Official Form 106A/B

Schedule A/B: Property 12/15 

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

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

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?

 Check if this is an

amended filing

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

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.

What is the property?

Check all that apply.

















Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Other

Do not deduct secured claims or exemptions. Put the

amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

Current value of the

portion you own?

Describe the nature of your ownership

interest (such as fee simple, tenancy by the

entireties, or a life estate), if known.

Who has an interest in the property?

Check one.









Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property

(see instructions)

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

property identification number:

1.1.

Street address, if available, or other description

City State ZIP Code

County

3000 Island Blvd., #1905

$327,424.00 

Co-Owner

$327,424.00 

28-2210-070-1480

Aventura

Miami-Dade

FL 33160

Homestead property

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 1 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

What is the property?

Check all that apply.

















Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Other

Do not deduct secured claims or exemptions. Put the

amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

Current value of the

portion you own?

Describe the nature of your ownership

interest (such as fee simple, tenancy by the

entireties, or a life estate), if known.

Who has an interest in the property?

Check one.









Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property

(see instructions)

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

property identification number:

1.2.

County

$1,500.00 

Owner

$1,500.00 

01407BI

La Cabana Beach

JE Irausquin Blvd.

250 Oranjestad, Aruba

Timeshare

Debtor owns this timeshare in full.

What is the property?

Check all that apply.

















Single-family home

Duplex or multi-unit building

Condominium or cooperative

Manufactured or mobile home

Land

Investment property

Timeshare

Other

Do not deduct secured claims or exemptions. Put the

amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

Current value of the

portion you own?

Describe the nature of your ownership

interest (such as fee simple, tenancy by the

entireties, or a life estate), if known.

Who has an interest in the property?

Check one.









Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property

(see instructions)

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

property identification number:

1.3.

County

$1,500.00 

Co-Owner

$1,500.00 

21128AI

La Cabana Beach

JE Irausquin Blvd.

250 Oranjestad, Aruba

Timeshare

Debtor shares ownership with 2 other 

people. 

Value of property is approxately 

$4,500.00. Debtor's 1/3 interest is 

$1,500.00

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......................................................... $330,424.00 

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 2 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

Part 2: Describe Your Vehicles

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

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

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





No

Yes

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





No

Yes

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

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

entries for pages you have attached for Part 2. Write that number here......................................................... $0.00 

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





No

Yes. Describe.....

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

2 Sofas, 2 Chairs, Dining Room Set, 2 Bedroom sets, China Set, Kitchenware, $1,775.00 

Washer, Dryer, Refrigerator, Microwave, Oven, and Coffee Maker. The total 

value is $3,550.00 Debtor has half interest.

7. Electronics





No

Yes. Describe.....

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

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

3 Televisions, 2 Computers, Printer, 2 Cellphones, Homephone, and Camera $2,000.00 

8. Collectibles of value





No

Yes. Describe.....

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

Pictures and artwork $1,600.00 

9. Equipment for sports and hobbies





No

Yes. Describe.....

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

canoes and kayaks; carpentry tools; musical instruments

Bicycle $50.00 

10. Firearms





No

Yes. Describe.....

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

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 3 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

11. Clothes





No

Yes. Describe.....

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

Clothing, Shoes, and Accessories $850.00 

12. Jewelry





No

Yes. Describe.....

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

gold, silver

Wedding Ring. $874.00 

13. Non-farm animals





No

Yes. Describe.....

Examples: Dogs, cats, birds, horses

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





No

Yes. Give specific

did not list

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 the number here........................................................................................................  $7,149.00 

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





No

Yes....................................................................................................................................

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

petition

Cash: ..........................

17. Deposits of money

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

brokerage houses, and other similar institutions. If you have multiple accounts with the same





No

Yes............................

institution, list each.

Institution name:

$5,121.43 

17.1. Checking account: We Florida Financial Credit Union

Checking 5398-90

$260.44 

17.2. Savings account: We Florida Financial Credit Union

Savings account 5398-00

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:

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 4 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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

Name of entity: % of ownership:

information about

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

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

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





No

Issuer name:

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

Yes. Give specific

information about

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

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

Type of account: Institution name:

Yes. List each

account separately.

