Fill in this information to identify your case:

United States Bankruptcy Court for the:

SOUTHERN DISTRICT OF FLORIDA

Case number (if known) Chapter 11

 Check if this an

amended filing

Official Form 201

Voluntary Petition for Non-Individuals Filing for Bankruptcy 4/19

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 case number (if known).

For more information, a separate document, Instructions for Bankruptcy Forms for Non-Individuals, is available.

1. Debtor's name Palm Beach Brain and Spine, LLC

2. All other names debtor

used in the last 8 years

Include any assumed

names, trade names and

doing business as names

DBA Neuro Ortho Interventional Services

DBA JaxNeuroSpine

DBA Neurological & Orthopedical Institute of FL

DBA Palm Beach Reconstructive Surgery

DBA Neuro Ortho Spine Institute

3. Debtor's federal

Employer Identification

Number (EIN)

03-0577493

4. Debtor's address Principal place of business Mailing address, if different from principal place of

business

1447 Medical Park Blvd.

Suite 101

Wellington, FL 33414

Number, Street, City, State & ZIP Code P.O. Box, Number, Street, City, State & ZIP Code

Palm Beach Location of principal assets, if different from principal

County place of business

Number, Street, City, State & ZIP Code

5. Debtor's website (URL) www.pbbsneuro.com

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

 Partnership (excluding LLP)

 Other. Specify:

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

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 1 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

Name

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.uscourts.gov/four-digit-national-association-naics-codes.

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?

 No.

 Yes.

If more than 2 cases, attach a

separate list. District When Case number

District When Case number

10. Are any bankruptcy cases

pending or being filed by a

business partner or an

affiliate of the debtor?

 No

 Yes.

List all cases. If more than 1,

attach a separate list Debtor Midtown Outpatient Surgery Center, LLC Relationship

District

Southern District of

Florida When Case number, if known

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

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 2 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

Name

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 to unsecured creditors.

14. Estimated number of

creditors

 1-49

 50-99

 100-199

 200-999

 1,000-5,000

 5001-10,000

 10,001-25,000

 25,001-50,000

 50,001-100,000

 More than100,000

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

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

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

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 3 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

Name

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 August 14, 2019

MM / DD / YYYY

X /s/ Dr. Amos O. Dare Dr. Amos O. Dare

Signature of authorized representative of debtor Printed name

Title Manager

18. Signature of attorney X /s/ Craig I. Kelley Date August 14, 2019

Signature of attorney for debtor MM / DD / YYYY

Craig I. Kelley 782203

Printed name

Kelley, Fulton & Kaplan, P.L.

Firm name

1665 Palm Beach Lakes Blvd

The Forum - Suite 1000

West Palm Beach, FL 33401

Number, Street, City, State & ZIP Code

Contact phone 561-491-1200 Email address dana@kelleylawoffice.com

782203 FL

Bar number and State

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

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 4 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number (if known)

 Check if this is an

amended filing

Official Form 202

Declaration Under Penalty of Perjury for Non-Individual Debtors 12/15

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

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

amendments of those documents. This form must state the individual’s position or relationship to the debtor, the identity of the document,

and the date. Bankruptcy Rules 1008 and 9011.

WARNING -- Bankruptcy fraud is a serious crime. Making a false statement, concealing property, or obtaining money or property by fraud in

connection with a bankruptcy case can result in fines up to $500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341,

1519, and 3571.

Declaration and signature

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

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

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

 Schedule A/B: Assets–Real and Personal Property (Official Form 206A/B)

 Schedule D: Creditors Who Have Claims Secured by Property (Official Form 206D)

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

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

 Schedule H: Codebtors (Official Form 206H)

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

 Amended Schedule

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

 Other document that requires a declaration

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

Executed on August 14, 2019 X /s/ Dr. Amos O. Dare

Signature of individual signing on behalf of debtor

Dr. Amos O. Dare

Printed name

Manager

Position or relationship to debtor

Official Form 202 Declaration Under Penalty of Perjury for Non-Individual Debtors

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 5 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF

FLORIDA

 Check if this is an

Case number (if known): amended filing

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 claim

(for example, trade

debts, bank loans,

professional services,

and government

contracts)

Indicate if claim

is contingent,

unliquidated, or

disputed

Amount of 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

American Horizon

Financial

5571 N University Dr

Suite 104

Pompano Beach, FL

33067

Various Letters of

Protection

Unknown $0.00 Unknown

Carecentric

Investments I, LLC

3091 Governors

Lake Drive

Suite 500

Norcross, GA 30071

Various Letters of

Protection

Unknown $0.00 Unknown

Echelon Medical

Capital

Lockbox Services

206136

2975 Regent

Boulevard

Irving, TX 75063

Various Letters of

Protection

Unknown $0.00 Unknown

Med-Link Medical

Financial Group

8833 Perimeter Park

Boulevard

Suite 804

Jacksonville, FL

32216

Various Letters of

Protection

Unknown $0.00 Unknown

Momentum Funding

6001 Broken Sound

Parkway

Suite 150

Boca Raton, FL

33487

Various Letters of

Protection

Unknown $0.00 Unknown

Northern Trust

Company

PO Box 75965

Chicago, IL 60675

Final Judgment $1,945,461.17

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

Software Copyright (c) 1996-2019 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 6 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

Name

Name of creditor and

complete mailing address,

including zip code

Name, telephone number

and email address of

creditor contact

Nature of claim

(for example, trade

debts, bank loans,

professional services,

and government

contracts)

Indicate if claim

is contingent,

unliquidated, or

disputed

Amount of 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

Northern Trust

Company

PO Box 75965

Chicago, IL 60675

Guaranty of Note

secured by

Mortgage on real

property located

at 1447 Medical

Park Blvd., Units

101, 102 and 103,

Wellington, FL

33414

$709,817.01

Well States

Healthcare

333 Perry Street

Suite 302

Castle Rock, CO

80104

Various Letters of

Protection

Unknown $0.00 Unknown

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

Software Copyright (c) 1996-2019 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 7 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number (if known)

