Fill in this information to identify your case:

Debtor 1 Sholem Grubin

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA  Check if this is an

amended filing

B 103B 

Application to Have the Chapter 7 Filing Fee Waived 12/15

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

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

number (if known).

Part 1: Tell the Court About Your Family and Your Family's Income

1. What is the size of your

family?

Check all that apply:

Your family includes you, your

spouse, and any dependents

listed on Schedule J: Your

Expenses (Official Form 106J).

 You

 Your spouse

 Your dependents 0 1

How many dependents? Total number of people

2. Fill in your family’s average

monthly income.

That person’s average

monthly net income

(take-home pay)

Include your spouse’s income if your

spouse is living with you, even if your

spouse is not filing.

Do not include your spouse’s income

if you are separated and your spouse

is not filing with you.

Add your income and your spouse’s income. Include

the value (if known) of any non-cash governmental

assistance that you receive, such as food stamps

(benefits under the Supplemental Nutrition Assistance

Program) or housing subsidies. You................ $ 1,288.00

If you have already filled out Schedule I: Your Income,

see line 10 of that schedule. Your spouse + $ 0.00

Subtotal......... $ 1,288.00

Subtract any non-cash governmental assistance that

you included above. - $ 0.00

Your family’s average monthly net income Total............... $ 1,288.00

Type of assistance

3. Do you receive non-cash governmental

assistance?





No

Yes. Describe.........

4. Do you expect your family’s average

monthly net income to increase or

decrease by more than 10% during the

next 6 months?





No

Yes. Explain. ...........

5. Tell the court why you are unable to pay the filing fee in

installments within 120 days. If you have some additional

circumstances that cause you to not be able to pay your filing fee in

installments, explain them.

B 103B (Official Form 103B) Application to Have the Chapter 7 Filing Fee Waived page 1

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Debtor 1 Sholem Grubin Case number(if known)

Part 2: Tell the Court About Your Monthly Expenses

6. Estimate your average monthly expenses.

Include amounts paid by any government assistance

that you reported on line 2. $ 1,450.00

If you have already filled out Schedule J, Your Expenses,

copy line 22 from that form.

7. Do these expenses cover anyone

who is not included in your family

as reported in line 1?





No

Yes. Identify who.....

8. Does anyone other than you

regularly pay any of these

expenses?

If you have already filled out

Schedule I: Your Income, copy the

total from line 11.





No

Yes. How much do you regularly receive as contributions? $ 0.00 monthly

9. Do you expect your average

monthly expenses to increase or

decrease by more than 10%

during the next 6 months?





No

Yes. Explain. ..........

Part 3: Tell the Court About Your Property

If you have already filled out Schedule A/B: Property (Official Form 106A/B) attach copies to this application and go to Part 4.

10. How much cash do you have?

Examples: Money you have in your wallet,

in your home, and on hand when you file

this application Cash: $

11. Bank accounts and other

deposits of money? Institution name: Amount:

Examples: Checking, savings,

money market, or other financial Checking account: $

accounts; certificates of deposit;

shares in banks, credit unions, Savings account: $

brokerage houses , and other Other financial accounts: $

similar institutions. If you have Other financial accounts: $

more than one account with the

same institution, list each. Do

not include 401(k) and IRA

accounts.

12. Your home? (if you own it outright

or are purchasing it) Current value: $

Number Street

Examples: House, condominium,

manufactured home, or mobile

home

Amount you

owe on

mortgage and

liens: $

City State Zip Code

13. Other real estate? Current value: $

Number Street

Amount you

owe on

mortgage and

liens: $

City State Zip Code

14. The vehicles you own? Make: Current value: $

Model:

Examples: Cars, vans, trucks Year: Amount you $

B 103B (Official Form 103B) Application to Have the Chapter 7 Filing Fee Waived page 2

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Debtor 1 Sholem Grubin Case number(if known)

owe

sports utility vehicles, motorcycles, Mileage on liens:

tractors, boats

Make: Current value: $

Model:

Year: Amount you

owe $

Mileage on liens:

15. Other assets? Describe the other assets: Current value: $

Do not include household

items and clothing.

