________ _ 

50. Other machinery, fixtures, and equipment (excluding farm 

machinery and equipment) 

51. Total of Part 8. 

Add lines 47 through 50. Copy the total to line 87. 

$. _____ _ 

$. _____ _ 

$. _____ _ 

$. _____ _ 

$. _____ _ 

52. Is a depreciation schedule available for any of the property listed in Part 8? 

1:1 No 

1:1 Yes 

Valuation method used 

for current value 

53. Has any of the property listed in Part 8 been appraised by a professional within the last year? 

1:1 No 

1:1 Yes 

Official Form 206AIB Schedule AlB: Assets- Real and Personal Property 

Current value of 

debtor's interest 

$. ______ _ 

$. ______ _ 

$ _______ _ 

$. ______ _ 

$. ______ _ 

$. _______ _ 

$. ______ _ 

$. _______ _ 

$ _______ _ 

1$. __ 

page 5 
Debtor Case number (if known) _____________ _ 

Name 

Real property 

54. Does the debtor own or lease any real property? 

D ]Jo. Go to Part 10. 

Ii2f Yes. Fill in the information below. 

55. Any building, other improved real estate, or land which the debtor owns or in which the debtor has an interest 

Description and location of property 

Include street address or other description such as 

Assessor Parcel Number (APN), and type of property 

(for example, acreage, factory, warehouse, apartment 

or office building), if available. 

55.1 2'UXJ ~- ~~~ 'f n,... 

55.2 biD JC zz~J.Jk£-r'-

55.3·---------------

55.4 ______________ _ 

55.5 ______________ _ 

55.6 ______________ _ 

56. Total of Part 9. 

Nature and extent Net book value of 

of debtor's interest debtor's interest 

in property (Where available) 

s /, lOP, (,t?c:> 

2/4W 

$. ____ _ 

$ _____ _ 

$ _____ _ 

$~ fPQtw 

Valuation method used 

for current value 

Add the current value on lines 55.1 through 55.6 and entries from any additional sheets. Copy the total to line 88. 

57. Is a pepreciation schedule available for any of the property listed in Part 9? 

i:D/ No 

D Yes 

58. ~: of the property listed in Part 9 been appraised by a professional within the last year? 

D Yes 

f§f(.ij Intangibles and intellectual property 

59. Doe,.t'he debtor have any interests in intangibles or intellectual property? 

ilY'No. Go to Part 11. 

D Yes. Fill in the information below. 

General description 

60. Patents, copyrights, trademarks, and trade secrets 

61. Internet domain names and websites 

62. Licenses, franchises, and royalties 

63. Customer lists, mailing lists, or other compilations 

64. Other intangibles, or intellectual property 

65. Goodwill 

66. Total of Part 10. 

Add lines 60 through 65. Copy the total to line 89. 

Net book value of 

debtor's interest 

(Where available) 

$ _____ _ 

$. _____ _ 

$ _____ _ 

$. _____ _ 

$. _____ _ 

$. _____ _ 

Valuation method 

used for current value 

Official Form 206A/B Schedule AlB: Assets- Real and Personal Property 

Current value of 

debtor's interest 

$ ______ _ 

$ _______ _ 

$ _______ _ 

$ _______ _ 

Current value of 

debtor's interest 

$. ______ _ 

$. ______ _ 

$. ______ _ 

$ ______ _ 

$. ______ _ 

$. ______ _ 

$ ______ _ 

page 6 
Debtor Case number (if known) ______________ _ 

Name 

67. Do your lists or records include personally identifiable information of customers (as defined in 11 U.S.C. §§ 101(41A) and 107)? 

D No 

D Yes 

68. Is there an amortization or other similar schedule available for any of the property listed in Part 1 0? 

D No 

D Yes 

69. Has any of the property listed in Part 10 been appraised by a professional within the last year? 

D No 

D Yes fbfll JUI other assets 

70. Does the debtor own any other assets that have not yet been reported on this form? 

lnc~e all interests in executory contracts and unexpired leases not previously reported on this form. 

Ef No. Go to Part 12. 

D Yes. Fill in the information below. 

71. Notes receivable 

Description (include name of obligor) 

Total face amount doubtful or uncollectible amount 

72. Tax refunds and unused net operating losses (NOLs) 

Description (for example, federal, state, local) 

=-+ 

Tax year ___ _ 

73. Interests in insurance policies or annuities 

74. Causes of action against third parties (whether or not a lawsuit 

has been filed) 

Nature of claim 

Amount requested $ _____ _ 

75. Other contingent and unliquidated claims or causes of action of 

every nature, including counterclaims of the debtor and rights to 

set off claims 

Nature of claim 

Amount requested $ _____ _ 

76. Trusts, equitable or future interests in property 

77. Other property of any kind not already listed Examples: Season tickets, 

country club membership 

78. Total of Part 11. 

Add lines 71 through 77. Copy the total to line 90. 

Tax year ___ _ 

Tax year ___ _ 

79. Has any of the property listed in Part 11 been appraised by a professional within the last year? 

D No 

D Yes 

Official Form 206A/B Schedule AlB: Assets- Real and Personal Property 

Current value of 

debtor's interest 

$ ______ _ 

$. ______ _ 

$ ______ _ 

$ ______ _ 

$ _______ _ 

$ _______ _ 

$ ________ _ 

$. _______ _ 

$ ______ _ 

$ ______ _ 

page 7 
Debtor Case number (if known), _____________ _ 

Name 

Summary 

In Part 12 copy all of the totals from the earlier parts of the form. 

Type of property 

80. Cash, cash equivalents, and financial assets. Copy line 5, Part 1. 

81. Deposits and prepayments. Copy line 9, Part 2. 

82. Accounts receivable. Copy line 12, Part 3. 

83. Investments. Copy line 17, Part 4. 

84. Inventory. Copy line 23, Part 5. 

85. Farming and fishing-related assets. Copy line 33, Part 6. 

86. Office furniture, fixtures, and equipment; and collectibles. 

Copy line 43, Part 7. 

