Official Form 201 Voluntary Petition for Non-Individuals Filing for Bankruptcy page 1 

Official Form 201

Voluntary Petition for Non-Individuals Filing for Bankruptcy 04/19

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

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

1. Debtor’s name ______________________________________________________________________________________________________

2. All other names debtor used

in the last 8 years

Include any assumed names,

trade names, and doing business

as names

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

3. Debtor’s federal Employer

Identification Number (EIN) ______________________________________

4. Debtor’s address Principal place of business

______________________________________________

Number Street

______________________________________________

______________________________________________ 

City State ZIP Code 

______________________________________________

County 

Mailing address, if different from principal place 

of business

_______________________________________________

Number Street

_______________________________________________

P.O. Box

_______________________________________________ 

City State ZIP Code

Location of principal assets, if different from 

principal place of business

_______________________________________________

Number Street

_______________________________________________

_______________________________________________ 

City State ZIP Code

5. Debtor’s website (URL) ____________________________________________________________________________________________________

6. Type of debtor  Corporation (including Limited Liability Company (LLC) and Limited Liability Partnership (LLP))

 Partnership (excluding LLP)

 Other. Specify: __________________________________________________________________

 Check if this is an

amended filing

United States Bankruptcy Court for the:

____________________ District of _________________

(State) 

Case number (If known): _________________________ Chapter you are filing under:

 Chapter 7 

 Chapter 11

 Chapter 12

 Chapter 13

 Fill in this information to identify your case:

West Palm Beach FL

✔

33407

http://goldenctr.org/

59-1171320

Southern District of Florida

✔

Palm Beach County

Jerome Golden Center for Behavioral Health, Inc.

1041 45th Street

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 1 of 9
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 201 Voluntary Petition for Non-Individuals Filing for Bankruptcy page 2

7. Describe debtor’s business

A. Check one:

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

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

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

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

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

 Clearing Bank (as defined in 11 U.S.C. § 781(3))

 None of the above

B. Check all that apply:

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

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

§ 80a-3)

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

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

See http://www.naics.com/search/ .

_________

8. Under which chapter of the

Bankruptcy Code is the

debtor filing?

Check one:

 Chapter 7

 Chapter 9

 Chapter 11. Check all that apply:

 Debtor’s aggregate noncontingent liquidated debts (excluding debts owed to

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

4/01/22 and every 3 years after that).

 The debtor is a small business debtor as defined in 11 U.S.C. § 101(51D). If the debtor 

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

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

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

 A plan is being filed with this petition.

 Acceptances of the plan were solicited prepetition from one or more classes of creditors,

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

 The debtor is required to file periodic reports (for example, 10K and 10Q) with the

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

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

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

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

12b-2.

 Chapter 12

9. Were prior bankruptcy cases

filed by or against the debtor

within the last 8 years?

If more than 2 cases, attach a

separate list.

 No

 Yes. District _______________________ When _______________ Case number _________________________

MM / DD / YYYY

District _______________________ When _______________ Case number _________________________

MM / DD / YYYY

10. Are any bankruptcy cases

pending or being filed by a

business partner or an

affiliate of the debtor?

List all cases. If more than 1,

attach a separate list.

 No

 Yes. Debtor _____________________________________________ Relationship _________________________

District _____________________________________________ When __________________ 

MM / DD / YYYY 

Case number, if known ________________________________

✔

623220

✔

✔

Jerome Golden Center for Behavioral Health, Inc.

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 2 of 9
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 201 Voluntary Petition for Non-Individuals Filing for Bankruptcy page 3

11. Why is the case filed in this

district?

Check all that apply:

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

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

district.

 A bankruptcy case concerning debtor’s affiliate, general partner, or partnership is pending in this district.

12. Does the debtor own or have

possession of any real

property or personal property

that needs immediate

attention?

 No

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

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

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

What is the hazard? _____________________________________________________________________

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

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

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

assets or other options).

 Other _______________________________________________________________________________

Where is the property?_____________________________________________________________________

Number Street

____________________________________________________________________

_______________________________________ _______ ________________

City State ZIP Code 

Is the property insured?

 No

 Yes. Insurance agency ____________________________________________________________________

Contact name ____________________________________________________________________

Phone ________________________________ 

Statistical and administrative information

13. Debtor’s estimation of

available funds

Check one:

 Funds will be available for distribution to unsecured creditors.

