Lorinie N. Huertas

Ftm;;--------------vr-ai.-l-*" Last Name

Debtor 2

(Spouse, if tiling) Fi6t Nam6 Middte Nane Lasl Name

United States Ban kruprcy Cou rf f or the :So Uthefn-tilStniCtt OlIlCfida

Case number

(lf knom) 

---i- --------

filing together, both are equally responsible for

you file bankruptcy schedules or amended

bry fraud in connection with a bankruptcy case

SS 152,1341,1519, and 3571.

resnrlt in fines

Bankruptcy

iiled with

D Cnr:ct< if this is an

amended filing

Official Form 1

Declaratio About an lndividual D btor's chedules

lf two married people

You must file this form a false statement, concealing pr'cperty, or

obtaining money or to $250,000, or imprisonment for up to 20

years, or both. 18 U,S.C

Sign Be

Did you pay or to pa't someone who is NOT an attorney to help you

EI t'to

D Yes. Nameof

Under penalty of

that they are true

JC s/ Lorinie N.

Signature of Debtor 1

^_. 07t17t2019 Date _-______lMM/ DD /

I declare that I have read the summary and

correct,

declaration and

Official Form 106Dec Declaration About an

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Debtor'1 Lorinie Huertas

F*t lr-" 

----- 

M'oar. tro." 

- ------G;[".; c as e nu m ber (" --.')-a0-1-9-19-19-5-

13 3266 Siafron Ave.

Street adclress, if available, or other description

P, Maliabar Unit 51 Lot16 Blk 1330

I_cEllevl_l_____

Citv 

- -silie -zp 

do;

What is the property? Check all that apply

E Single-family home

D Duplex or multFunit building

I Condominium or cooperative

E Manufactured or mobile horne

Z Lano

E Investment property

E Timeshare

Do not deduct secured claims or exemptions. Put

the amount oJ any secured claims on Schedu/e Di

Credttors Who Have Clams Secu,ed by Propefty.

Current value of the Current value of the

entire property? portion you own?

fl oth"t

County

Who has an interest in the property? Check one

E Debtor 1 only

D Debtor 2 onty

I D"btor 1 and Debtor 2 only

E At least one of the debtors and another

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

property identification number:

2 Add the dollar value of the portion you own for all of your entries from Part 1 , including any entries for pages

you have attached for Part 1. Write that number here............. .............)

$------199-o-q $-- 1 8000

Describe the nature of your ownership

interest (such as fee simple, tenancy by

T :l:11'_"_"_illll : l_"ll__

E Check if this is community property

(see instructions)

24000

Verhicles

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 lf you lease a vehicle, also report it on Schedu/e G: Executory Contracts and Unexpired Leases

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

I tto

EI Yes

lVercedes 3.1, Make:

Model:

Year:

Approxirnate mileage:

Other information.

t\41 350

1 80000

lf you own or have more than one, describe here

3 2 Make:

Model:

Year:

Approximate mileage:

Other information:

Who has an interest in the property? Check one

E Debtor 1 onty

fJ Debror 2 onty

I Debtor 1 and Debtor 2 only

f] At least one of the debtors and another

E Check if this is community property (see

instructions)

Do not deduct secured claims or exemDtions Put

the amoun{ of any secured claims on Schedule D:

Craditots Who Have Claims Secwed by propedy

Current value of the Current value of the

entire property? porlion you own?

s______Z.gg_0.9_0_ $___ 7,000 00

:2009

Who has an interest in the property? Check one

D Debtor 1 onty

D Debtor 2 onty

E Debto|. 1 and Debtor 2 only

I At least one of the debtors and another

E Cneck if this is community property (see

instructions)

Do not deduct secured claims or eremplions_ put

lhe amounl of any secured claims cn Schedule D:

Creditors Who Have Claims Secured by propefty

Current value of the Current value of the

entire property? portion you own?