87. Machinery, equipment, and vehicles. Copy line 51, Part 8. 

Current value of 

personal property 

$ ____ _ 

$ ____ _ 

$ ____ _ 

$ ____ _ 

$ ____ _ 

$ ____ _ 

$ ____ _ 

$ ____ _ 

88. Real property. Copy line 56, Part 9 ....................................................................................... -+ 

89. Intangibles and intellectual property. Copy line 66, Part 10. $ _____ _ 

90. All other assets. Copy line 78, Part 11. + $. ____ _ 

Current value 

of real property 

$ i, lOP, OOV 

91. Total. Add lines 80 through 90 for each column •............................ 91a. 

...__$-=--====---~1 + "'I· /,)Ill._,~ 

92. Total of all property on Schedule AlB. Lines 91 a + 91 b = 92 .............................................................................................. . 

Official Form 206A/B Schedule AlB: Assets- Real and Personal Property page 8 
Fill 1n this mformat1on to 1dent1fy the case: 

Debrorname ---------------------------------------------------

United States Bankruptcy Court for the: 

Case number (If known): 

Official Form 2060 

-------------------District of ="7'"7"---

(Siate) 

D Check if this is an 

amended filing 

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

Be as complete and accurate as possible. 

1. Do any creditors have claims secured by debtor's property? 

CljNo. Check this box and submit page 1 of this form to the court with debtor's other schedules. Debtor has nothing else to report on this form. 

a' Yes. Fill in all of the information below. 

List Creditors Who Have Secured Claims 

2. List in alphabetical order all creditors who have secured claims. If a creditor has more than one 

secured claim, list the creditor separately for each claim. 

Describe debtor's property that is subject to a lien 

Column A Column B 

Amount of claim Value of collateral 

Do not deduct the value that supports this 

of collateral. claim 

fJI CtJitor's namei'la ce04 Ml::.. '}.WD .S-+~ ~ $ i,t~O,Pr:D 

Creditor's mailing addre~..J .1'1 

-ziD tJ\t.J 7z: -LJ-Jv e t~41ttAt·' F& :JJJZ.i 

Creditor's email address, if known 

Date debt was incurred 

Last 4 digits of account 

number 

Do multiple creditors have an interest in the 

!lli'P property? 

C3'No 

[J Yes. Specify each creditor, including this creditor, 

and its relative priority. 

fiJ Creditor's name 

Creditor's mailing address 

Creditor's email address, if known 

Date debt was incurred 

Last 4 digits of account 

number 

Do multiple creditors have an interest in the 

same property? 

D No 

D Yes. Have you already specified the relative 

priority? 

D No. Specify each creditor, including this 

creditor, and its relative priority. 

D Yes. The relative priority of creditors is 

..... ~JlE!C:ifit)dOr11Lne.s __ 

610 fczz.~ [-E~c::.-t- F rt...... Fe_ 

UMt~~ I c;-c,;-L 1 kL 

Describe the lien /leaf_ r:_;fW M6/l 

Is t!)e creditor an insider or related party? 

Ef"No 

[J Yes 

'!YJYOne else liable on this claim? 

l!f No 

-

D Yes. Fill out Schedule H: Codebtors (Official Form 206H). 

As of the petition filing date, the claim is: 

Check all that apply. 

Dfoontingent 

El Unliquidated 

D Disputed 

Describe debtor's property that is subject to a lien 

___________________________________ $. __________ __ 

Describe the lien 

Is the creditor an insider or related party? 

D No 

DYes 

Is anyone else liable on this claim? 

D No 

D Yes. Fill out Schedule H: Codebtors (Official Form 206H). 

As of the petition filing date, the claim is: 

Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

3. Total of the dollar amounts from Part 1, Column A, including the amounts from the Additional $. ______ __ 

Official Form 2060 Schedule D: Creditors Who Have Claims Secured by Property 

$ __________ _ 

page 1 of_ 
Debtor Case number (if known)'--------------- Name 

ColumnA Column 8 

Additional Page Amount of claim Value of collateral 

---..... ------------------------------------- Do not deduct the value that supports this 

of collateral. claim 

Copy this page only If more space is needed. Continue numbering the lines sequentially from the 

previous page. 

§J Creditor's name 

Creditor's mailing address 

Creditor's email address, if known 

Date debt was incurred 

Last 4 digits of account 

number 

Do multiple creditors have an interest in the 

same property? 

0 No 

0 Yes. Have you already specified the relative 

priority? 

0 No. Specify each creditor, including this 

creditor, and its relative priority. 

0 Yes. The relative priority of creditors is 

specified on lines __ 

name 

Creditor's mailing address 

Creditor's email address, if known 

Date debt was incurred 

Last 4 digits of account 

number 

Do multiple creditors have an interest in the 

same property? 

0 No 

0 Yes. Have you already specified the relative 

priority? 

0 No. Specify each creditor, including this 

creditor, and its relative priority. 

0 Yes. The relative priority of creditors is 

specified on lines __ 

Describe debtor's property that is subject to a lien 

------------------------------------$. ___________ _ 

Describe the lien 

Is the creditor an insider or related party? 

0 No 

0 Yes 

Is anyone else liable on this claim? 

0 No 

0 Yes. Fill out Schedule H: Codebtors (Official Form 206H). 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Describe debtor's property that is subject to a lien 

-------------------$ ·------

Describe the lien 

Is the creditor an insider or related party? 

0 No 

0 Yes 

Is anyone else liable on this claim? 

0 No 

0 Yes. Fill out Schedule H: Codebtors (Official Form 206H). 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Official Form 2060 Additional Page of Schedule D: Creditors Who Have Claims Secured by Property 

$ _____ _ 

$, ______ _ 

page_of_ 
'Debtor Case number (it known)•--------------- Name 

List Others to Be Notified for a Debt Already Listed in Part 1 

List in alphabetical order any others who must be notified for a debt already listed in Part 1. Examples of entities that may be listed are collection 

agencies, assignees of claims listed above, and attorneys for secured creditors. 

If no others need to be notified for the debts listed in Part 1, do not fill out or submit this page. If additional pages are needed, copy this page. 

Name and address 

~J E(.... 21JZ6 

On which line in Part 1 

did you enter the 

related creditor? 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Line 2. 

Last 4 digits of 

account number 

for this entity 

~~---- ·----···-

Line 2. 

Line 2. 