 Check if this is an

amended filing

Official Form 206Sum

Summary of Assets and Liabilities for Non-Individuals 12/15

Part 1: Summary of Assets

1. Schedule A/B: Assets-Real and Personal Property (Official Form 206A/B)

1a. Real property:

 Copy line 88 from Schedule A/B............................................................................................................................. $ 0.00

1b. Total personal property:

 Copy line 91A from Schedule A/B......................................................................................................................... $ 13,412,202.11

1c. Total of all property:

 Copy line 92 from Schedule A/B........................................................................................................................... $ 13,412,202.11

Part 2: Summary of Liabilities

2. Schedule D: Creditors Who Have Claims Secured by Property (Official Form 206D)

Copy the total dollar amount listed in Column A, Amount of claim, from line 3 of Schedule D.................................... $ 30,000.00

3. Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 206E/F)

3a. Total claim amounts of priority unsecured claims:

 Copy the total claims from Part 1 from line 5a of Schedule E/F.......................................................................... $ 0.00

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

 Copy the total of the amount of claims from Part 2 from line 5b of Schedule E/F................................................ +$ 2,655,278.18

4. Total liabilities .......................................................................................................................................................

Lines 2 + 3a + 3b $ 2,685,278.18

Official Form 206Sum Summary of Assets and Liabilities for Non-Individuals page 1

Software Copyright (c) 1996-2019 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 8 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number (if known)

 Check if this is an

amended filing

Official Form 206A/B

Schedule A/B: Assets - Real and Personal Property 12/15

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

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

which have no book value, such as fully depreciated assets or assets that were not capitalized. In Schedule A/B, list any executory contracts

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

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

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

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

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

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

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

Part 1: Cash and cash equivalents

1. Does the debtor have any cash or cash equivalents?

 No. Go to Part 2.

 Yes Fill in the information below.

All cash or cash equivalents owned or controlled by the debtor Current value of

debtor's interest

2. Cash on hand $40.00

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

Name of institution (bank or brokerage firm) Type of account Last 4 digits of account

number

3.1.

Branch Banking & Trust

Business Value Checking Checking 0498 $0.00

3.2.

Branch Banking & Trust

Neurological & Orthopedical Institute

of FL

Business Value Checking Checking 0471 $56.00

4. Other cash equivalents (Identify all)

5. Total of Part 1. $96.00

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

Part 2: Deposits and Prepayments

6. Does the debtor have any deposits or prepayments?

 No. Go to Part 3.

 Yes Fill in the information below.

Part 3: Accounts receivable

10. Does the debtor have any accounts receivable?

 No. Go to Part 4.

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 1

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 9 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

 Yes Fill in the information below.

11. Accounts receivable

11a. 90 days old or less: 473,430.41 - 0.00 = .... $473,430.41

face amount doubtful or uncollectible accounts

11b. Over 90 days old: 11,040,400.70 - 0.00 =.... $11,040,400.70

face amount doubtful or uncollectible accounts

12. Total of Part 3. $11,513,831.11

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

Part 4: Investments

13. Does the debtor own any investments?

 No. Go to Part 5.

 Yes Fill in the information below.

Part 5: Inventory, excluding agriculture assets

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

 No. Go to Part 6.

 Yes Fill in the information below.

Part 6: Farming and fishing-related assets (other than titled motor vehicles and land)

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

 No. Go to Part 7.

 Yes Fill in the information below.

Part 7: Office furniture, fixtures, and equipment; and collectibles

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

 No. Go to Part 8.

 Yes Fill in the information below.

General description Net book value of

debtor's interest

(Where available)

Valuation method used

for current value

Current value of

debtor's interest

39. Office furniture

Desk - 1

Conference Table

Chairs - 20

Exam Tables - 4 $0.00 $6,000.00

Viztek CR and Summit Integrity with Quantum

Q-Rad and Konica $0.00 $3,000.00

40. Office fixtures

41. Office equipment, including all computer equipment and

communication systems equipment and software

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 2

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 10 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

Desktop Computers with monitors - 12 $0.00 $2,000.00

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

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

collections; other collections, memorabilia, or collectibles

43. Total of Part 7. $11,000.00

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

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

 No

 Yes

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

 No

 Yes

Part 8: Machinery, equipment, and vehicles

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

 No. Go to Part 9.

 Yes Fill in the information below.

General description

Include year, make, model, and identification numbers

(i.e., VIN, HIN, or N-number)

Net book value of

debtor's interest

(Where available)

Valuation method used

for current value

Current value of

debtor's interest

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

47.1. 2017 Cadillac Escalada

VIN# 1GYS3HKJ4HR373273

This is a leased vehicle $0.00 $41,125.00

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

floating homes, personal watercraft, and fishing vessels

49. Aircraft and accessories

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

machinery and equipment)

51. Total of Part 8. $41,125.00

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

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

 No

 Yes

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

 No

 Yes

Part 9: Real property

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

 No. Go to Part 10.

 Yes Fill in the information below.

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 3

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 11 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

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

Description and location of

property

Include street address or other

description such as Assessor

Parcel Number (APN), and type

of property (for example,

acreage, factory, warehouse,

apartment or office building, if

available.

Nature and

extent of

debtor's interest

in property

Net book value of

debtor's interest

(Where available)

Valuation method used

for current value

Current value of

debtor's interest

55.1. Lease for medical

office space located

at:

1447 Medical Park

Boulevard

Suite 101

Wellington, FL 33414 Lease $0.00 $0.00

55.2. Lease for medical

office space located

at:

4848 Coconut Creek

Parkway

Suite 200

Coconut Creek, FL

33063 Lease $0.00 $0.00

55.3. Lease for medical

office space located

at:

644 Cesery

Boulevard

Jacksonville, FL

32211 Lease $0.00 $0.00

56. Total of Part 9. $0.00

Add the current value on lines 55.1 through 55.6 and entries from any additional sheets.