Official Form 1064'/8 Schedule A/B: Property

$_____________ $

page 2

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U n ited States B a n kru prcy Co u rt ror tr e : S O Ut h e r n _Di.Sfi rdc6r qlF_bfida

case number 2i19_19199I1M

(lf known)

Official Form 106J

Schedule J: Your Expenses

Be as complete and accurate as possibre. rf two married peopre are firing togr:l

information. lf more space is needed, attach another sheet to this form. on the

(if known). Answer every question,

Describe Your Household

ls this a joint case?

El ruo. co to tine 2

D yes. Does Debtor 2 live in a separate household?

0 t,to

E Yes. Debtor 2must file Official Form 106J-2,

Check if this is:

D An amended filing

r-r .

rJ A supptement showing postpetiticrn chapter .13

expenses as of the following date:

MM / DD/ YYYY

12t15

both are equally responsible for supplying corect

of any additional pages, write your name and case number

of Debtor 2.

Dependent's Does dependent live

age wlth you?

fl t,to

E Yes

DNo

E 'ye"

fl tvo

D 'r'e"

E tvo

D '/.s

E t'to

D ./es

Expenses for Separate

Do you have dependents?

Do not list Debtor 1 and

Debtor 2

Do not state the dependents'

names

I Yes Fill out this information for Debtor 1 Debtor 2

each dependent

06r.)

[II No

relationship to

Do your expenses include

expenses ofpeople otherthan 3 to

yourself and your dependents? 15 Yes

Estimate Your Ongoing Monthly Expenses

Estimate your expenses as of your bankruptcy filing date unless you are using; form as a supplement in a Chapter 13 case to report expenses as of a date after the bankruptcy is fired. rf this is a suppremental

applicable date.

J, checkthe box atthe top ofthe form and filt in the

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

such assistance and have incruded it on Sctredu/e !: your lncome (official Forrn

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

$ 3398.07

Your expenses

any rent for the ground or lot.

lf not included in line 4:

4a Real estate taxes

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

4c Home maintenance, repair, and upkeep expenses

4a

4b

4c

4d.

$_________

Official Form 106J

tron or condominium dues

Schedule J: Your Expenses

payments and

u__

page 1

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 32 of 45
Debtor 1 Lorinie

Fi6t Name

Calculate your

22a. Add lines 4

22b. Copy line 22

22c. Addline 22a and

Huertas

Middk! Name rasrruime 

----_--_.=---

ly expenses.

expenses for Debtor 2), if any, from Official Form 1

The result is your monthly expenses.

23. Calculate your rlet income,

23a. Copy line 12 oombined monthly income\ from Schedule t.

23b Copy your Y expenses from line 22c above

23c Subtract your expenses from your monthly Income.

The result is mQnthly net income.

Do you expect an or decrease in your expenses within the year after

For example, do you to finish paying for your car loan within the year or do

mongage payment to or decrease because of a modification to the terms

El ruo.

E yes. Explain

Official Form 106J Schedule J: your Expenses

page 3

your

(/kno,r 2019_19495 RAM

+$ 0.00

$ _ 6t587.17

$____--__q_0!

$ 6587.17

3288

- $ 6587.17

zza.

22b

22c.

23a

zSD.

- 3:299.17

file this

expect your

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 33 of 45
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

	
 107 

Statement of Financial Affairs for Individuals Filing for Bankruptcy 

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

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

number (if known). Answer every question. 

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

1. What is your current marital status?

Married

Not married

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

No

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

Debtor 1: Dates Debtor 1 

lived there 

Debtor 2: Dates Debtor 2 

lived there 

__________________________________________

Number Street 

__________________________________________

__________________________________________

City State ZIP Code

From ________

To ________

Same as Debtor 1 

___________________________________________

Number Street 

___________________________________________

___________________________________________

City State ZIP Code

Same as Debtor 1

From ________

To ________

__________________________________________

Number Street 

 __________________________________________ 

__________________________________________

City State ZIP Code

From ________

To ________

Same as Debtor 1 

___________________________________________

Number Street 

___________________________________________

___________________________________________

City State ZIP Code

Same as Debtor 1

From ________

To ________

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

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

No

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

Part 2: Explain the Sources of Your Income 

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ 

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

United States Bankruptcy Court for the: __________ District of ______________

Case number ___________________________________________ 

 (If known) 

Fill in this information to identify your case: 

Check if this is an

amended filing

Lorinie Huertas

Southern District of Florida

2019-19495 RAM

✔

✔

✔

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 34 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 2

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

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

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

No

Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income 

Check all that apply. 