Retirement account: Fidelity Investments 403(b) $61,111.96 

22. Security deposits and prepayments

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

companies, or others





No

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

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

23. Annuities (A contract for a specific 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.





No

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

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

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





No

Yes. Give specific

powers exercisable for your benefit

information about them

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





No

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

Yes. Give specific

information about them

27. Licenses, franchises, and other general intangibles





No

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

Yes. Give specific

information about them

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 5 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

Money or property owed to you? Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

28. Tax refunds owed to you





No

Yes. Give specific information

about them, including whether

you already filed the returns

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

Federal:

State:

Local:

29. Family support





No

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

Yes. Give specific information Alimony:

Maintenance:

Support:

Divorce settlement:

Property settlement:

30. Other amounts someone owes you





No

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

Yes. Give specific information

compensation, Social Security benefits; unpaid loans you made to someone else

31. Interests in insurance policies





No

Yes. Name the insurance

Company name: Beneficiary:

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

Surrender or refund value: 

company of each policy

and list its value................

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





No

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

Yes. Give specific information

entitled to receive property because someone has died

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





No

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

Yes. Describe each claim........ Case #04-18250 CC 05 (06) $0.00 

Debtor has judgment against defendant, CS, in the amount of 

$15,011.00 in addition to legal fees and costs. Debtor hired the 

Law offices of Sprechman and Associates, to collect. 

Steven Sprechman, 2775 Northeast 163rd Street, Suite 100, 

North Miami Beach, Florida 33160; (305)-931-0100. 

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





No

rights to set off claims

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

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 6 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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.......................................................................................................  $66,493.83 

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.

38. Accounts receivable or commissions you already earned





No

Yes. Describe..

Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

39. Office equipment, furnishings, and supplies





No

Yes. Describe..

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones,

desks, chairs, electronic devices

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





No

Yes. Describe..

41. Inventory





No

Yes. Describe..

42. Interests in partnerships or joint ventures





No

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

43. Customer lists, mailing lists, or other compilations





No

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





No

Yes. Describe.....

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





No

Yes. Give specific information.

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

attached for Part 5. Write that number here.......................................................................................................  $0.00 

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 7 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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

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





No. Go to Part 7.

Yes. Go to line 47.

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

47. Farm animals





No

Yes....

Examples: Livestock, poultry, farm-raised fish

Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

48. Crops--either growing or harvested





No

Yes. Give specific

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

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





No

Yes....

50. Farm and fishing supplies, chemicals, and feed





No

Yes....

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

 No

 Yes. Give specific

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

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

attached for Part 6. Write that number here.......................................................................................................  $0.00 

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?





No

Yes. Give specific information.

Examples: Season tickets, country club membership

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

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 8 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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

55. Part 1: Total real estate, line 2..............................................................................................................................

56. Part 2: Total vehicles, line 5

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

58. Part 4: Total financial assets, line 36

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

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

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

62. Total personal property.

63. Total of all property on Schedule A/B.

Add lines 56 through 61..................

Copy personal

property total 

+

+

Add line 55 + line 62................................................................................

$330,424.00 

$0.00 

$7,149.00 

$66,493.83 

$0.00 

$0.00 

$0.00 

$73,642.83 $73,642.83 

$404,066.83 

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 9 of 47
Official Form 106C

Schedule C: The Property You Claim as Exempt 04/19 

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

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).

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)

 Check if this is an

amended filing

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.

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

Copy the value from

Schedule A/B

Amount of the 

exemption you claim

Check only one box for 

each exemption

Current value of Specific laws that allow exemption

the portion you 

own

Brief description:

Line from Schedule A/B:





1.1

$327,424.00 $327,424.00

3000 Island Blvd., #1905

Homestead property

Parcel: 28-2210-070-1480

Fla. Const. art. X § 4(a)(1); Fla. Stat. 

100% of fair market Ann. §§ 222.01, .02

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





6

$1,775.00 $1,000.00

2 Sofas, 2 Chairs, Dining Room Set, 2 

Bedroom sets, China Set, Kitchenware, 

Washer, Dryer, Refrigerator, Microwave, 

Oven, and Coffee Maker. The total value is 

$3,550.00 Debtor has half interest.