Form 2060 Official Part 2 of Schedule D: Creditors Who Have Claims Secured by Property page_of_ 
Fill in this informatiOn to identify the case: 

Debtor 

United States Bankruptcy Court for the: ----------District of-:=--:-:----

(Slate) 

Case number 

(If known) 

Official Form 206E/F 

Schedule E/F: Creditors Who Have Unsecured Claims 

D Check if this is an 

amended filing 

12/15 

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

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

on Schedule AlB: Assets- Real and Personal Property (Official Form 206AIBJ and on Schedule G: Executory Contracts and Unexpired Leases 

(Official Form 206G). Number the entries in Parts 1 and 2 in the boxes on the left. If more space is needed for Part 1 or Part 2, fill out and attach 

the Additional Page of that Part included in this form. 

List All Creditors with PRIORITY Unsecured Claims 

1. Do_.ilny creditors have priority unsecured claims? (See 11 U.S.C. § 507). 

ef No. Go to Part 2. 

0 Yes. Go to line 2. 

2. List in alphabetical order all creditors who have unsecured claims that are entitled to priority in whole or in part. If the debtor has more than 

3 creditors with priority unsecured claims, fill out and attach the Additional Page of Part 1. 

~~- Priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account 

number 

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S. C. § 507(a) L_) 

IJ Priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account 

number 

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) L_) 

IJ Priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account 

number 

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) L_) 

Total claim 

As of the petition filing date, the claim is: $ 

Check all that apply. ---------

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: 

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: $ 

Check all that apply. ---------

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: 

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: $ 

Check all that apply. ·---------

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: 

Is the claim subject to offset? 

0 No 

0 Yes 

Official Form 206EIF Schedule E/F: Creditors Who Have Unsecured Claims 

Priority amount 

$ _____ _ 

$ _____ _ 

$. _____ _ 

page 1 of_ 
Debtor Case number (if known). ______________ _ 

Name 

Additional Page 

Copy this page if more space is needed. Continue numbering the lines sequentially from the 

previous page. If no additional PRIORITY creditors exist, do not fill out or submit this page. 

D Priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account 

number 

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) (_) 

D Priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account 

number 

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) (_) 

D Priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account 

number 

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) (_) 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: 

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: 

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: 

Is the claim subject to offset? 

0 No 

0 Yes 

Total claim 

$ ______________ ___ 

$ _______ _ 

$ _______ _ 

k- I Priority creditor's name and mailing address 

As of the petition filing date, the claim is: $ ________ __ 

Check all that apply. 

------------------ 0 Contingent 

Date or dates debt was incurred 

Last 4 digits of account 

number 

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) (_) 

0 Unliquidated 

0 Disputed 

Basis for the claim: 

Is the claim subject to offset? 

0 No 

0 Yes 

Official Form 206EIF Schedule ElF: Creditors Who Have Unsecured Claims 

Priority amount 

$. __________ _ 

$. _____ _ 

$. _____ _ 

$. _____ _ 

page_of ___ 
Debtor Case number (if known) ______________ _ 

Name 

List All Creditors with NON PRIORITY Unsecured Claims 

3. List in alphabetical order all of the creditors with nonpriority unsecured claims. If the debtor has more than 6 creditors with nonpriority 

unsecured claims, fill out and attach the Additional Page of Part 2. 

B Non priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

3.2 Non priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

Nonpriority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

Nonpriority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

Nonpriority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

Nonpriority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: _________ __ 

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: _________ __ 

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Amount of claim 

$ ____________________ __ 

$ ________________ __ 

$ ____________________ __ 

Basis for the claim:-----------

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim:-----------

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim: _________ __ 

Is the claim subject to offset? 

0 No 

0 Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

0 Contingent 

0 Unliquidated 

0 Disputed 

Basis for the claim:-----------

Is the claim subject to offset? 

0 No 

0 Yes 

$ ______________ __ 

$ _______________ __ 

$ ______________________ _ 

Official Form 206EJF Schedule ElF: Creditors Who Have Unsecured Claims page_of_ 
Debtor Case number (ifknown)1 ______________ _ 

Name 

Additional Page 

Copy this page only if more space Is needed. Continue numbering the lines sequentially from the 

previous page. If no additional NON PRIORITY creditors exist, do not fill out or submit this page. 

Amount of claim 

13. I Non priority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

L=J n Nonpriority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

As of the petition filing date, the claim is: 

Check all that apply 

Q Contingent 

D Unliquidated 

D Disputed 

D Liquidated and neither contingent nor 

disputed 

Basis for the claim:----------

Is the claim subject to offset? 

D No 

D Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

$. ________________ __ 

$. ____________________ __ 

Basis for the claim: _________ _ 

Is the claim subject to offset? 

D No 

D Yes 

. --------··-----------------------------------·-·-----~~--· ···-·········----·······---··-----·-···-·······--------------------------·-··· 

Nonpriority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

As of the petition filing date, the claim is: 

Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

Basis for the claim:----------

Is the claim subject to offset? 

D No 

D Yes 

$. _________ __ 

liJ Non priority -~redito-;:;-;~ame and-mailing addres·s------··--~-s-of-t~e-pe-::-n -fi;i~g d-at_e_, -th_e_c-la_i_m_i-s:·--------------···-·---------------·-·· 

Check all that apply. $. ____________ _ 

Date or dates debt was incurred 

Last 4 digits of account number 

Nonpriority creditor's name and mailing address 

Date or dates debt was incurred 

Last 4 digits of account number 

D Contingent 

D Unliquidated 

D Disputed 

Basis for the claim:----------

Is the claim subject to offset? 

D No 

0 Yes 

As of the petition filing date, the claim is: 

Check all that apply. 

D Contingent 

D Unliquidated 

D Disputed 

Basis for the claim: _________ _ 

Is the claim subject to offset? 

D No 

0 Yes 

Official Form 206EIF Schedule ElF: Creditors Who Have Unsecured Claims 

$. __________________ __ 

page_of __ 
Debtor Case number (if known), ______________ _ 

Name 

List Others to Be Notified About Unsecured Claims 

4. List in alphabetical order any others who must be notified for claims listed in Parts 1 and 2. Examples of entities that may be listed are collection agencies, 

assignees of claims listed above, and attorneys for unsecured creditors. 

If no others need to be notified for the debts listed in Parts 1 and 2, do not fill out or submit this page. If additional pages are needed, copy the next page. 