Gross income 

(before deductions and 

exclusions)

Sources of income 

Check all that apply.

Gross income 

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy:

Wages, commissions, 

bonuses, tips

Operating a business

$________________

Wages, commissions,

bonuses, tips

Operating a business

$________________

For last calendar year:

(January 1 to December 31, _________) YYYY

Wages, commissions, 

bonuses, tips

Operating a business

$________________

Wages, commissions,

bonuses, tips

Operating a business

$________________

For the calendar year before that: 

(January 1 to December 31, _________) YYYY

Wages, commissions, 

bonuses, tips

Operating a business $________________

Wages, commissions,

bonuses, tips

Operating a business $________________

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

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

unemployment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and

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

List each source and the gross income from each source separately. Do not include income that you listed in line 4.

No

Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income 

Describe below.

Gross income from 

each source 

(before deductions and 

exclusions)

Sources of income 

Describe below.

Gross income from 

each source 

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy:

__________________

__________________

__________________

$_________________

$_________________

$_________________

_____________________

_____________________

_____________________

$_________________

$_________________

$_________________

For last calendar year:

(January 1 to December 31, ______) YYYY

__________________

__________________

__________________

$_________________

$_________________

$_________________

_____________________

_____________________

_____________________

$_________________

$_________________

$_________________

For the calendar year before that: 

(January 1 to December 31, ______) YYYY

__________________

__________________

__________________

$_________________

$_________________

$_________________

_____________________

_____________________

_____________________

$_________________

$_________________

$_________________

Lorinie Huertas 2019-19495 RAM

✔

✔ 37000

89000

2018

2017

120000

✔

2017

2016

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 35 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3

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 $6,25* or more? 

No. Go to line 7.

Yes. List below each creditor to whom you paid a total of $6,25* or more in one or more payments and the

total amount you paid that creditor. Do not include payments for domestic support obligations, such as 

child support and alimony. Also, do not include payments to an attorney for this bankruptcy case. 

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

Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts.

During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more? 

No. Go to line 7.

Yes. List below each creditor to whom you paid a total of $600 or more and the total amount you paid that

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

alimony. Also, do not include payments to an attorney for this bankruptcy case. 

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Dates of 

payment

Total amount paid Amount you still owe Was this payment for...

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

____________________________________

Creditor’s Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________ Mortgage

Car

Credit card

Loan repayment

Suppliers or vendors

Other ____________

Lorinie Huertas 2019-19495 RAM

✔

✔

✔

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 36 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 4

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

Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner;

corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing

agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations,

such as child support and alimony.

No

Yes. List all payments to an insider.

____________________________________________

Insider’s Name 

____________________________________________

Number Street 

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe 

Reason for this payment

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name 

____________________________________________

Number Street 

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________ 

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

an insider?

Include payments on debts guaranteed or cosigned by an insider.

No

Yes. List all payments that benefited an insider.

____________________________________________

Insider’s Name 

____________________________________________

Number Street 

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment 

Total amount 

paid

Amount you still 

owe 

Reason for this payment 

Include creditor’s name 

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name 

____________________________________________

Number Street 

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

Lorinie Huertas 2019-19495 RAM

✔

✔

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 37 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 5

 Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

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

and contract disputes.

No

Yes. Fill in the details.

Case title_____________________________ 

____________________________________

Case number ________________________ 

Nature of the case Court or agency Status of the case

________________________________________

Court Name 

________________________________________

Number Street 

________________________________________

City State ZIP Code

Pending

On appeal

Concluded

Case title_____________________________ 

____________________________________

Case number ________________________

________________________________________

Court Name 

________________________________________

Number Street 

________________________________________

City State ZIP Code

Pending

On appeal

Concluded

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

Check all that apply and fill in the details below.