Fla. Const. art. X, § 4(a)(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 1 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 10 of 47
Case number (if known)

Part 2: Additional Page

Brief description of the property and line on

Schedule A/B that lists this property

Copy the value from

Schedule A/B

19-21842

Amount of the 

exemption you claim

Check only one box for 

each exemption

Current value of Specific laws that allow exemption

the portion you 

own

Debtor 1 Ana Maria Restrepo

Brief description:

Line from Schedule A/B:





17.1

$5,121.43 $5,121.43

We Florida Financial Credit Union

Checking 5398-90

Fla. Stat. Ann. § 222.11(2)(b)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





17.2

$260.44 $0.00

We Florida Financial Credit Union

Savings account 5398-00

Fla. Stat. Ann. § 222.11(2)(a)

100% of fair market 

value, up to any 

applicable statutory 

limit

Brief description:

Line from Schedule A/B:





21

$61,111.96 $61,111.96

Fidelity Investments 403(b)

Fla. Stat. Ann. § 222.21(2)

100% of fair market 

value, up to any 

applicable statutory 

limit

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 11 of 47
Official Form 106D

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

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.

 Check if this is an

amended filing

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).

Part 1: List All Secured Claims

2. List all secured claims. If a creditor has more than one secured

Column A Column B Column C

Amount of claim Value of collateral Unsecured

portion

If any

that supports this

claim

Do not deduct the

value of collateral

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.

2.1 Describe the property that

secures the claim:

Creditor's name

Number Street

City State ZIP Code

Who owes the debt? Check one.









Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this claim relates 

to a community debt

Date debt was incurred

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







Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.









An agreement you made (such as mortgage or secured car loan)

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

Judgment lien from a lawsuit

Other (including a right to offset)

Last 4 digits of account number

3000 Island Boulevard Condominium

5300 Island Blvd

Aventura FL 33160

$0.00 $327,424.00 

1670

Homestead

Maintenance Dues

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

$0.00 Add the dollar value of your entries in Column A on this page. Write 

that number here:

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 12 of 47
Part 1:

Additional Page Column A Column B Column C

Amount of claim Value of collateral Unsecured

portion

If any

that supports this

claim

Do not deduct the

value of collateral

Case number (if known) 19-21842

After listing any entries on this page, number them 

sequentially from the previous page.

Debtor 1 Ana Maria Restrepo

2.2 Describe the property that

secures the claim:

Creditor's name

Number Street

City State ZIP Code

Who owes the debt? Check one.









Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this claim relates 

to a community debt

Date debt was incurred

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







Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.









An agreement you made (such as mortgage or secured car loan)

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

Judgment lien from a lawsuit

Other (including a right to offset)

Last 4 digits of account number

William Island POA Club

5300 Island Blvd.

Aventura FL 33160

$0.00 $327,424.00 

1670

Homestead property

Maintenance Fees

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

$0.00 

$0.00 

Add the dollar value of your entries in Column A on this page. Write 

that number here:

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

all pages. Write that number here:

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 13 of 47
Official Form 106E/F

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

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





No. Go to Part 2.

Yes.

 Check if this is an

amended filing

on Schedule A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases

Do not include any creditors with partially secured claims that are listed in Schedule D: Creditors Who Hold Claims Secured by Property.

If more space is needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page

to this page. On the top of any additional pages, write your name and case number (if known).

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

Part 1: List All of Your PRIORITY Unsecured Claims

(Official Form 106G).

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

Total claim Priority

amount

Nonpriority

amount

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

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

show both priority and nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor's name. If 

more space is needed for priority unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular 

claim, list the other creditors in Part 3.

2.1

Last 4 digits of account number Priority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of PRIORITY unsecured claim:









Domestic support obligations

Taxes and certain other debts you owe the government

Claims for death or personal injury while you were

Other. Specify

intoxicated

 

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 14 of 47
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

Part 2: List All of Your NONPRIORITY Unsecured Claims

Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim.

Total 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 more space is needed for nonpriority unsecured claims, fill out the Continuation Page of Part 2.