Copy the total to line 88.

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

 No

 Yes

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

 No

 Yes

Part 10: Intangibles and intellectual property

59. Does the debtor have any interests in intangibles or intellectual property?

 No. Go to Part 11.

 Yes Fill in the information below.

Part 11: All other assets

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

Include all interests in executory contracts and unexpired leases not previously reported on this form.

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 4

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 12 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

 No. Go to Part 12.

 Yes Fill in the information below.

Current value of

debtor's interest

71. Notes receivable

Description (include name of obligor)

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

Description (for example, federal, state, local)

73. Interests in insurance policies or annuities

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

has been filed)

Palm Beach Brain & Spine, LLC v. Cassidy Camp

Case Number 502019CA006841XXXXMB

Circuit Court of the 15th Judicial Circuit in and for Palm

Beach County, Florida Unknown

Nature of claim

Amount requested $0.00

Palm Beach Brain & Spine, LLC v. Steve Bowman

502018CA015548

Circuit Court of the 15th Judicial Circuit in and for Palm

Beach County, Florida Unknown

Nature of claim

Amount requested $0.00

Palm Beach Brain & Spine, LLC, assignee of Felix Than

v. State Farm Mutual Automobile Insurance

50-2016-SC-005460-XXXX-SB Unknown

Nature of claim Personal Injury Protection

Claim

Amount requested $0.00

Palm Beach Brain & Spine, LLC, as assignee of Puentes

Leticia v. United Automobile Insurance Company

50-2016-CC-007356-XXXX-SB Unknown

Nature of claim Personal Injury Protection

Claim

Amount requested $0.00

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

every nature, including counterclaims of the debtor and rights to

set off claims

76. Trusts, equitable or future interests in property

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

country club membership

Letter of Protection for services provided to OG

Lien in favor of Gallop $44,149.00

Letter of Protection for services provided to JN

Lien in favor of Momentum $53,315.00

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 5

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 13 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

Letter of Protection for services provided to JM

Lien in favor of Momentum $18,050.00

Letter of Protection for services provided to AS

Lien in favor of Momentum $62,650.00

Letter of Protection for services provided to SP

Lien in favor of Momentum $12,000.00

Letter of Protection for services provided to FC

Lien in favor of Momentum $46,300.00

Letter of Protection for services provided to AET

Lien in favor of Momentum $22,900.00

Letter of Protection for services provided to JD

Lien in favor of Med-Link $83,170.00

Letter of Protection for services provided to RP

Lien in favor of Med-Link $36,570.00

Letter of Protection for services provided to SK

Lien in favor of American Horizon $19,400.00

Letter of Protection for services provided to MR

Lien in favor of American Horizon $46,355.00

Letter of Protection for services provided to SN

Lien in favor of American Horizon $37,110.00

Letter of Protection for services provided to RA

Lien in favor of American Horizon $26,590.00

Letter of Protection for services provided to MT

Lien in favor of Echelon $8,250.00

Letter of Protection for services provided to GG

Lien in favor of Echelon $22,210.00

Letter of Protection for services provided to CJ

Lien in favor of Echelon $17,330.00

Letter of Protection for services provided to MM

Lien in favor of Echelon $22,080.00

Letter of Protection for services provided to LK

Lien in favor of Echelon $32,125.00

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 6

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 14 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

Letter of Protection for services provided to TK

Lien in favor of Echelon $48,890.00

Letter of Protection for services provided to TCB

Lien in favor of Echelon $23,474.00

Letter of Protection for services provided to WR

Lien in favor of Echelon $42,800.00

Letter of Protection for services provided to SN

Lien in favor of Echelon $34,120.00

Letter of Protection for services provided to JL

Lien in favor of Echelon $37,390.00

Letter of Protection for services provided to PB

Lien in favor of Echelon $23,200.00

Letter of Protection for services provided to DM

Lien in favor of Echelon $30,580.00

Letter of Protection for services provided to BS

Lien in favor of Echelon $29,640.00

Letter of Protection for services provided to WT

Lien in favor of Echelon $33,090.00

Letter of Protection for services provided to BB

Lien in favor of Echelon $25,685.00

Letter of Protection for services provided to DC

Lien in favor of Echelon $23,740.00

Letter of Protection for services provided to MK

Lien in favor of Echelon $54,365.00

Letter of Protection for services provided to DJ

Lien in favor of Echelon $31,055.00

Letter of Protection for services provided to JD

Lien in favor of Echelon $18,100.00

Letter of Protection for services provided to LW

Lien in favor of Echelon $16,850.00

Letter of Protection for services provided to PF

Lien in favor of Echelon $21,185.00

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 7

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 15 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

Letter of Protection for services provided to DD

Lien in favor of Echelon $27,545.00

Letter of Protection for services provided to RP

Lien in favor of Echelon $2,300.00

Letter of Protection for services provided to AA

Lien in favor of Echelon $43,730.00

Letter of Protection for services provided to LL

Lien in favor of Echelon $26,345.00

Letter of Protection for services provided to RM

Lien in favor of Echelon $29,550.00

Letter of Protection for services provided to ND

Lien in favor of Echelon $17,160.00

Letter of Protection for services provided to CVW

Lien in favor of Echelon $31,350.00

Letter of Protection for services provided to ET

Lien in favor of Echelon $5,825.00

Letter of Protection for services provided to PJ

Lien in favor of Echelon $19,370.00

Letter of Protection for services provided to ED

Lien in favor of Echelon $30,105.00

Letter of Protection for services provided to HA

Lien in favor of Echelon $29,030.00

Letter of Protection for services provided to JP

Lien in favor of Echelon $17,045.00

Letter of Protection for services provided to RN

Lien in favor of Echelon $18,950.00

Letter of Protection for services provided to PM

Lien in favor of Echelon $14,815.00

Letter of Protection for services provided to CF

Lien in favor of Echelon $14,720.00

Letter of Protection for services provided to DB

Lien in favor of Echelon $13,160.00

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 8

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 16 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