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

14. Estimated number of

creditors

 1-49

 50-99

 100-199

 200-999

 1,000-5,000

 5,001-10,000

 10,001-25,000

 25,001-50,000

 50,001-100,000

 More than 100,000

15. Estimated assets

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

✔

✔

✔

✔

Jerome Golden Center for Behavioral Health, Inc.

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 3 of 9
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 201 Voluntary Petition for Non-Individuals Filing for Bankruptcy page 4

16. Estimated liabilities

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

Request for Relief, Declaration, and Signatures

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

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

17. Declaration and signature of

authorized representative of

debtor

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

petition.

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

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

correct.

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

Executed on _________________

MM / DD / YYYY

_____________________________________________ _______________________________________________

Signature of authorized representative of debtor Printed name

Title _________________________________________ 

18. Signature of attorney _____________________________________________ Date _________________

Signature of attorney for debtor MM / DD / YYYY

_________________________________________________________________________________________________

Printed name

_________________________________________________________________________________________________

Firm name

_________________________________________________________________________________________________

Number Street

____________________________________________________ ____________ ______________________________

City State ZIP Code 

____________________________________ __________________________________________

Contact phone Email address

______________________________________________________ ____________

Bar number State

philip@philipbharris.com

FL

Dr. Linda DePiano

Royal Palm Beach

Philip B. Harris, P.A.

19781

FL 33411

✔

561-543-7963

/s/ Philip Harris

09/24/2019

09/24/2019

Philip Harris

685 Royal Palm Beach Blvd. Suite 205

/s/ Dr. Linda DePiano

CEO

Jerome Golden Center for Behavioral Health, Inc.

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 4 of 9
ASD Healthcare, LLC

P.O. Box 848104

Dallas, TX 75284-8104

Agency for Health Care

2727 Mahan Dr., MS 31

Tallahassee, FL 32308

Amerisource Bergen

10910 Lee Vista Blvd., Ste. 401

Orlando, FL 32829-8076

Blue Cross Blue Shield of FL

P.O. Box 660299

Dallas, TX 75266-0299

Fidelity Brokerage Services

P.O. Box 770002

Cincinnati, OH 45277-8009

First Rate Janitorial

5644 Maypop Rd.

West Palm Beach, FL 33415

Florida Linen Services

1407 SW 8th St.

Pompano Beach, FL 33069

Healthcare Services Group

P.O. Box 829677

Philadelphia, PA 11918-9677

IPFS Corporation

P.O. Box 730223

Dallas, TX 75373-0223

Iron Mountain

P.O. Box 27128

New York, NY 10087-7128

Jerome Golden

3341 Monet Dr.

Palm Beach Gardens, FL 33410

Keefe, McCullough & Co.

6550 N. Federal Hwy., Ste. 410

Fort Lauderdale, FL 33308

Libertas Funding, LLC

382 Greenwich Ave.

Suite 2, Second Floor

Taftville, CT 06380

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 5 of 9
Locumtenens

P.O. Box 405547

Atlanta, GA 30384-5547

Mercury Capital

100 Merrick Rd., Ste. 540E

Rockville Center, NY 11570

Mercury Capital

100 Merrick Rd., Ste. 504E

Rockville Centre, NY 11570

Netsmart Technologies, Inc.

P.O. Box 823519

Philadelphia, PA 19182-3519

Osman Page, LLC

185 Townsend Ave., Ste. Q

Boothbay Harbor, ME 04538-1895

Quality Automotive Services

226 10th St.

West Palm Beach, FL 33403

Quest Diagnostics

P.O. Box 530440

Atlanta, GA 30353-3011

Roth Staffing Companies, L.P.

P.O. Box 60003

Anaheim, CA 92812

Speedy Rooter

2196 Spafford Ave.

West Palm Beach, FL 33409

U.S. Bank

P.O. Box 790448

St. Louis, MO 63179-5371

U.S. Dept. Agriculture

420 S. State Rd. 7, Ste. 166

Royal Palm Beach, FL 33414

Ultimate Software

P.O. Box 930593

Atlanta, GA 31193-0953

VFI KR SPE I, LLC

27655 Middlebelt Rd., Ste. 150

Farmington, MI 48334

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 6 of 9
United States Bankruptcy Court

In re: Case No.

Chapter

Debtor(s)

Verification of Creditor Matrix

The above-named Debtor(s) hereby verify that the attached list of creditors is

true and correct to the best of their knowledge.

Date:

Signature of Individual signing on behalf of debtor

Position or relationship to debtor

11

CEO

Southern District of Florida

09/24/2019 /s/ Dr. Linda DePiano

Jerome Golden Center for Behavioral Health,

Inc.