Name and mailing address On which line in Part 1 or Part 2 is the Last 4 digits of 

related creditor (If any) listed? account number, if 

any 

4.1. Line 

0 Not listed. Explain ----

4.2. Line 

0 Not listed. Explain ----

4.3. Line 

0 Not listed. Explain ----

4.4. Line 

0 Not listed. Explain ----

41. Line 

0 Not listed. Explain ----

uu•--------·----•• 

4.5. Line 

0 Not listed. Explain ----

4.6. Line 

0 Not listed. Explain ----

4.7. Line 

0 Not listed. Explain ----

4.8. Line 

0 Not listed. Explain ----

4.9. Line 

0 Not listed. Explain ----

4.10. Line 

0 Not listed. Explain ----

4.11. 

Line 

0 Not listed. Explain ----

Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page_of_ 
Debtor Case number (if known), ______________ _ 

Name 

Additional Page for Others to Be Notified About Unsecured Claims 

Name and mailing address 

4 

4. 

4. 

4 

4 

4 

4 

4. 

4. 

4._ 

4. 

4 

4._ 

4 

Official Form 206EIF 

On which line in Part 1 or Part 2 is the 

related creditor (if any) listed? 

Line 

0 Not listed. Explain _____ _ 

Line 

0 Not listed. Explain _____ _ 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Line 

0 Not listed. Explain 

Schedule E/F: Creditors Who Have Unsecured Claims 

Last 4 digits of 

account number, 

if any 

page_of_ 
Debtor Name 

Total Amounts of the Priority and Non priority Unsecured Claims 

5. Add the amounts of priority and nonpriority unsecured claims. 

sa. Total claims from Part 1 

Sb. Total claims from Part 2 

Sc. Total of Parts 1 and 2 

Lines Sa + 5b = 5c. 

Case number (if known), ______________ _ 

Total of claim amounts 

Sa. 

$ __________________ _ 

Sb. + $. __________ __ 

Sc. $ __________ __ 

Official Form 206EIF Schedule ElF: Creditors Who Have Unsecured Claims page __ of_ 
F1ll m this information to identify the case: 

Debtor name --------------------------

United States Bankruptcy Court for the: __________ District of 

Case number (If known): Chapter 

Official Form 206G 

(~ 

D Check if this is an 

amended filing 

Schedule G: Executory Contracts and Unexpired Leases 12/15 

Be as cqmplete and accurate as possible. If more space is needed, copy and attach the additional page, numbering the entries consecutively. 

1. Dls the debtor have any executory contracts or unexpired leases? 

;;r'No. Check this box and file this form with the court with the debtor's other schedules. There is nothing else to report on this form. 

0 Yes. Fill in all of the information below even if the contracts or leases are listed on Schedule AlB: Assets - Real and Personal Property (Official 

Form 206A/B). 

2. List all contracts and unexpired leases State the name and mailing address for all other parties with 

whom the debtor has an executory contract or unexpired lease 

State what the contract or 

2.1 lease is for and the nature 

of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

State what the contract or 

2.2 . lease is for and the nature 

of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

State what the contract or 

2.3 . lease is for and the nature 

of the debtor's interest 

2.4 

State the term remaining 

List the contract number of 

any government contract 

State what the contract or 

lease is for and the nature 

of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

State what the contract or 

2.5 • lease is for and the nature 

of the debtor's interest 

State the term remaining 

Official Form 206G 

----·----·-··-·· ----·-~ 

Schedule G: Executory Contracts and Unexpired Leases page 1 of_ 
Debtor Case number (if known) ______________ _ 

Name 

. Additional Page if Debtor Has More Executory Contracts or Unexpired Leases 

Copy this page only if more space is needed. Continue numbering the lines sequentially from the previous page. 

List all contracts and unexpired leases State the name and mailing address for all other parties with 

whom the debtor has an executory contract or unexpired lease 

State what the contract or 

2._ lease is for and the nature 

of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

State what the contract or 

2._ lease is for and the nature 

of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

---~·····-~·----·-------·-··~········-----···--···-- ····-····················-···--···--··-··-····-·-········--·····-····---·--·-----J 

State what the contract or 

2. lease is for and the nature - of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

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

State what the contract or 

lease is for and the nature 

of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

.--. 

State what the contract or 

2. lease is for and the nature -. of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

State what the contract or 

lease is for and the nature 

of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract 

State what the contract or 

2 lease is for and the nature 

of the debtor's interest 

State the term remaining 

List the contract number of 

any government contract ···················-···-···· 

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases page_of_ 
Fill m thts mformatton to identify the case: 

Debtorname --------------------------

United States Bankruptcy Court for the: __________ District of-::::::-:-:---

(State) 

Case number (If known): 

Official Form 206H 

Schedule H: Codebtors 

CJ Check if this is an 

amended filing 

12/15 

Be as complete and accurate as possible. If more space is needed, copy the Additional Page, numbering the entries consecutively. Attach 

the Additional Page to this page. 

1. Dqes the debtor have any codebtors? 

1!::'1 No. Check this box and submit this form to the court with the debtor's other schedules. Nothing else needs to be reported on this form. 

0 Yes 

2. In Column 1, list as codebtors all of the people or entitles who are also liable for any debts listed by the debtor in the schedules of 

creditors, Schedules D-G. Include all guarantors and co-obligors. In Column 2, identify the creditor to whom the debt is owed and each 

schedule on which the creditor is listed. If the codebtor is liable on a debt to more than one creditor, list each creditor separately in Column 2. 

Column 1: Codebtor 

Name Mailing address 

2.1 

Street 

City 

2.2 

Street 

City 

2.3 

Street 

·------·-.... ·-----· 

2.4 

Street 

2.5 

Street 

City 

2.6 

Street 

City 

Official Form 206H 

State ZIP Code 

State ZIP Code 

State ZIP Code 

State ZIP Code 

Schedule H: Codebtors 

Column 2: Creditor 

Name Check all schedules 

that apply: 

0 D 

0 ElF 

0 G 

0 D 

0 ElF 

0 G 

0 D 

0 ElF 

0 G 

0 D 

0 ElF 

0 G 

0 D 

0 ElF 

0 G 

0 D 

0 E/F 

0 G 

page 1 of_ 
• Debtor • Case number (if known) ______________ _ 

Name 

Additional Page if Debtor Has More Codebtors 

Copy this page only if more space Is needed. Continue numbering the lines sequentially from the previous page. 

Column 1: Codebtor 

Name Mailing address 

2. 

Street 

City 

2. 