Letter of Protection for services provided to KW

Lien in favor of Echelon $13,757.00

Letter of Protection for services provided to MM

Lien in favor of Echelon $21,160.00

Letter of Protection for services provided to JB

Lien in favor of Echelon $30,745.00

Letter of Protection for services provided to PJ

Lien in favor of Echelon $20,900.00

Letter of Protection for services provided to SB

Lien in favor of Echelon $23,835.00

Letter of Protection for services provided to FJ

Lien in favor of Echelon $15,450.00

Letter of Protection for services provided to LS

Lien in favor of Echelon $18,955.00

Letter of Protection for services provided to AT

Lien in favor of Echelon $25,170.00

Letter of Protection for services provided to AV

Lien in favor of Echelon $24,090.00

Letter of Protection for services provided to EL

Lien in favor of Echelon $25,935.00

Letter of Protection for services provided to MVJ

Lien in favor of Echelon $15,320.00

Letter of Protection for services provided to RP

Lien in favor of Echelon $15,095.00

Letter of Protection for services provided to SK

Lien in favor of Echelon $16,045.00

Letter of Protection for services provided to RJ

Lien in favor of Echelon $7,900.00

Letter of Protection for services provided to RMC

Lien in favor of Echelon $18,390.00

Letter of Protection for services provided to FMY

Lien in favor of Echelon $36,930.00

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 9

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 17 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

Letter of Protection for services provided to SJ

Lien in favor of Echelon $43,470.00

Letter of Protection for services provided to HS

Lien in favor of Echelon $27,285.00

78. Total of Part 11. $1,846,150.00

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

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

 No

 Yes

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 10

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 18 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (If known)

Name

Part 12: Summary

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

Type of property Current value of

personal property

Current value of real

property

80. Cash, cash equivalents, and financial assets.

Copy line 5, Part 1 $96.00

81. Deposits and prepayments. Copy line 9, Part 2. $0.00

82. Accounts receivable. Copy line 12, Part 3. $11,513,831.11

83. Investments. Copy line 17, Part 4. $0.00

84. Inventory. Copy line 23, Part 5. $0.00

85. Farming and fishing-related assets. Copy line 33, Part 6. $0.00

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

Copy line 43, Part 7. $11,000.00

87. Machinery, equipment, and vehicles. Copy line 51, Part 8. $41,125.00

88. Real property. Copy line 56, Part 9.........................................................................................> $0.00

89. Intangibles and intellectual property. Copy line 66, Part 10. $0.00

90. All other assets. Copy line 78, Part 11. + $1,846,150.00

91. Total. Add lines 80 through 90 for each column $13,412,202.11 + 91b. $0.00

92. Total of all property on Schedule A/B. Add lines 91a+91b=92 $13,412,202.11

Official Form 206A/B Schedule A/B Assets - Real and Personal Property page 11

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 19 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number (if known)

 Check if this is an

amended filing

Official Form 206D

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

Be as complete and accurate as possible.

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

 No. Check this box and submit page 1 of this form to the court with debtor's other schedules. Debtor has nothing else to report on this form.

 Yes. Fill in all of the information below.

Part 1: List Creditors Who Have Secured Claims

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

claim, list the creditor separately for each claim.

Column A

Amount of claim

Do not deduct the value

of collateral.

Column B

Value of collateral

that supports this

claim

2.1 American Horizon Financial Describe debtor's property that is subject to a lien Unknown $0.00

Creditor's Name Various Letters of Protection

5571 N University Dr

Suite 104

Pompano Beach, FL 33067

Creditor's mailing address Describe the lien

Security Agreement

Is the creditor an insider or related party?

 No

Creditor's email address, if known  Yes

Is anyone else liable on this claim?

Date debt was incurred  No

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

Last 4 digits of account number

Do multiple creditors have an

interest in the same property?

As of the petition filing date, the claim is:

Check all that apply

 No  Contingent

 Unliquidated

 Disputed

 Yes. Specify each creditor,

including this creditor and its relative

priority.

2.2

Carecentric Investments I,

LLC Describe debtor's property that is subject to a lien Unknown $0.00

Creditor's Name Various Letters of Protection

3091 Governors Lake Drive

Suite 500

Norcross, GA 30071

Creditor's mailing address Describe the lien

Security Agreement

Is the creditor an insider or related party?

 No

Creditor's email address, if known  Yes

Is anyone else liable on this claim?

Date debt was incurred  No

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

Last 4 digits of account number

Do multiple creditors have an

interest in the same property?

As of the petition filing date, the claim is:

Check all that apply

Official Form 206D Schedule D: Creditors Who Have Claims Secured by Property page 1 of 4

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 20 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if know)

Name

 No  Contingent

 Unliquidated

 Disputed

 Yes. Specify each creditor,

including this creditor and its relative

priority.

2.3 Echelon Medical Capital Describe debtor's property that is subject to a lien Unknown $0.00

Creditor's Name Various Letters of Protection

Lockbox Services 206136

2975 Regent Boulevard

Irving, TX 75063

Creditor's mailing address Describe the lien

Security Agreement

Is the creditor an insider or related party?

 No

Creditor's email address, if known  Yes

Is anyone else liable on this claim?

Date debt was incurred  No

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

Last 4 digits of account number

Do multiple creditors have an

interest in the same property?

As of the petition filing date, the claim is:

Check all that apply

 No  Contingent

 Unliquidated

 Disputed

 Yes. Specify each creditor,

including this creditor and its relative

priority.