4.1

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Affirm Inc

650 California St Fl 12

San Francisco CA 94108

$21.00 

WE 7 6

07/2018

Unsecured

4.2

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Amex

Po Box 297871

Fort Lauderdale FL 33329

$31,466.00 

4733

02/2004

Credit Card

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 2 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 15 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.3

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Amex

Po Box 297871

Fort Lauderdale FL 33329

$30,364.00 

0793

04/2004

Credit Card

4.4

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Amex

Po Box 297871

Fort Lauderdale FL 33329

$20,479.00 

0503

02/2004

Credit Card

4.5

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Amex/dsnb

Po Box 8218

Mason OH 45040

$1,591.00 

1759

04/2009

Credit Card

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 3 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 16 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.6

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Bank Of America

Po Box 982238

El Paso TX 79998

$24,130.00 

7057

10/2011

Credit Card

4.7

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Bank Of America

Po Box 982238

El Paso TX 79998

$10,822.00 

7777

06/2006

Credit Card

4.8

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Barclays Bank Delaware

P.o. Box 8803

Wilmington DE 19899

$9,980.00 

5606

06/2016

Credit Card

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 4 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 17 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.9

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Barclays Bank Delaware

P.o. Box 8803

Wilmington DE 19899

$0.00 

2835

03/2012

Credit Card

4.10

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Bloomingdales American Express

PO Box 9001108

Louisville KY 40290

$1,519.24 

1759

Credit Card

4.11

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Bluegreen Vacations Co

4960 Conference Way N #

Boca Raton FL 33431

$0.00 

9904

10/2012

Time Shared Loan

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 5 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 18 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.12

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Capital One Bank Usa N

Po Box 30281

Salt Lake City UT 84130

$12,047.00 

2529

12/2003

Charge Account

4.13

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Capital One Bank Usa N

Po Box 30281

Salt Lake City UT 84130

$0.00 

9039

03/2002

Credit Card

4.14

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Citicards Cbna

Credit Bureau Dispute Unit

Sioux Falls SD 57117

$0.00 

4895

11/24/2008

Credit Card

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 6 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 19 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.15

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Dfs/webbank

1 Dell Way

Round Rock TX 78682

$0.00 

5933

10/15/2011

Charge Account

4.16

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Firstsource Advantage, LLC

PO Box 628

Buffalo NY 14240

$31,467.02 

2363

Collecting for -Amex

4.17

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Honorable Benjamin Greenberg

United States Attorney

99 NE 4 St

Miami FL 33132

$0.00 

0557

Notice Only

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 7 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 20 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.18

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Honorable William Barr

Attny General of United States

950 Pennsylvania Ave NW

Washington DC 20530

$0.00 

0557

Notice Only

4.19

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Internal Revenue Service

POB 7346

Philadelphia PA 19101

$0.00 

0557

Notice Only

4.20

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Internal Revenue Service

2970 Market Street

Mail Stop 5Q30.133

Philadelphia PA 19104

$0.00 

0557

Notice Only

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 21 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.21

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Internal Revenue Service

Compliance Serv/Insolvency STOP 5730

7850 SW 6 Ct

Plantation FL 33324

$0.00 

0557

Notice Only

4.22

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Lending Club Corp

71 Stevenson St Ste 300

San Francisco CA 94105

$21,374.00 

3617

10/2017

Unsecured

4.23

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Lendingpoint Llc

1201 Roberts Boulevard

Kennesaw GA 30144

$3,529.00 

3386

06/12/2018

Unsecured

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 9 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 22 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.24

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Lexus Financial Servic

Po Box 9786

Cedar Rapids IA 52409

$0.00 

0001

05/2013

Automobile

4.25

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Lincoln Automotive Fin

12110 Emmet St

Omaha NE 68164

$10,602.00 

1757

04/2019

Lease

4.26

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Lincoln Automotive Fin

12110 Emmet St

Omaha NE 68164

$12,000.00 

1231

2019 Licoln Nautlis

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 10 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 23 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.27

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Macys/dsnb

Po Box 8218

Mason OH 45040

$1,897.00 

2900

07/2008

Charge Account

4.28

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Mercedes Benz Financia

P.o. Box 961

Roanoke TX 76262

$0.00 

9001

08/2014

Lease

4.29

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Mercedes Benz Financia

P.o. Box 961

Roanoke TX 76262

$0.00 

9001

08/2014

Lease

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 11 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 24 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.30

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Mt Sinai Federal Cred

11645 Biscayne Blvd Ste

North Miami FL 33181

($1.00) 

9801

01/2003

Unknown Loan Type

4.31

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Radius Global Solutions, LLC

500 North Franklin Turnpike, Suite 200

Mail Code 747

Ramsey NJ 07446

$20,479.00 

8169

Collecting for - American Express

4.32

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Radius Global Solutions, LLC

500 North Franklin Turnpike, Suite 200

Mail Code 747

Ramsey NJ 07446

$30,364.76 

8166

Collecting for -Amex

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 12 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 25 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.33