Street 

City 

2 

Street 

City 

2._ 

Street 

City 

2._ 

Street 

City 

2._ 

Street 

City 

2._ 

Street 

City 

2. -

Street 

City 

Official Form 206H 

State ZIP Code 

State ZIP Code 

State ZIP Code 

State ZIP Code 

State ZIP Code 

State ZIP Code 

State ZIP Code 

State ZIP Code 

Schedule H: Codebtors 

Column 2: Creditor 

Name Check all schedules 

that apply: 

r:J D 

r:J ElF 

r:J G 

r:J D 

r:J E/F 

r:J G 

r:J D 

r:J ElF 

r:J G 

r:J D 

r:J ElF 

r:J G 

r:J D 

r:J ElF 

r:J G 

r:J D 

r:J ElF 

r:J G 

r:J D 

r:J ElF 

r:J G 

r:J D 

r:J ElF 

r:J G 

page_of_ 
Fill in this information to Identify the case and this f1ling: 

Debtor Name-------------------------

United States Bankruptcy Court for the: ----------District of=-:-:---

(State) 

Case number (If known): 

Official Form 202 

Declaration Under Penalty of Perjury for Non-Individual Debtors 

An individual who is authorized to act on behalf of a non-individual debtor, such as a corporation or partnership, must sign and submit 

this form for the schedules of assets and liabilities, any other document that requires a declaration that is not included in the document, 

and any amendments of those documents. This form must state the individual's position or relationship to the debtor, the identity of the 

document, and the date. Bankruptcy Rules 1008 and 9011. 

12/15 

WARNING - Bankruptcy fraud is a serious crime. 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 $500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 

1519, and 3571. 

Declaration and signature 

I am the president, another officer, or an authorized agent of the corporation; a member or an authorized agent of the partnership; or 

another individual serving as a representative of the debtor in this case. 

I have examined the information in the documents checked below and I have a reasonable belief that the information is true and correct: 

D Schedule AlB: Assets-Real and Personal Property (Official Form 206AIB) 

D Schedule D: Creditors Who Have Claims Secured by Property (Official Form 2060) 

D Schedule ElF: Creditors Who Have Unsecured Claims (Official Form 206EIF) 

D Schedule G: Executory Contracts and Unexpired Leases (Official Form 206G) 

D Schedule H: Codebtors (Official Form 206H) 

D Summary of Assets and Liabilities for Non-Individuals (Official Form 206Sum) 

D Amended Schedule 

D Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims and Are Not Insiders (Official Form 204) 

D Other document that requires a declaration. _______________________________ _ 

I declare under penalty of perjury that the foregoing is true and correct. 

Executed on (}1)'1> 1J) 1{ 

MM/DD/YYYY 

Official Form 202 

Signature of individu I · ning on behalf of debtor 

. (1~ '\&C'WI\ 

Pnnted name 

/2M 

Position or relationshiJ)tO'debtor 

Declaration Under Penalty of Perjury for Non-Individual Debtors 
2 

3 

4 

5 

6 

7 

8 

Fill in this mformation to identtfy the case: 

Debtor name -------------------------

United States Bankruptcy Court for the: ----------District of-:::::-:-:---

(State) 

Case number (If known): 

Official Form 20_4 

D Check if this is an 

amended filing 

Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest 

Unsecured Claims and Are Not Insiders 12/15 

A list of creditors holding the 20 largest unsecured claims must be filed in a Chapter 11 or Chapter 9 case. Include claims which the debtor 

disputes. Do not include claims by any person or entity who is an insider, as defined in 11 U.S. C.§ 101(31). Also, do not include claims by 

secured creditors, unless the unsecured claim resulting from inadequate collateral value places the creditor among the holders of the 20 

largest unsecured claims. 

Name of creditor and complete 

mailing address, including zip code 

/Jo Ut'U~v~ 

{,f"~itorj k j-/~ 

Name, telephone number, and 

email address of creditor 

contact 

Nature of the claim 

(for example, trade 

debts, bank loans, 

professional 

services, and 

government 

contracts) 

Indicate if Amount of unsecured claim 

claim is If the claim is fully unsecured, fill in only unsecured 

contingent, claim amount. If claim is partially secured, fill in 

unliquidated, total claim amount and deduction for value of 

or disputed . collateral or setoff to calculate unsecured claim. 

Total claim, if 

partially 

secured 

Deduction for 

value of 

collateral or 

setoff 

Unsecured 

claim 

Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 1 
9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

Debtor Name 

Name of creditor and complete 

mailing address, including zip code 

Name, telephone number, and 

email address of creditor 

contact 

Nature of the claim 

(for example, trade 

debts, bani< loans, 

professional 

services, and 

government 

contracts) 

Case number lit known>'---------------

Indicate if Amount of unsecured claim 

claim is lfthe claim is fully unsecured, fill in only unsecured 

co'!tin!J&nt, claim amount. If claim is partially secured, fill in 

unliquidated, total claim amount and deduction for value of 

or disputed : collateral or setoff to calculate unsecured claim. 

Total claim, if 

partially 

secured 

Deduction for 

value of 

collateral or 

setoff 

Unsecured 

claim 

Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 2 
Fill in this information to identify the case: 

Debtor name --------------------------

Unrted States Bankruptcy Court for the: ----------District of=:--:-:---

(State) 

Case number (If known): 

Official Form 207 

0 Check if this is an 

amended filing 

Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy 04/19 

The debtor must answer every question. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, 

write the debtor's name and case number (if known). 

·Income 

1. G,Ss revenue from business 

f!6 None 

Identify the beginning and ending dates of the debtor's fiscal year, which 

may be a calendar year 

From the beginning of the 

fiscal year to filing date: From to Filing date MM/DD/YYYY 

For prior year: From to MM/DD/YYYY MM/DD/YYYY 

For the year before that: From to MM/ DD/YYYY MM/DD/YYYY 

2. Non-business revenue 

Sources of revenue 

Check all that apply 

0 Operating a business 

0 Other---------

0 Operating a business 

0 Other ---------

0 Operating a business 

0 Other _______ _ 

Gross revenue 

(before deductions and 

exclusions) 

$ ____ _ 

$ ____ _ 

$ ____ _ 

Include revenue regardless of whether that revenue is taxable. Non-business income may include interest, dividends, money collected troT lawsuits. and royalties. List each source and the gross revenue for each separately. Do not include revenue listed in line 1. 

fii None 

Description of sources of revenue 

From the beginning of the 

fiscal year to filing date: From to Filing date MM/DD/YYYY 

For prior year: From to MM/DD/YYYY MM/DD/YYYY 

For the year before that: From to MM/DD/YYYY MM/DD/YYYY 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy 

Gross revenue from each 

source 

(before deductions and 

exclusions) 

$. _____ _ 

$. _____ _ 

$. _____ _ 

page 1 
Debtor Case number (if known), ______________ _ 

Name 

EMFJ List Certain Transfers Made Before Filing for Bankruptcy 

I 

i 3. Certain payments or transfers to creditors within 90 days before filing this case 

List p yments or transfers---including expense reimbursements-to any creditor, other than regular employee compensation, within 90 

day before filing this case unless the aggregate value of all property transferred to that creditor is less than $6,825. (This amount may be 

adj sted on 4/01/22 and every 3 years after that with respect to cases filed on or after the date of adjustment.) 