2.4

Med-Link Medical Financial

Group Describe debtor's property that is subject to a lien Unknown $0.00

Creditor's Name Various Letters of Protection

8833 Perimeter Park

Boulevard

Suite 804

Jacksonville, FL 32216

Creditor's mailing address Describe the lien

Security Agreement

Is the creditor an insider or related party?

 No

Creditor's email address, if known  Yes

Is anyone else liable on this claim?

Date debt was incurred  No

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

Last 4 digits of account number

Do multiple creditors have an

interest in the same property?

As of the petition filing date, the claim is:

Check all that apply

 No  Contingent

 Unliquidated

 Disputed

 Yes. Specify each creditor,

including this creditor and its relative

priority.

2.5 Momentum Funding Describe debtor's property that is subject to a lien Unknown $0.00

Creditor's Name Various Letters of Protection

6001 Broken Sound

Parkway

Suite 150

Boca Raton, FL 33487

Creditor's mailing address Describe the lien

Security Agreement

Official Form 206D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page 2 of 4

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 21 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if know)

Name

Is the creditor an insider or related party?

 No

Creditor's email address, if known  Yes

Is anyone else liable on this claim?

Date debt was incurred  No

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

Last 4 digits of account number

Do multiple creditors have an

interest in the same property?

As of the petition filing date, the claim is:

Check all that apply

 No  Contingent

 Unliquidated

 Disputed

 Yes. Specify each creditor,

including this creditor and its relative

priority.

2.6 Well States Healthcare Describe debtor's property that is subject to a lien Unknown $0.00

Creditor's Name Various Letters of Protection

333 Perry Street

Suite 302

Castle Rock, CO 80104

Creditor's mailing address Describe the lien

Security Agreement

Is the creditor an insider or related party?

 No

Creditor's email address, if known  Yes

Is anyone else liable on this claim?

Date debt was incurred  No

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

Last 4 digits of account number

Do multiple creditors have an

interest in the same property?

As of the petition filing date, the claim is:

Check all that apply

 No  Contingent

 Unliquidated

 Disputed

 Yes. Specify each creditor,

including this creditor and its relative

priority.

2.7 Wells Fargo As CTL AGT Describe debtor's property that is subject to a lien $30,000.00 $41,125.00

Creditor's Name 2017 Cadillac Escalada

VIN# 1GYS3HKJ4HR373273

This is a leased vehicle

P.O Box 9000

Lutherville Timonium, MD

21094

Creditor's mailing address Describe the lien

Lease

Is the creditor an insider or related party?

 No

Creditor's email address, if known  Yes

Is anyone else liable on this claim?

Date debt was incurred  No

12/19/2017  Yes. Fill out Schedule H: Codebtors (Official Form 206H)

Last 4 digits of account number

Do multiple creditors have an

interest in the same property?

As of the petition filing date, the claim is:

Check all that apply

 No  Contingent

 Unliquidated

 Disputed

 Yes. Specify each creditor,

including this creditor and its relative

priority.

Official Form 206D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page 3 of 4

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 22 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if know)

Name

3. Total of the dollar amounts from Part 1, Column A, including the amounts from the Additional Page, if any. $30,000.00

Part 2: List Others to Be Notified for a Debt Already Listed in Part 1

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

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

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

Name and address On which line in Part 1 did

you enter the related creditor?

Last 4 digits of

account number for

this entity

LITVAK BEASLEY WILSON & BALL, LLP

226 East Government Street

Birmingham, AL 35202

Line 2.2 

Official Form 206D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page 4 of 4

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 23 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number (if known)

 Check if this is an

amended filing

Official Form 206E/F

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

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

List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule A/B: Assets - Real and

Personal Property (Official Form 206A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 206G). Number the entries in Parts 1 and

2 in the boxes on the left. If more space is needed for Part 1 or Part 2, fill out and attach the Additional Page of that Part included in this form.

Part 1: List All Creditors with PRIORITY Unsecured Claims

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

 No. Go to Part 2.

 Yes. Go to line 2.

2. List in alphabetical order all creditors who have unsecured claims that are entitled to priority in whole or in part. If the debtor has more than 3 creditors

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

Total claim Priority amount

2.1 Priority creditor's name and mailing address As of the petition filing date, the claim is: $0.00 $0.00

Palm Beach County - Tax Collector

301 North Olive Avenue

West Palm Beach, FL 33401

Check all that apply.

 Contingent

 Unliquidated

 Disputed

Date or dates debt was incurred Basis for the claim:

Last 4 digits of account number

Specify Code subsection of PRIORITY

unsecured claim: 11 U.S.C. § 507(a) (8)

Is the claim subject to offset?

 No

 Yes

Part 2: List All Creditors with NONPRIORITY Unsecured Claims

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

out and attach the Additional Page of Part 2.

Amount of claim

3.1 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $1,945,461.17

Northern Trust Company

PO Box 75965

Chicago, IL 60675

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Final Judgment 

Is the claim subject to offset?  No  Yes

3.2 Nonpriority creditor's name and mailing address As of the petition filing date, the claim is: Check all that apply. $709,817.01

Northern Trust Company

PO Box 75965

Chicago, IL 60675

Date(s) debt was incurred 

Last 4 digits of account number 

 Contingent

 Unliquidated

 Disputed

Basis for the claim: Guaranty of Note secured by Mortgage on real 

property located at 1447 Medical Park Blvd., Units 101, 102 and 103, 

Wellington, FL 33414 

Is the claim subject to offset?  No  Yes

Part 3: List Others to Be Notified About Unsecured Claims

Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of 2

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 24 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

Name

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

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

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

Name and mailing address On which line in Part1 or Part 2 is the

related creditor (if any) listed?