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Syncb/care Credit

C/o Po Box 965036

Orlando FL 32896

$0.00 

9184

09/11/2009

Charge Account

4.34

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Syncb/city Furniture

C/o Po Box 965036

Orlando FL 32896

$6,872.00 

9217

06/2015

Charge Account

4.35

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Syncb/city Furniture

C/o Po Box 965036

Orlando FL 32896

$0.00 

8130

03/02/2014

Charge Account

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 13 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 26 of 47
Case number (if known)

Part 2: Your NONPRIORITY Unsecured Claims -- Continuation Page

Total claim After listing any entries on this page, number them sequentially from the

previous page.

Debtor 1 Ana Maria Restrepo 19-21842

4.36

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Syncb/netwrk

C/o Po Box 965036

Orlando FL 32896

$0.00 

2068

11/15/2016

Charge Account

4.37

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Td Rcs/diamonds Intern

1000 Macarthur Blvd

Mahwah NJ 07430

$0.00 

1362

10/2011

Charge Account

4.38

Last 4 digits of account number

Nonpriority Creditor's Name

Number Street

City State ZIP Code

Who incurred the debt? Check one.











Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

When was the debt incurred?

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







Contingent

Unliquidated

Disputed

Type of NONPRIORITY unsecured claim:









Student loans

Obligations arising out of a separation agreement or divorce

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

Other. Specify

that you did not report as priority claims

Wffnb/mattress Firm

Cscl Dispute Team N8235-04m

Des Moines IA 50306

$0.00 

5746

05/24/2015

Charge Account

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 14 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 27 of 47
Part 4: Add the Amounts for Each Type of Unsecured Claim

6.

6a. Domestic support obligations

6b. Taxes and certain other debts you owe the government

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

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

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

6a.

Total claim

6b.

6c.

6d.

6d.

+ 

6f. Student loans

6g. Obligations arising out of a separation agreement or divorce

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

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

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

6f.

Total claim

6g.

6h.

6i.

6j.

+ 

that you did not report as priority claims

debts

Case number (if known) 19-21842

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$281,003.02 

$281,003.02 

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 claims 

from Part 1

Total claims 

from Part 2

Debtor 1 Ana Maria Restrepo

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 15 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 28 of 47
Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15 

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

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





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

Yes. Fill in all of the information below even if the contracts or leases are listed on

 Check if this is an

amended filing

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

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).

2. List separately each person or company with whom you have the contract or lease. Then state what each contract or lease

is for (for example, rent, vehicle lease, cell phone). See the instructions for this form in the instruction booklet for more examples of

executory contracts and unexpired leases.

Person or company with whom you have the contract or lease State what the contract or lease is for

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 29 of 47
Official Form 106H

Schedule H: Your Codebtors 12/15 

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

1. Do you have any codebtors?





No

Yes

 Check if this is an

amended filing

(If you are filing a joint case, do not list either spouse as a codebtor.)

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.

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

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

 No. Go to line 3.

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





No

Yes

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

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

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

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

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

Check all schedules that apply:

Official Form 106H Schedule H: Your Codebtors page 1 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 30 of 47
Official Form 106I

Schedule I: Your Income 12/15 

Part 1: Describe Employment

1.

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

 An amended filing

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

Fill in your employment

Check if this is:

 A supplement showing postpetition

chapter 13 income as of the following date:

MM / DD / YYYY

information.

Employment status

Occupation

Employer's name

Employer's address

How long employed there?

Debtor 1 Debtor 2 or non-filing spouse

 Employed

 Not employed

 Employed

 Not employed

Number Street Number Street

City State Zip Code City State Zip Code

Registered Nurse

1400 NW 12th Avenue

Miami FL 33136

3 years

Retired

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.

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.

University of Miami, Hospital

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.

2. List monthly gross wages, salary, and commissions

For Debtor 1 For Debtor 2 or

non-filing spouse

(before all

payroll deductions). If not paid monthly, calculate what the monthly wage

2. $8,115.12 $0.00 

would be.

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.

3. Estimate and list monthly overtime pay. 3. + $0.00 $0.00 

4. Calculate gross income. Add line 2 + line 3. 4. $8,115.12 $0.00 

Official Form 106I Schedule I: Your Income page 1 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 31 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

Copy line 4 here .................................................................................