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 7 of 9
Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 1 

Official Form 204 

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

Unsecured Claims and Are Not Insiders 12/15

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

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

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

largest unsecured claims. 

Name of creditor and complete 

mailing address, including zip code

Name, telephone number, 

and email address of 

creditor contact 

Nature of the claim 

(for example, trade

debts, bank loans, 

professional 

services, and 

government 

contracts)

Indicate if 

claim is 

contingent, 

unliquidated, 

or disputed 

Amount of unsecured claim

If the claim is fully unsecured, fill in only unsecured 

claim amount. If claim is partially secured, fill in 

total claim amount and deduction for value of 

collateral or setoff to calculate unsecured claim. 

Total claim, if 

partially 

secured

Deduction for 

value of 

collateral or 

setoff

Unsecured 

claim

1

2

3

4

5

6

7

8

 Check if this is an

amended filing

Debtor name __________________________________________________________________ 

United States Bankruptcy Court for the:_______________________________ 

Case number (If known): _________________________ 

 Fill in this information to identify the case:

Jerome Golden Center for Behavioral Health, Inc.

Services

Suppliers or Vendors

Services

Suppliers or Vendors

Suppliers or Vendors

Telephone / Internet

services

295,217.07

186,494.92

158,868.99

92,790.89

79,572.00

72,252.50

61,872.25

51,796.60

Southern District of Florida

Netsmart Technologies, Inc.

P.O. Box 823519

Philadelphia, PA, 19182-3519

Healthcare Services Group

P.O. Box 829677

Philadelphia, PA, 11918-9677

Locumtenens

P.O. Box 405547

Atlanta, GA, 30384-5547

Agency for Health Care

2727 Mahan Dr., MS 31

Tallahassee, FL, 32308

Amerisource Bergen

10910 Lee Vista Blvd., Ste. 401

Orlando, FL, 32829-8076

Blue Cross Blue Shield of FL

P.O. Box 660299

Dallas, TX, 75266-0299

VFI KR SPE I, LLC

27655 Middlebelt Rd., Ste. 150

Farmington, MI, 48334

Fidelity Brokerage Services

P.O. Box 770002

Cincinnati, OH, 45277-8009

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 8 of 9
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 2 

Name of creditor and complete 

mailing address, including zip code

Name, telephone number, 

and email address of 

creditor contact 

Nature of the claim 

(for example, trade

debts, bank loans, 

professional 

services, and 

government 

contracts)

Indicate if 

claim is 

contingent, 

unliquidated, 

or disputed 

Amount of unsecured claim

If the claim is fully unsecured, fill in only unsecured 

claim amount. If claim is partially secured, fill in 

total claim amount and deduction for value of 

collateral or setoff to calculate unsecured claim. 

Total claim, if 

partially 

secured

Deduction for 

value of 

collateral or 

setoff

Unsecured 

claim

9

10

11

12

13

14

15

16

17

18

19

20

Quest Diagnostics

P.O. Box 530440

Atlanta, GA, 30353-3011

Osman Page, LLC

185 Townsend Ave., Ste. Q

Boothbay Harbor, ME, 04538-1895

U.S. Bank

P.O. Box 790448

St. Louis, MO, 63179-5371

Speedy Rooter

2196 Spafford Ave.

West Palm Beach, FL, 33409

Services

Florida Linen Services

1407 SW 8th St.

Pompano Beach, FL, 33069

Suppliers or Vendors

Roth Staffing Companies, L.P.

P.O. Box 60003

Anaheim, CA, 92812

Services

Ultimate Software

P.O. Box 930593

Atlanta, GA, 31193-0953

Services

First Rate Janitorial

5644 Maypop Rd.

West Palm Beach, FL, 33415

Services

IPFS Corporation

P.O. Box 730223

Dallas, TX, 75373-0223

Jerome Golden Center for Behavioral Health, Inc.

15,427.07

Services

Iron Mountain

P.O. Box 27128

New York, NY, 10087-7128

Suppliers or Vendors

ASD Healthcare, LLC

P.O. Box 848104

Dallas, TX, 75284-8104

Services

21,632.28

21,690.57

Services

22,945.00

23,583.15

26,435.60

32,194.37

32,198.10

35,542.00

36,265.64

42,294.04

43,000.00

18003285371

Keefe, McCullough & Co.

6550 N. Federal Hwy., Ste. 410

Fort Lauderdale, FL, 33308

1-800-223-3011

305-771-0896

Case 19-22704-MAM Doc 1 Filed 09/24/19 Page 9 of 9