Creditor's name and address Dates 

3.1. 

Creditors name 

Street 

City State ZIP Code 

3.2. 

Creditors name 

Street 

City State ZIP Code 

Total amount or value 

$ _____ _ 

$ ____ _ 

Reasons for payment or transfer 

Check all that apply 

0 Secured debt 

0 Unsecured loan repayments 

0 Suppliers or vendors 

0 Services 

0 Other 

0 Secured debt 

0 Unsecured loan repayments 

0 Suppliers or vendors 

0 Services 

0 Other 

4. Payments or other transfers of property made within 1 year before filing this case that benefited any insider 

List payments or transfers, including expense reimbursements, made within 1 year before filing this case on debts owed to an insider or 

guaranteed or cosigned by an insider unless the aggregate value of all property transferred to or for the benefit of the insider is less than 

$6,825. (This amount may be adjusted on 4/01/22 and every 3 years after that with respect to cases filed on or after the date of adjustment.) 

Do not include any payments listed in line 3. Insiders include officers, directors, and anyone in control of a corporate debtor and their relatives; 

;1,n ral partners of a partnership debtor and their relatives; affiliates of the debtor and insiders of such affiliates; and any managing agent of 

the ebtor. 11 U.S.C. § 101(31). 

None 

Insider's name and address Dates Total amount or value Reasons for payment or transfer 

4.1. 

$. _____ _ 

Insiders name 

Street 

City State ZIP Code 

Relationship to debtor 

4.2. 

$. _____ _ Insider's name 

Street 

City State ZIP Code 

Relationship to debtor 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 2 
Debtor Case number (if known)'--------------- Name 

sessions, foreclosures, and returns 

List all property of the debtor that was obtained by a creditor within 1 year before filing this case, including property repossessed by a creditor, 

sol at a foreclosure sale, transferred by a deed in lieu of foreclosure, or returned to the seller. Do not include property listed in line 6. 

Creditor's name and address Description of the property Date Value of property 

5.1. 

Creditors name 

$ ___ _ 

Street 

City State ZIP Code 

5.2. 

Creditors name 

$ ___ _ 

Street 

City State ZIP Code 

&. Setoffs 

L" t ny creditor, including a bank or financial institution, that within 90 days before filing this case set off or otherwise took anything from an account of 

ebtor without permission or refused to make a payment at the debtor's direction from an account of the debtor because the debtor owed a debt. 

one 

Creditor's name and address 

Creditors name 

Street 

I 

I 1 City State Zl P Code 

Iii' Legal Actions or Assignments 

Description of the action creditor took 

Last 4 digits of account number: XXXX- ___ _ 

Date action was 

taken 

! 7. Legal actions, administrative proceedings, court actions, executions, attachments, or governmental audits 

Amount 

$ __ _ 

List the legal actions, proceedings, investigations, arbitrations, mediations, and audits by federal or state agencies in which the debtor 

was involved in any capacity-within 1 year before filing this case. 

0 None 

Case title 

Case number 

Case title 

7.2. 

Case number 

Official Form 207 

Nature of case Court or agency's name and address 

City 

Court or agency's name and address 

Name 

Street 

City State 

Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy 

ZIP Code 

ZIP Code 

Status of case 

~nding 

D On appeal 

0 Concluded 

0 Pending 

D On appeal 

0 Concluded 

page 3 
Debtor Case number (if known)·--------------- Name 

s. Assignments and receivership 

L. t y property in the hands of an assignee for the benefit of creditors during the 120 days before filing this case and any property in the 

of a receiver, custodian, or other court-appointed officer within 1 year before filing this case. 

one 

Custodian's name and address Description of the property Value 

$. ____ _ 

Custodian's name 

Case title Court name and .address 

Street 

Name 

Case number 

City State ZIP Code Street 

Date of order or assignment 

City State ZIP Code 

Certain Gifts and Charitable Contributions 

9. L~"st a I gifts or charitable contributions the debtor gave to a recipient within 2 years before filing this case unless the aggregate value 

oft gifts to that recipient is less than $1,000 

None 

Recipient's name and address Description of the gifts or contributions 

9

·

1

· Recipienrs name 

Street 

City State ZIP Code 

Recipient's relationship to debtor 

9·2· Recipienfs name 

Street 

City State ZIP Code 

Recipient's relationship to debtor 

; 

,,,, Certain Losses 

1

110. Alll~ses from fire, theft, or other casualty within 1 year before filing this case. 

~one 

I Description of the property lost and how the loss I occurred 

I 

Amount of payments received for the loss 

if you have received payments to cover the loss, for 

example, from insurance, government compensation, or 

tort liability, list the total received. 

List unpaid claims on Official Fonm 1 06A/B (Schedule AIS: 

Assets- Real and Personal Property). 

Dates given 

Date of loss 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy 

Value 

$ __ _ 

$ __ _ 

Value of property 

lost 

$. ___ _ 

page4 
Debtor Case number (if known), ______________ _ 

Name 

Certain Payments or Transfers 

11. Payments related to bankruptcy 

List any payments of money or other transfers of property made by the debtor or person acting on behalf of the debtor within 1 year before 

the filing of this case to another person or entity, including attorneys, that the debtor consulted about debt consolidation or restructuring, 

seekijg bankruptcy relief, or filing a bankruptcy case. 

~one 

Who was paid or who received the transfer? If not money, describe any property transferred 

11.1. 

Address 

Street 

City State ZIP Code 

Email or website address 

Who made the payment, if not debtor? 

Who was paid or who received the transfer? If not money, describe any property transferred 

11.2. 