For Debtor 1 For Debtor 2 or

non-filing spouse

 4. $8,115.12 $0.00 

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a.

5b. Mandatory contributions for retirement plans 5b.

5c. Voluntary contributions for retirement plans 5c.

5d. Required repayments of retirement fund loans 5d.

5e. Insurance 5e.

5f. Domestic support obligations 5f.

5g. Union dues 5g.

5h.

5h. Other deductions.

Specify: +

$1,660.71 $0.00 

$212.00 $0.00 

$0.00 $0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 $0.00 

See continuation sheet $1,273.45 $0.00 

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e + 5f + 6. $3,146.16 $0.00 5g + 5h.

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $4,968.96 $0.00 

8. List all other income regularly received:

8a. 8a.

8b. Interest and dividends 8b.

8c. 8c.

8d. Unemployment compensation 8d.

8f.

8f.

8e. Social Security 8e.

Other government assistance that you regularly receive

Specify:

8h.

8h.

8g. Pension or retirement income 8g.

Other monthly income.

Specify: +

$0.00 $0.00 

$0.00 $0.00 

$0.00 $0.00 

$0.00 $0.00 

$0.00 $0.00 

$0.00 $1,332.00 

$0.00 $0.00 

$0.00 $0.00 

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.

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.

Include cash assistance and the value (if known) or any noncash assistance that you receive, such as food stamps 

(benefits under the Supplemental Nutrition Assistance Program) 

or housing subsidies.

9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f + 8g + 8h. 9. $0.00 $1,332.00 

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

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

$4,968.96 $1,332.00 + = $6,300.96 

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

Specify: 11. + $0.00 

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.

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

income. Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, Combined

monthly income

$6,300.96 

if it applies.

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

No.

Yes. Explain:





None.

Official Form 106I Schedule I: Your Income page 2 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 32 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

1. Additional Employers Debtor 1 Debtor 2 or non-filing spouse

Occupation

Employer's name

Employer's address

How long employed there?

Registered Nurse-Teacher

Miami Ostomy Aftercare

555 NE 15th Street, Suite 2L 

Miami, Florida 33

2 years

City State Zip Code City State Zip Code

5h. Other Payroll Deductions (details)

For Debtor 1 For Debtor 2 or

non-filing spouse

Disability Insurance $56.18 

401k $1,217.27 

Totals: $1,273.45 $0.00 

Official Form 106I Schedule I: Your Income page 3 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 33 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

Expense Category Amount 

Self Employment

8a. Attached Statement (Debtor 1)

Gross Monthly Income: $0.00 

Total Monthly Expenses $0.00 

Net Monthly Income: $0.00 

Official Form 106I Schedule I: Your Income page 4 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 34 of 47
Official Form 106J

Schedule J: Your Expenses 12/15 

Part 1: Describe Your Household

1.

 An amended filing

Is this a joint case?

Check if this is:

 A supplement showing postpetition

chapter 13 expenses as of the

following date:

MM / DD / YYYY

 No. Go to line 2.

 Yes.

 No

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

Does Debtor 2 live in a separate household?

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.

2. Do you have dependents? 



No

Yes. Fill out this information

for each dependent....................

Dependent's relationship to

Debtor 1 or Debtor 2

Dependent's

age

Does dependent

live with you?





No

Yes





No

Yes





No

Yes





No

Yes





No

Yes

Husband 68

Do not list Debtor 1 and 

Debtor 2.

Do not state the dependents' 

names.

3. 



No

Yes

Do your expenses include 

expenses of people other than 

yourself and your dependents?

Part 2: Estimate Your Ongoing Monthly Expenses

Your expenses

4. The rental or home ownership expenses for your residence.

Include first mortgage payments and any rent for the ground or lot.

4.

If not included in line 4:

4a. Real estate taxes

4b. Property, homeowner's, or renter's insurance

4c. Home maintenance, repair, and upkeep expenses

4d. Homeowner's association or condominium dues

4a.

4b.

4c.

4d.

$1,468.43 

$220.00 

$495.00 

$1,425.31 

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.)

Official Form 106J Schedule J: Your Expenses page 1 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 35 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

Your expenses

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

6. Utilities:

6a. Electricity, heat, natural gas

6b. Water, sewer, garbage collection

6c. Telephone, cell phone, Internet, satellite, and 

6d. Other. Specify:

6a.