Last 4 digits of

account number, if

any

Part 4: Total Amounts of the Priority and Nonpriority Unsecured Claims

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

Total of claim amounts

5a. Total claims from Part 1 5a. $ 0.00

5b. Total claims from Part 2 5b. + $ 2,655,278.18

5c. Total of Parts 1 and 2

Lines 5a + 5b = 5c. 5c. $ 2,655,278.18

Official Form 206 E/F Schedule E/F: Creditors Who Have Unsecured Claims Page 2 of 2

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 25 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number (if known)

 Check if this is an

amended filing

Official Form 206G

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

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

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

 Yes. Fill in all of the information below even if the contacts of leases are listed on Schedule A/B: Assets - Real and Personal Property

(Official Form 206A/B).

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

whom the debtor has an executory contract or unexpired

lease

2.1. State what the contract or

lease is for and the nature of

the debtor's interest

Lease for real property

located 644 Cesery

Boulevard,

Jacksonville, FL 32211

644 Cesery Corporation

P.O. 2426

Orange Park, FL 32067

State the term remaining

List the contract number of any

government contract

2.2. State what the contract or

lease is for and the nature of

the debtor's interest

Lease for medical

office space located

4848 Coconut Creek

Parkway, Unit 200,

Coconut Creek, FL

33063

Hamsa Hand Holdings LLC,

2700 West Cypress Creek Road, Suite C-10

Fort Lauderdale, FL 33309

State the term remaining

List the contract number of any

government contract

Official Form 206G Schedule G: Executory Contracts and Unexpired Leases Page 1 of 1

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 26 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number (if known)

 Check if this is an

amended filing

Official Form 206H

Schedule H: Your Codebtors 12/15

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

Additional Page to this page.

1. Do you have any codebtors?

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

 Yes

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

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

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

Column 1: Codebtor Column 2: Creditor

Name Mailing Address Name Check all schedules

that apply:

2.1  D

Street  E/F

 G

City State Zip Code

2.2  D

Street  E/F

 G

City State Zip Code

2.3  D

Street  E/F

 G

City State Zip Code

2.4  D

Street  E/F

 G

City State Zip Code

Official Form 206H Schedule H: Your Codebtors Page 1 of 1

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 27 of 40
Fill in this information to identify the case:

Debtor name Palm Beach Brain and Spine, LLC

United States Bankruptcy Court for the: SOUTHERN DISTRICT OF FLORIDA

Case number (if known)

 Check if this is an

amended filing

Official Form 207

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

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

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

Part 1: Income

1. Gross revenue from business

 None.

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

which may be a calendar year

Sources of revenue

Check all that apply

Gross revenue

(before deductions and

exclusions)

From the beginning of the fiscal year to filing date:

From 1/01/2019 to Filing Date

 Operating a business $1,053,627.61

 Other

For prior year:

From 1/01/2018 to 12/31/2018

 Operating a business $1,761,868.94

 Other

For year before that:

From 1/01/2017 to 12/31/2017

 Operating a business $2,933,894.00

 Other

2. Non-business revenue

Include revenue regardless of whether that revenue is taxable. Non-business income may include interest, dividends, money collected from lawsuits,

and royalties. List each source and the gross revenue for each separately. Do not include revenue listed in line 1.

 None.

Description of sources of revenue Gross revenue from

each source

(before deductions and

exclusions)

Part 2: List Certain Transfers Made Before Filing for Bankruptcy

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

List payments or transfers--including expense reimbursements--to any creditor, other than regular employee compensation, within 90 days before

filing this case unless the aggregate value of all property transferred to that creditor is less than $6,825. (This amount may be adjusted on 4/01/22

and every 3 years after that with respect to cases filed on or after the date of adjustment.)

 None.

Creditor's Name and Address Dates Total amount of value Reasons for payment or transfer

Check all that apply

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

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

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 1

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Debtor Palm Beach Brain and Spine, LLC Case number (if known)

or cosigned by an insider unless the aggregate value of all property transferred to or for the benefit of the insider is less than $6,825. (This amount

may be adjusted on 4/01/22 and every 3 years after that with respect to cases filed on or after the date of adjustment.) Do not include any payments

listed in line 3. Insiders include officers, directors, and anyone in control of a corporate debtor and their relatives; general partners of a partnership

debtor and their relatives; affiliates of the debtor and insiders of such affiliates; and any managing agent of the debtor. 11 U.S.C. § 101(31).

 None.

Insider's name and address

Relationship to debtor

Dates Total amount of value Reasons for payment or transfer

5. Repossessions, foreclosures, and returns

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

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

 None

Creditor's name and address Describe of the Property Date Value of property

6. Setoffs

List any creditor, including a bank or financial institution, that within 90 days before filing this case set off or otherwise took anything from an account

of the debtor without permission or refused to make a payment at the debtor’s direction from an account of the debtor because the debtor owed a

debt.

 None

Creditor's name and address Description of the action creditor took Date action was

taken

Amount

Part 3: Legal Actions or Assignments

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

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

in any capacity—within 1 year before filing this case.

 None.

Case title

Case number

Nature of case Court or agency's name and

address

Status of case

7.1. CARECENTRIC

INVESTMENTS I, LLC, F/K/A

CARECENTRIC-GALLOP P.I.

CAPITAL PARTNERS, LLC, a

Delaware limited liability

company v.

PALM BEACH BRAIN &

SPINE, LLC individually and

d/b/a MIDTOWN

REHABILITATION CENTER

d/b/a MIDTOWN REHAB AND

AQUATIC THERAPY d/b/a

NEUROLOGICAL &

ORTHOPEDIC INSTITUTE OF

FLORIDA, and d/b/a

NEUROLOGICAL &

ORTHOPEDIC INSTITUTE OF

FL, a Florida limited liability

company;

PALM BEACH BRAIN &

SPINE, P.A., a dissolved

Florida corp

CASE NO. 2017-CA-010593

Breach of contract 15th Judicial Circuit

205 N Dixie Highway

West Palm Beach, FL 33401

 Pending

 On appeal

 Concluded

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 2

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 29 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

Case title

Case number

Nature of case Court or agency's name and

address

Status of case

7.2. Palm Beach Brain & Spine,

LLC v. Cassidy Camp

502019CA006841XXXXMB

Breach of contract 15th Judicial Circuit

205 N Dixie Highway

West Palm Beach, FL 33401

 Pending

 On appeal

 Concluded

7.3. Palm Beach Brain & Spine,

LLC v. Steve Bowman

502018CA015548

Breach of contract 15th Judicial Circuit

205 N Dixie Highway

West Palm Beach, FL 33401

 Pending

 On appeal

 Concluded

7.4. Northern Trust Company v.

Midtown Outpatient Surgery

Center, LLC, et al.