No. Go to line 11.

Yes. Fill in the information below.

_________________________________________

Creditor’s Name 

_________________________________________

Number Street 

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened 

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

_________________________________________

Creditor’s Name 

_________________________________________

Number Street 

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened 

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.

Lorinie Huertas 2019-19495 RAM

✔

Foreclosure Collection

Worl O World Corp. vs L

MIAMI DADE ✔

73 West Flagler Street 

2108-005150-CA 01 Miami FL 33

✔

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 38 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 6

11. Within 90 days before you filed for bankruptcy, did any creditor, including a bank or financial institution, set off any amounts from your

accounts or refuse to make a payment because you owed a debt?

No

Yes. Fill in the details.

______________________________________

Creditor’s Name 

______________________________________

Number Street 

______________________________________

______________________________________

City State ZIP Code 

Describe the action the creditor took Date action 

was taken 

Amount

____________ $________________

Last 4 digits of account number: XXXX–___ ___ ___ ___ 

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

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

No

Yes

Part 5: List Certain Gifts and Contributions 

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

No

Yes. Fill in the details for each gift.

Gifts with a total value of more than $600 

per person 

Describe the gifts Dates you gave 

the gifts 

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

Number Street 

______________________________________

City State ZIP Code

Person’s relationship to you ______________ 

_________

_________

$_____________

$_____________

Gifts with a total value of more than $600 

per person 

Describe the gifts Dates you gave 

the gifts 

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

Number Street 

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

Lorinie Huertas 2019-19495 RAM

✔

✔

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 39 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 7

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

No

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

Gifts or contributions to charities 

that total more than $600 

Describe what you contributed Date you 

contributed

Value 

_____________________________________

Charity’s Name 

_____________________________________

_____________________________________

Number Street 

_____________________________________

City State ZIP Code

_________

_________

$_____________

$_____________

Part 6: List Certain Losses 

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

disaster, or gambling?

No

Yes. Fill in the details.

Describe the property you lost and 

how the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending insurance 

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

Date of your 

loss 

Value of property 

lost 

_________ $_____________

Part 7: List Certain Payments or Transfers 

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

you consulted about seeking bankruptcy or preparing a bankruptcy petition?

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

No

Yes. Fill in the details.

___________________________________

Person Who Was Paid 

___________________________________

Number Street 

___________________________________

___________________________________

City State ZIP Code

____________________________________________

Email or website address

Description and value of any property transferred Date payment or 

transfer was 

made 

Amount of payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

Lorinie Huertas 2019-19495 RAM

✔

✔

✔

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 40 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 8

____________________________________

Person Who Was Paid 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

________________________________________________

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of 

payment 

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

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

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

Do not include any payment or transfer that you listed on line 16.

No

Yes. Fill in the details.

____________________________________

Person Who Was Paid 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code 

Description and value of any property transferred Date payment or 

transfer was 

made 

Amount of payment

_________

_________

$____________

$____________

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

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

Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property).

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

No

Yes. Fill in the details.

___________________________________

Person Who Received Transfer 

___________________________________

Number Street 

___________________________________

___________________________________

City State ZIP Code

Description and value of property 

transferred 

Describe any property or payments received 

or debts paid in exchange 

Date transfer 

was made 

_________

Person’s relationship to you _____________ 

___________________________________

Person Who Received Transfer 

___________________________________

Number Street 

___________________________________

___________________________________

City State ZIP Code

_________

Person’s relationship to you _____________ 

Lorinie Huertas 2019-19495 RAM

✔

✔

Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 41 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 9

19. Within 10 years before you filed for bankruptcy, did you transfer any property to a self-settled trust or similar device of which you

are a beneficiary? (These are often called asset-protection devices.)

No

Yes. Fill in the details.