Address 

Street 

City State ZIP Code 

Email or website address 

Who made the payment, if not debtor? 

12. Self-settled trusts of which the debtor is a beneficiary 

Dates 

Dates 

Total amount or 

value 

$. __ _ 

Total amount or 

value 

$. __ _ 

List any payments or transfers of property made by the debtor or a person acting on behalf of the debtor within 10 years before the filing of this case to 

a self-settled trust or similar device. 

Do ~ include transfers already listed on this statement. 

~None 

Name of trust or device Describe any property transferred Dates transfers Total amount or 

were made value 

$ __ _ 

Trustee 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 5 
Debtor Case number (if known)'--------------- Name 

13. Transfers not already listed on this statement 

List any transfers of money or other property--by sale, trade, or any other means-made by the debtor or a person acting on behalf of the debtor 

within 2 years before the filing of this case to another person, other than property transferred in the ordinary course of business or financial affairs. 

Include both outright transfers and transfers made as security. Do not include gifts or transfers previously listed on this statement. 

J-ane 

Who received transfer? Description of property transferred or payments received Date transfer 

or debts paid in exchange was made 

13.1. 

Address 

Street 

Crty State ZIP Code 

Relationship to debtor 

Who received transfer? 

13.2. 

Address 

Street 

City State ZIP Code 

Relationship to debtor 

·Previous Locations 

us addresses 

all previous addresses used by the debtor within 3 years before filing this case and the dates the addresses were used. 

Does not apply 

Address Dates of occupancy 

14.1 From 

Street 

City State ZIP Code 

14.2. From 

Street 

City State ZIP Code 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy 

Total amount or 

value 

$ ___ _ 

$. __ _ 

To 

To 

page 6 
Debtor Case number (if known) ______________ _ 

I 

Name 

Health Care Bankruptcies 

Is the debtor primarily engaged in offering services and facilities for: 

iagnosing or treating injury, deformity, or disease, or 

- roviding any surgical, psychiatric, drug treatment, or obstetric care? 

No. Go to Part 9. 

0 Yes. Fill in the information below. 

Facility name and address 

15.1. 

Facility name 

Street 

City State 

Facility name and address 

15.2. 

F ac11ity name 

Street 

City State 

ZIP Code 

ZIP Code 

Nature of the business operation, including type of services the 

debtor provides 

Location where patient records are maintained (if different from facility 

address). If electronic, identify any service provider. 

Nature of the business operation, including type of services the 

debtor provides 

Location where patient records are maintained (if different from facility 

address). If electronic, identify any service provider. 

- Personally Identifiable Information 

116. t:~he debtor collect and retain personally identifiable information of customers? 

1 No. 

If debtor provides meals 

and housing, number of 

patients in debtor's care 

How are records kept? 

Check all that apply: 

0 Electronically 

0 Paper 

If debtor provides meals 

and housing, number of 

patients in debtor's care 

How are records kept? 

Check all that apply: 

0 Electronically 

0 Paper 

1 0 Yes. State the nature of the information collected and retained. --------------------------

Does the debtor have a privacy policy about that information? 

0 No 

0 Yes 

17. w~·t .in 6 years before filing this case, have any employees of the debtor been participants in any ERISA, 401(k), 403(b), or other 

pe sion or profit-sharing plan made available by the debtor as an employee benefit? 

No. Go to Part 10. 

Yes. Does the debtor serve as plan administrator? 

0 No. Go to Part 10. 

0 Yes. Fill in below: 

Name of plan 

Has the plan been terminated? 

0 No 

0 Yes 

Employer identification number of the plan 

EIN: 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 7 
Debtor ( 11' Case number (if known), ______________ _ 

Name -

Certain Financial Accounts, Safe Deposit Boxes, and Storage Units 

18. Closed financial accounts 

Within 1 year before filing this case, were any financial accounts or instruments held in the debtor's name, or for the debtor's benefit, closed, sold, 

moved, or transferred? 

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

age houses, cooperatives, associations, and other financial institutions. 

ne 

Financial institution name and address 

18.1. 

Name 

Street 

City State ZIP Code 

18.2. 

Name 

Street 

City State ZIP Code 

Last 4 digits of account 

number 

XXXX-___ _ 

XXXX-___ _ 

Type of account 

0 Checking 

0 Savings 

0 Money market 

0 Brokerage 

0 Other ____ _ 

0 Checking 

0 Savings 

0 Money market 

0 Brokerage 

0 Other ____ _ 

Date account was 

closed, sold, moved, 

or transferred 

Last balance 

before closing or 

transfer 

$ ___ _ 

$ ___ _ 

L' I any safe deposit box or other depository for securities, cash, or other valuables the debtor now has or did have within 1 year before filing this case. 

19. te deposit boxes 

None 

Depository institution name and address 

Name 

Street 

City State ZIP Code 

20. Off-premises storage 

Names of anyone with access to it Description of the contents 

Address 

Does debtor 

still have it? 

0 No 

0 Yes 

·s any property kept in storage units or warehouses within 1 year before filing this case. Do not include facilities that are in a part of a building in 

wh ch the debtor does business. 

None 

Facility name and address 

Name 

Street 

City State 

Official Form 207 

Names of anyone with access to it Description of the contents 

Address 

ZIP Code 

Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy 

Does debtor 

still have it? 

DNo 

DYes 

page 8 
Debtor Case number (if known)•--------------- Name 

Property the Debtor Holds or Controls That the Debtor Does Not Own 

21. Property held for another 

;z·st ny property that the debtor holds or controls that another entity owns. Include any property borrowed from, being stored for, or held in 

tru . Do not list leased or rented property. 

None 

Owner's name and address Location of the property Description of the property Value 

$ __ 

Name 

Street 

State Zl P Code 

Details About Environmental Information 

For the purpose of Part 12, the following definitions apply: 

I • Environmental law means any statute or governmental regulation that concerns pollution, contamination, or hazardous material, 1 regardless of the medium affected (air, land, water, or any other medium). 

• Site means any location, facility, or property, including disposal sites, that the debtor now owns, operates, or utilizes or that the debtor 

formerly owned, operated, or utilized. 

• Hazardous material means anything that an environmental law defines as hazardous or toxic, or describes as a pollutant, contaminant, 

or a similarly harmful substance. 

Report all notices, releases, and proceedings known, regardless of when they occurred. 