502019-CA-004818-XXXX-MB

Breach of contract 15th Judicial Circuit

205 N Dixie Highway

West Palm Beach, FL 33401

 Pending

 On appeal

 Concluded

7.5. Anne Gannon v. Wycliffe

Dental Center, Inc., et al.

50-2019-CA-006411-XXXX-MB

Annual Validation

Tax Warrants

15th Judicial Circuit

205 N Dixie Highway

West Palm Beach, FL 33401

 Pending

 On appeal

 Concluded

7.6. Alfonso Blasquez.

Interventional Pain and

Wellness Institute, et al.

50-2017-CA-009870-XXXX-MB

Petition for

Equitable

Distribution

15th Judicial Circuit

205 N Dixie Highway

West Palm Beach, FL 33401

 Pending

 On appeal

 Concluded

7.7. Palm Beach Brain & Spine,

LLC, assignee of Felix Than v.

State Farm Mutual

Automobile Insurance

50-2016-SC-005460-XXXX-SB

Personal Injury

Protection Claim

15th Judicial Circuit

205 N Dixie Highway

West Palm Beach, FL 33401

 Pending

 On appeal

 Concluded

7.8. Palm Beach Brain & Spine,

LLC, as assignee of Puentes

Leticia v. United Automobile

Insurance Company

50-2016-CC-007356-XXXX-SB

Personal Injury

Protection Claim

15th Judicial Circuit

205 N Dixie Highway

West Palm Beach, FL 33401

 Pending

 On appeal

 Concluded

7.9. Momentum Funding, LLC v.

Palm Beach Brain & Spine,

LLC

01-18-0003-4089

Breach of

Contract

American Arbitration

Assoc.

120 Broadway

21st Floor

New York, NY 10271

 Pending

 On appeal

 Concluded

7.10

.

Med-Link Capital, LLC and

Medical Financial Group

Holdings, LLC v. Palm Beach

Brain & Spine LLC,

01-18-0003-4102

Breach of

Contract

American Arbitration

Assoc.

120 Broadway

21st Floor

New York, NY 10271

 Pending

 On appeal

 Concluded

8. Assignments and receivership

List any property in the hands of an assignee for the benefit of creditors during the 120 days before filing this case and any property in the hands of a

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

 None

Part 4: Certain Gifts and Charitable Contributions

9. List all gifts or charitable contributions the debtor gave to a recipient within 2 years before filing this case unless the aggregate value of

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

 None

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 3

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 30 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

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

Part 5: Certain Losses

10. All losses from fire, theft, or other casualty within 1 year before filing this case.

 None

Description of the property lost and

how the loss occurred

Amount of payments received for the loss

If you have received payments to cover the loss, for

example, from insurance, government compensation, or

tort liability, list the total received.

List unpaid claims on Official Form 106A/B (Schedule

A/B: Assets – Real and Personal Property).

Dates of loss Value of property

lost

Part 6: Certain Payments or Transfers

11. Payments related to bankruptcy

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

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

relief, or filing a bankruptcy case.

 None.

Who was paid or who received

the transfer?

Address

If not money, describe any property transferred Dates Total amount or

value

11.1. Kelley, Fulton & Kaplan, P.L.

1665 Palm Beach Lakes

Boulevard

The Forum - Suite 1000

West Palm Beach, FL 33401 $27,500.00

Email or website address

Who made the payment, if not debtor?

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

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

to a self-settled trust or similar device.

Do not include transfers already listed on this statement.

 None.

Name of trust or device Describe any property transferred Dates transfers

were made

Total amount or

value

13. Transfers not already listed on this statement

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

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

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

 None.

Who received transfer?

Address

Description of property transferred or

payments received or debts paid in exchange

Date transfer

was made

Total amount or

value

Part 7: Previous Locations

14. Previous addresses

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

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 4

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 31 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

 Does not apply

Address Dates of occupancy

From-To

Part 8: Health Care Bankruptcies

15. Health Care bankruptcies

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

- diagnosing or treating injury, deformity, or disease, or

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

 No. Go to Part 9.

 Yes. Fill in the information below.

Facility name and address Nature of the business operation, including type of services

the debtor provides

If debtor provides meals

and housing, number of

patients in debtor’s care

15.1. Palm Beach Brain & Spine,

LLC

1447 Medical Park Boulevard

Suite 101

Wellington, FL 33414

Medical Practice

Location where patient records are maintained (if different from

facility address). If electronic, identify any service provider.

How are records kept?

1447 Medical Park Boulevard, Suite 101

Wellington, FL 33414

Check all that apply:

 Electronically

 Paper

15.2. Palm Beach Brain & Spine,

LLC

4848 Coconut Creek

Parkway

Suite 200

Pompano Beach, FL 33063

Medical Practice

Location where patient records are maintained (if different from

facility address). If electronic, identify any service provider.

How are records kept?

4848 Coconut Creek Parkway

Suite 200

Coconut Creek, FL 33063

Check all that apply:

 Electronically

 Paper

15.3. Palm Beach Brain & Spine,

LLC

644 Cesery Boulevard

Jacksonville, FL 32211

Medical practice

Location where patient records are maintained (if different from

facility address). If electronic, identify any service provider.