Name of trust __________________________ 

______________________________________

Description and value of the property transferred Date transfer 

was made 

_________

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

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

closed, sold, moved, or transferred?

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

brokerage houses, pension funds, cooperatives, associations, and other financial institutions.

No

Yes. Fill in the details.

____________________________________

Name of Financial Institution

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code 

Last 4 digits of account number Type of account or 

instrument 

Date account was 

closed, sold, moved, 

or transferred 

Last balance before 

closing or transfer 

XXXX–___ ___ ___ ___ Checking 

Savings

Money market

Brokerage

Other__________

_________ $___________

____________________________________

Name of Financial Institution

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

XXXX–___ ___ ___ ___ Checking 

Savings

Money market

Brokerage

Other__________

_________ $___________

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

securities, cash, or other valuables?

No

Yes. Fill in the details.

____________________________________

Name of Financial Institution

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Who else had access to it? Describe the contents Do you still 

have it? 

_______________________________________

Name 

_______________________________________

Number Street 

_______________________________________

City State ZIP Code

No

Yes



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Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 42 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 10

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

No

Yes. Fill in the details.

___________________________________

Name of Storage Facility 

___________________________________

Number Street 

___________________________________

___________________________________

City State ZIP Code

Who else has or had access to it? Describe the contents Do you still 

have it? 

_______________________________________

Name 

_______________________________________

Number Street 

_______________________________________

City State ZIP Code

No

Yes



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

23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for,

or hold in trust for someone.

No

Yes. Fill in the details.

___________________________________

Owner’s Name 

___________________________________

Number Street 

___________________________________

___________________________________

City State ZIP Code

Where is the property? Describe the property Value 

_________________________________________

Number Street 

_________________________________________

_________________________________________

City State ZIP Code

$__________

Part 10: Give Details About Environmental Information 

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

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

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

including statutes or regulations controlling the cleanup of these substances, wastes, or material. 

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

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

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

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

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

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

No

Yes. Fill in the details.

____________________________________

Name of site 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit 

_______________________________

Number Street 

_______________________________

City State ZIP Code

_________

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Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 43 of 45
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 11

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

No

Yes. Fill in the details.

____________________________________

Name of site 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice 

_______________________________

Governmental unit 

_______________________________

Number Street 

_______________________________

City State ZIP Code

_________

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

No

Yes. Fill in the details.

Case title______________________________ 

______________________________________

______________________________________

Case number 

Court or agency Nature of the case Status of the 

case

________________________________

Court Name 

________________________________

Number Street 

________________________________

City State ZIP Code

Pending

On appeal

Concluded



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

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

A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time

A member of a limited liability company (LLC) or limited liability partnership (LLP)

A partner in a partnership

An officer, director, or managing executive of a corporation

An owner of at least 5% of the voting or equity securities of a corporation

No. None of the above applies. Go to Part 12.

Yes. Check all that apply above and fill in the details below for each business.

____________________________________

Business Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN. 

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___ 

Name of accountant or bookkeeper Dates business existed

From _______ To _______ 

____________________________________

Business Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN. 

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______ 

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

	

 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 12

____________________________________

Business Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN. 

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___ 

Name of accountant or bookkeeper Dates business existed

From _______ To _______ 

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

institutions, creditors, or other parties.

No

Yes. Fill in the details below.

____________________________________

Name 

____________________________________

Number Street 

____________________________________

____________________________________

City State ZIP Code

Date issued 

____________

MM / DD / YYYY

Part 12: Sign Below 

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

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

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

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

______________________________________________ _____________________________ Signature of Debtor 1 Signature of Debtor 2 

Date ________________ Date _________________

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

No

Yes

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

No

Yes. Name of person_____________________________________________________________. Attach the Bankruptcy Petition Preparer’s Notice,

Declaration, and Signature (Official Form 119).

Lorinie Huertas 2019-19495 RAM

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S/ Lorinie Huertas

08/12/2019

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Case 19-19495-RAM Doc 13 Filed 08/13/19 Page 45 of 45