22. Hajs the debtor been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders. 

~No 0 Yes. Provide details below. 

Case title 

Case number 

Court or agency name and address 

Name 

Street 

City State ZIP Code 

Nature of the case Status of case 

0 Pending 

0 On appeal 

0 Concluded 

23.1 any governmental unit otherwise notified the debtor that the debtor may be liable or potentially liable under or in violation of an 

e vironmental law? 

No 

0 Yes. Provide details below. 

Site name and address Governmental unit name and address Environmental law, If known Date of notice 

Name Name 

Street Street 

City State ZIP Code City State ZIP Code 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 9 
Debtor Case number (if known) _______________ _ 

Name 

the debtor notified any governmental unit of any release of hazardous material? 

No 

Yes. Provide details below. 

Site name and address Governmental unit name and address 

Name Name 

Street Street 

City State ZIP Code City State ZIP Code 

Environmental law, if known 

Details About the Debtor's Business or Connections to Any Business 

Date of notice 

25. ¥:r businesses in which the debtor has or has had an Interest 

Li any business for which the debtor was an owner, partner, member, or otherwise a person in control within 6 years before filing this case. 

I lude this information even if already listed in the Schedules. 

None 

Business name and address Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN. 

EIN: 25.1. 

Name Dates business existed 

Street 

From To 

CHy State ZIP Code 

25.2. Business name and address Describe the nature ofthe business Employer Identification number 

Do not include Social Security number or ITIN. 

EIN: 

Name Dates business existed 

Street 

From To 

City State ZIP Code 

Business name and address Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN. 

25.3. EIN: 

Name 

Dates business existed 

Street 

From To 

City State ZIP Code 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 10 
Debtor Case number (it known). ______________ _ 

Name 

26. Books, records, and financial statements 

2sa List all accountants and bookkeepers who maintained the debtor's books and records within 2 years before filing this case. 

D None 

Name and address Dates of service 

26a.1. From To 

Name 

Street 

City State ZIP Code 

Name and address Dates of service 

From 26a.2. To 

Name 

Street 

City State ZIP Code 

26b. List all firms or individuals who have audited, compiled, or reviewed debtor's books of account and records or prepared a financial 

statement within 2 years before filing this case. 

D None 

Name and address Dates of service 

From To 26b.1. 

Name 

Street 

City State ZIP Code 

Name and address Dates of service 

From To 26b.2. 

Name 

Street 

, City State ZIP Code 

26c. L t all finms or individuals who were in possession of the debtor's books of account and records when this case is filed. 

None 

Name and address If any books of account and records are 

unavailable, explain why 

26c.1. 

Name 

Street 

City State ZIP Code 

Official Fonm 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 11 
Debtor 

Name and address 

26c.2. 

Name 

Street 

City State 

Case number (it known), _______________ _ 

ZIP Code 

If any books of account and records are 

unavailable, explain why 

26d. L~·s all financial institutions, creditors, and other parties, including mercantile and trade agencies, to whom the debtor issued a financial statement 

wi in 2 years before filing this case. 

None 

Name and address 

26d.1. 

Name 

Street 

City State ZIP Code 

Name and address 

26d.2. 

Name 

Street 

City State ZIP Code 

27. Inventories 

Hte any inventories of the debtor's property been taken within 2 years before filing this case? 

f1 No 

0 Yes. Give the details about the two most recent inventories. 

Name of the person who supervised the taking of the inventory 

Name and address of the person who has possession of inventory records 

27.1. 

Name 

Street 

City State ZIP Code 

Date of 

inventory 

The dollar amount and basis (cost, market, or 

other basis) of each inventory 

$ _____ _ 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 12 
Debtor Name 

Name of the person who supervised the taking of the inventory 

Case number (if known), ______________ _ 

Date of 

inventory 

The dollar amount and basis (cost, market, or 

other basis) of each inventory 

$. ______ _ 

Name and address of the person who has possession of inventory records 

27.2. 

Name 

Street 

City State ZIP Code 

2B. List the debtor's officers, directors, managing members, general partners, members in control, controlling shareholders, or other 

people in control of the debtor at the time of the filing of this case. 

Name Address Position and nature of any 

interest 

"to of interest, if any 

29. w~· in 1 year before the filing of this case, did the debtor have officers, directors, managing members, general partners, members in control 

of he debtor, or shareholders in control of the debtor who no longer hold these positions? 

No 

0 Yes. Identify below. 

Name Address 

30. Payments, distributions, or withdrawals credited or given to insiders 

Position and nature of 

any interest 

Period during which 

position or interest was 

held 

From To 

From To 

From To 

From To 

in 1 year before filing this case, did the debtor provide an insider with value in any form, including salary, other compensation, draws, 

b uses, loans, credits on loans, stock redemptions, and options exercised? 

No 

0 Yes. Identify below. 

Name and address of recipient 

30.1. 

Name 

Street 

City 

Relationship to debtor 

Official Form 207 

State ZIP Code 

Amount of money or 

description and value of 

property 

Dates 

Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy 

Reason for 

providing the value 

page 13 
Debtor Case number (it known). ______________ _ 

Name 

Name and address of recipient 

30.2 

Name 

Street 

City State ZIP Code 

Relationship to debtor 

31. W (in 6 years before filing this case, has the debtor been a member of any consolidated group for tax purposes? 

~hNo 

0 Yes. Identify below. 

Name of the parent corporation Employer Identification number of the parent 

corporation 

EIN: __ -------

32. W~in 6 years before filing this case, has the debtor as an employer been responsible for contributing to a pension fund? 

!)"~0 

0 Yes. Identify below. 

Name of the pension fund Employer Identification number of the pension fund 

EIN: ________ _ 

Signature and Declaration 

WARNING-- Bankruptcy fraud is a serious crime. 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 $500,000 or imprisonment for up to 20 years, or both. 

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

I have examined the information in this Statement of Financial Affairs and any attachments and have a reasonable belief that the information 

is true and correct. 

I declare under penalty of perjury that the foregoing is true and correct. 

Executed on 

Printed name -+{l;~U~L ......... XC"tf"--'«.\~..,.;-· _____ _ Signature of i 

Arladditional pages to Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy (Official Form 207) attached? 

if~o 

0 Yes 

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 14 
{) CRo-VL fl&\. ~ 

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V\f-. )t ~vu) T L- tJ 3 1 2~