6b.

6c.

6d.

$225.00 

$96.00 

Cellphone $174.00 

cable services

7. Food and housekeeping supplies 7. $500.00 

8. Childcare and children's education costs 8.

9. Clothing, laundry, and dry cleaning 9. $50.00 

10. Personal care products and services 10. $488.00 

11. Medical and dental expenses 11. $60.00 

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

fare. Do not include car payments.

$190.00 

13. Entertainment, clubs, recreation, newspapers, 13. $40.00 

magazines, and books

14. Charitable contributions and religious donations 14. $100.00 

15. Insurance.

15a. Life insurance

15b. Health insurance

15c. Vehicle insurance

15d. Other insurance. Specify:

15a.

15b.

15c.

15d.

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

$225.00 

16. Taxes.

Specify: 16.

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

17. Installment or lease payments:

17a. Car payments for Vehicle 1

17b. Car payments for Vehicle 2

17c. Other. Specify:

17d. Other. Specify:

17a.

17b.

17c.

17d.

Car Lease $342.00 

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

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

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

Specify: 19.

20. Other real property expenses not included in lines 4 or 5 of this form or on

20a. Mortgages on other property

20b. Real estate taxes

20c. Property, homeowner's, or renter's insurance

20d. Maintenance, repair, and upkeep expenses

20a.

20b.

20c.

20d.

Schedule I: Your Income.

20e. Homeowner's association or condominium dues 20e.

Official Form 106J Schedule J: Your Expenses page 2 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 36 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

21. Other. Specify: 21. +

22. Calculate your monthly expenses.

22a. Add lines 4 through 21.

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

22c. Add line 22a and 22b. The result is your monthly expenses. 22c.

$6,098.74 

$6,098.74 

22a.

22b.

23. Calculate your monthly net income.

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

23b. Copy your monthly expenses from line 22c above.

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

23a.

23b.

The result is your monthly net income. 23c.

–

$6,300.96 

$6,098.74 

$202.22 

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





No.

Yes. Explain here:

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?

None.

Official Form 106J Schedule J: Your Expenses page 3 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 37 of 47
Official Form 106Dec

Declaration About an Individual Debtor's Schedules 12/15 

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842  Check if this is an

amended filing

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).

X X

Ana Maria Restrepo, Debtor 1 Signature of Debtor 2

Date

MM / DD / YYYY

Date

MM / DD / YYYY

10/08/2019

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.

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.

Official Form 106Dec Declaration About an Individual Debtor's Schedules page 1 

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 38 of 47
Official Form 107

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842

1. What is your current marital status?





Married

Not married

 Check if this is an

amended filing

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

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.

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.

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





No

Yes. Make sure you fill out

(Community property states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas,

Washington, and Wisconsin.)

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?





No

Yes. Fill in the details.

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.



Operating a business

For the last calendar year:

(January 1 to December 31,

YYYY

)



Operating a business



Operating a business

For the calendar year before that:

(January 1 to December 31,

YYYY

)



Operating a business



Operating a business



Operating a business

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

2018

2017

$56,805.84 

$89,267.00 

$88,321.00 

Wages, commissions, 

bonuses, tips

From January 1 of the current year until 

the date you filed for bankruptcy:

Wages, commissions, 

bonuses, tips

Wages, commissions, 

bonuses, tips

Wages, commissions, 

bonuses, tips

Wages, commissions, 

bonuses, tips

Wages, commissions, 

bonuses, tips

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 39 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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





No

Yes. Fill in the details.

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 in 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.

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.

* 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 $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.

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.

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;





No

Yes. List all payments to an insider.

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.

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?





No

Yes. List all payments that benefited an insider.

Include payments on debts guaranteed or cosigned by an insider.

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 40 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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?





No

Yes. Fill in the details.

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

modifications, and contract disputes.

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





No. Go to line 11.

Yes. Fill in the information below.

seized, or levied?

Check all that apply and fill in the details below.

11.





No

Yes. Fill in the details.

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?

12.





No

Yes

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?

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.

14.





No

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

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?

Gifts or contributions to charities

that total more than $600

Describe what you contributed Date you

contributed

Value

Charity's Name

Number Street

City State ZIP Code

Centro de Esperanza

18411 West Dixie Highway

North Miami Beach FL 33160

03/05/2019 $1,100.19

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 41 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

Part 6: List Certain Losses

15.