Amount you owe

on liens: $

16. Money or property due you? Who owes you the money or property? How much is owed? Do you believe you will likely

receive payment in the next 180

days?

Examples: Tax refunds, past

due or lump sum alimony,

spousal support, child support, $

 No

 Yes. Explain:

maintenance, divorce or

property settlements, Social

Security benefits, workers

compensation, personal injury

recovery $

Part 4: Answer These Additional Questions

17. Have you paid anyone for

services for this case,

including filling out this

application, the bankruptcy

filing package, or the

schedules?

 No

 Yes. Whom did you pay? Check all that apply: How much did you pay?

 An Attorney

 A bankruptcy petition preparer, paralegal, or typing service

 Someone else 

$ 0.00

18. Have you promised to pay or

do you expect to pay

someone for services for your

bankruptcy case?

 No

 Yes. Whom do you expect to pay? Check all that apply:

How much do you

expect to pay?

 An Attorney

 A bankruptcy petition preparer, paralegal, or typing service

 Someone else 

$ 0.00

19. Has anyone paid someone on

your behalf for services for

this case?

 No

 Yes. Who was paid on your behalf?

Check all that apply:

Who paid?

Check all that apply:

How much did

someone else pay?

 An Attorney

 A bankruptcy petition preparer,

paralegal, or typing service

 Someone else 

 Parent

 Brother or sister

 Friend

 Pastor or clergy

 Someone else $ 0.00

20. Have you filed for

bankruptcy within the

last 8 years?

 No

 Yes. District When

Case

Number

MM/ DD/ YYYY

District When

Case

Number

MM/ DD/ YYYY

District When

Case

Number

MM/ DD/ YYYY

B 103B (Official Form 103B) Application to Have the Chapter 7 Filing Fee Waived page 3

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Debtor 1 Sholem Grubin Case number(if known)

Part 5: Sign Below

By signing here under penalty of perjury, I declare that I cannot afford to pay the filing fee either in full or in installments. I also declare that

the information I provided in this application is true and correct.

x /s/ Sholem Grubin x

Sholem Grubin

Signature of Debtor 1 Signature of Debtor 2

Date October 6, 2020 Date

B 103B (Official Form 103B) Application to Have the Chapter 7 Filing Fee Waived page 4

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Debtor 1 Sholem Grubin Case number(if known)

Fill in this information to identify the case:

Debtor 1 Sholem Grubin

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number

(if known)

Order on the Application to Have the Chapter 7 Filing Fee Waived

After considering the debtor’s Application to Have the Chapter 7 Filing Fee Waived (Official Form 103B), the court orders

that the application is:

 GRANTED. However, the court may order the debtor to pay the fee in the future if developments in administering the

bankruptcy case show that the waiver was unwarranted.

 DENIED. The debtor must pay the filing fee according to the following terms:

You must pay... On or before this date...

$

Month/ day/ year

$

Month/ day/ year

$

Month/ day/ year

+ $

Month/ day/ year

Total $

If the debtor would like to propose a different payment timetable, the debtor must file a motion promptly with a

payment proposal. The debtor may use Application for Individuals to Pay the Filing Fee in Installments (Official

Form 103A) for this purpose. The court will consider it.

The debtor must pay the entire filing fee before making any more payments or transferring any more property to

an attorney, bankruptcy petition preparer, or anyone else in connection with the bankruptcy case. The debtor

must also pay the entire filing fee to receive a discharge. If the debtor does not make any payment when it is due,

the bankruptcy case may be dismissed and the debtor’s rights in future bankruptcy cases may be affected.

 Scheduled for hearing.

A hearing to consider the debtor's application will be held

on at AM/PM at

Month/ day/ year Address of courthouse

If the debtor does not appear at this hearing, the court may deny the application.

By the court:

United States Bankruptcy Judge

B 103B (Official Form 103B) Application to Have the Chapter 7 Filing Fee Waived page 5

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

Debtor 1 Sholem Grubin

First Name Middle Name Last Name

Debtor 2

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

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number  Check if this is an

amended filing

Official Form 106A/B

Schedule A/B: Property 12/15

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

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

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

Answer every question.

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

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

 No. Go to Part 2.

 Yes. Where is the property?

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

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

 No

 Yes

5

.

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

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

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

 No

 Yes. Describe.....

7. Electronics

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

including cell phones, cameras, media players, games

 No

 Yes. Describe.....

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

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8. Collectibles of value

Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects; stamp, coin, or baseball card collections;

other collections, memorabilia, collectibles

 No

 Yes. Describe.....

9. Equipment for sports and hobbies

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

musical instruments

 No

 Yes. Describe.....

10. Firearms

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

 No

 Yes. Describe.....

11. Clothes

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

 No

 Yes. Describe.....

Clothing $100.00

12. Jewelry

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

 No

 Yes. Describe.....

Jewelry - NONE $0.00

13. Non-farm animals

Examples: Dogs, cats, birds, horses

 No

 Yes. Describe.....

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

 No

 Yes. Give specific information.....

15. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached

for Part 3. Write that number here .............................................................................. $100.00

Part 4: Describe Your Financial Assets

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

portion you own?

Do not deduct secured

claims or exemptions.

16. Cash

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

 No

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

Cash $10.00

17. Deposits of money

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

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

 No

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

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 Yes........................ Institution name:

17.1. Checking

Grupo Bancolombia

Acct: 0023 $25.00

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:

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

joint venture

 No

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

Name of entity: % of ownership:

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

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

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

 No

 Yes. Give specific information about them

Issuer name:

21. Retirement or pension accounts

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

 No

 Yes. List each account separately.

Type of account: Institution name:

22. Security deposits and prepayments

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

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

 No

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

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

 No

 Yes............. Issuer name and description.

24. Interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program.

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

 No

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

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

 No

 Yes. Give specific information about them...

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

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

 No

 Yes. Give specific information about them...

27. Licenses, franchises, and other general intangibles

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

 No

 Yes. Give specific information about them...

Money or property owed to you? Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

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

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28. Tax refunds owed to you

 No

 Yes. Give specific information about them, including whether you already filed the returns and the tax years.......

29. Family support

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

 No

 Yes. Give specific information......

30. Other amounts someone owes you

Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compensation, Social Security

benefits; unpaid loans you made to someone else

 No

 Yes. Give specific information..

31. Interests in insurance policies

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

 No

 Yes. Name the insurance company of each policy and list its value.

Company name: Beneficiary: Surrender or refund

value:

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

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

someone has died.

 No

 Yes. Give specific information..

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

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

 No

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

34. Other contingent and unliquidated claims of every nature, including counterclaims of the debtor and rights to set off claims

 No

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

35. Any financial assets you did not already list

 No

 Yes. Give specific information..

36. Add the dollar value of all of your entries from Part 4, including any entries for pages you have attached

for Part 4. Write that number here..................................................................................................................... $35.00

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

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

 No. Go to Part 6.

 Yes. Go to line 38.

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

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

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

 No. Go to Part 7.

 Yes. Go to line 47.

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

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

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

Examples: Season tickets, country club membership

 No

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

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

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

55. Part 1: Total real estate, line 2 ...................................................................................................................... $0.00

56. Part 2: Total vehicles, line 5 $0.00

57. Part 3: Total personal and household items, line 15 $100.00

58. Part 4: Total financial assets, line 36 $35.00

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

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

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

62. Total personal property. Add lines 56 through 61... $135.00 Copy personal property total $135.00

63. Total of all property on Schedule A/B. Add line 55 + line 62 $135.00

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

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