No

Yes. Fill in the details.

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?

Part 7: List Certain Payments or Transfers

16.





No

Yes. Fill in the details.

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

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?

17.





No

Yes. Fill in the details.

Do not include any payment or transfer that you listed on line 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 who promised to help you deal with your creditors or to make payments to your creditors?

18.





No

Yes. Fill in the details.

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 granting of a security interest or mortgage on your property).

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

19.





No

Yes. Fill in the details.

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.)

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

20.





No

Yes. Fill in the details.

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.











Checking

Savings

Money market

Brokerage

Other

XXXXName of Financial Institution

Number Street

City State ZIP Code

Bank of America

18305 Biscayne Blvd

Aventura FL 33160

8153 07/19/2019 $4.70

Type of account or 

instrument

Last 4 digits of account 

number

Date account 

was closed, 

sold, moved, 

or transferred

Last balance 

before closing 

or transfer

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 42 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842











Checking

Savings

Money market

Brokerage

Other

XXXXName of Financial Institution

Number Street

City State ZIP Code

Bank of America, NA

18305 Biscayne Blvd

Aventura FL 33160

8593 07/19/2019 $0.31

Type of account or 

instrument

Last 4 digits of account 

number

Date account 

was closed, 

sold, moved, 

or transferred

Last balance 

before closing 

or transfer











Checking

Savings

Money market

Brokerage

Other

XXXXName of Financial Institution

Number Street

City State ZIP Code

Bank of America, NA

18305 Biscayne Blvd

Aventura FL 33160

4196 07/19/2019 $48.08

Type of account or 

instrument

Last 4 digits of account 

number

Date account 

was closed, 

sold, moved, 

or transferred

Last balance 

before closing 

or transfer

21.





No

Yes. Fill in the details.

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?

22.





No

Yes. Fill in the details.

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

Name of Storage Facility

Number Street

City State ZIP Code

Name

Number Street

City State ZIP Code

Who else has or had access to it?





No

Yes

Describe the contents

Public Storage

21288 Biscayne Blvd

Aventura FL 33180

Arthur Schinitsky

21288 Biscayne Blvd, 

Aventura Fl 33180

Do you still 

have it?

Christmas Decor, Luggage, Used 

clothing

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 43 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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

23.





No

Yes. Fill in the details.

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.

Part 10: Give Details About Environmental Information





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

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

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

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

Environmental law

Site

Hazardous material

hazardous or toxic substance, 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.

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

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

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

24.





No

Yes. Fill in the details.

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

law?

25.





No

Yes. Fill in the details.

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

26.





No

Yes. Fill in the details.

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

orders.

27.

 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)

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

 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.

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

business?

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 44 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

28.





No

Yes. Fill in the details below.

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.

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

X X

Ana Maria Restrepo, Debtor 1 Signature of Debtor 2

Date Date

Did you attach additional pages toYour 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).

10/08/2019

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

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

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

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 45 of 47
Official Form 106Sum

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

Part 1: Summarize Your Assets

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

1a.

1b.

1c.

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

Copy line 62, Total personal property, from Schedule A/B........................................................................................

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

Fill in this information to identify your case:

Debtor 1

Debtor 2

(Spouse, if filing)

First Name Middle Name Last Name

First Name Middle Name Last Name

United States Bankruptcy Court for the:

Case number

(if known)

Ana Maria Restrepo

SOUTHERN DISTRICT OF FLORIDA

19-21842  Check if this is an

amended filing

$330,424.00 

$73,642.83 

$404,066.83 

Your assets

Value of what you own

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 2: Summarize Your Liabilities

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

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

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

3a.

3b.

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

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

Your total liabilities

2a. $0.00 

$0.00 

$281,003.02 

$281,003.02 

Your liabilities

Amount you owe

Part 3: Summarize Your Income and Expenses

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

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

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

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

$6,300.96 

$6,098.74 

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 46 of 47
Debtor 1 Ana Maria Restrepo Case number (if known) 19-21842

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.

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. $7,655.65 

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.

9b.

Domestic support obligations. (Copy line 6a.)

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

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

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

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

priority claims. (Copy line 6g.)

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

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

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

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

Case 19-21842-AJC Doc 14 Filed 10/14/19 Page 47 of 47