How are records kept?

644 Cesery Boulevard

Jacksonville, FL 32211

Check all that apply:

 Electronically

 Paper

Part 9: Personally Identifiable Information

16. Does the debtor collect and retain personally identifiable information of customers?

 No.

 Yes. State the nature of the information collected and retained.

Social Security Numbers

Does the debtor have a privacy policy about that information?

 No

 Yes

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 5

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 32 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

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

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

 No. Go to Part 10.

 Yes. Does the debtor serve as plan administrator?

Part 10: Certain Financial Accounts, Safe Deposit Boxes, and Storage Units

18. Closed financial accounts

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

moved, or transferred?

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

cooperatives, associations, and other financial institutions.

 None

Financial Institution name and

Address

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

19. Safe deposit boxes

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

case.

 None

Depository institution name and address Names of anyone with

access to it

Address

Description of the contents Do you still

have it?

20. Off-premises storage

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

which the debtor does business.

 None

Facility name and address Names of anyone with

access to it

Description of the contents Do you still

have it?

Part 11: Property the Debtor Holds or Controls That the Debtor Does Not Own

21. Property held for another

List any property that the debtor holds or controls that another entity owns. Include any property borrowed from, being stored for, or held in trust. Do

not list leased or rented property.

 None

Part 12: Details About Environment Information

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

Environmental law means any statute or governmental regulation that concerns pollution, contamination, or hazardous material, regardless of the

medium affected (air, land, water, or any other medium).

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

owned, operated, or utilized.

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

similarly harmful substance.

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

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

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 6

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 33 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

 No.

 Yes. Provide details below.

Case title

Case number

Court or agency name and

address

Nature of the case Status of case

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

environmental law?

 No.

 Yes. Provide details below.

Site name and address Governmental unit name and

address

Environmental law, if known Date of notice

24. Has the debtor notified any governmental unit of any release of hazardous material?

 No.

 Yes. Provide details below.

Site name and address Governmental unit name and

address

Environmental law, if known Date of notice

Part 13: Details About the Debtor's Business or Connections to Any Business

25. Other businesses in which the debtor has or has had an interest

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

Include this information even if already listed in the Schedules.

 None

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

Do not include Social Security number or ITIN.

Dates business existed

26. Books, records, and financial statements

26a. List all accountants and bookkeepers who maintained the debtor’s books and records within 2 years before filing this case.

 None

Name and address Date of service

From-To

26a.1. Kriss Hammond, CPA

1935 Commerce Lane

Suite 6

Jupiter, FL 33458

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

within 2 years before filing this case.

 None

26c. List all firms or individuals who were in possession of the debtor’s books of account and records when this case is filed.

 None

Name and address If any books of account and records are

unavailable, explain why

26d. List all financial institutions, creditors, and other parties, including mercantile and trade agencies, to whom the debtor issued a financial

statement within 2 years before filing this case.

 None

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 7

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 34 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

Name and address

27. Inventories

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

 No

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

Name of the person who supervised the taking of the

inventory

Date of inventory The dollar amount and basis (cost, market,

or other basis) of each inventory

28. List the debtor’s officers, directors, managing members, general partners, members in control, controlling shareholders, or other people

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

Name Address Position and nature of any

interest

% of interest, if

any

Amos Dare, M.D. 1447 Medical Park Boulevard

Suite 101

Wellington, FL 33414

Manager

Name Address Position and nature of any

interest

% of interest, if

any

Amose Dare and Maria

Marchetti TBTE Trus

1447 Medical Park Boulevard

Wellington, FL 33414

100%

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

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

 No

 Yes. Identify below.

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

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

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

 No

 Yes. Identify below.

Name and address of recipient Amount of money or description and value of

property

Dates Reason for

providing the value

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

 No

 Yes. Identify below.

Name of the parent corporation Employer Identification number of the parent

corporation

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

 No

 Yes. Identify below.

Name of the pension fund Employer Identification number of the parent

corporation

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 8

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 35 of 40
Debtor Palm Beach Brain and Spine, LLC Case number (if known)

Part 14: Signature and Declaration

WARNING -- Bankruptcy fraud is a serious crime. Making a false statement, concealing property, or obtaining money or property by fraud in

connection with a bankruptcy case can result in fines up to $500,000 or imprisonment for up to 20 years, or both.

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

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

and correct.

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

Executed on August 14, 2019

/s/ Dr. Amos O. Dare Dr. Amos O. Dare

Signature of individual signing on behalf of the debtor Printed name

Position or relationship to debtor Manager

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

 No

 Yes

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 9

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 36 of 40
United States Bankruptcy Court

Southern District of Florida

In re Palm Beach Brain and Spine, LLC Case No.

Debtor(s) Chapter 11

LIST OF EQUITY SECURITY HOLDERS

Following is the list of the Debtor's equity security holders which is prepared in accordance with rule 1007(a)(3) for filing in this Chapter 11 Case

Name and last known address or place of

business of holder

Security Class Number of Securities Kind of Interest

Amos Dare and Maria Marchetti TBTE Trust

1447 Medical Park Boulevard

Wellington, FL 33414

100% Member

DECLARATION UNDER PENALTY OF PERJURY ON BEHALF OF CORPORATION OR PARTNERSHIP

I, the Manager of the corporation named as the debtor in this case, declare under penalty of perjury that I have read

the foregoing List of Equity Security Holders and that it is true and correct to the best of my information and belief.

Date August 14, 2019 Signature /s/ Dr. Amos O. Dare

Dr. Amos O. Dare

Penalty for making a false statement of concealing property: Fine of up to $500,000 or imprisonment for up to 5 years or both.

 18 U.S.C. §§ 152 and 3571.

Sheet 1 of 1 in List of Equity Security Holders

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 37 of 40
United States Bankruptcy Court

Southern District of Florida

In re Palm Beach Brain and Spine, LLC Case No.

Debtor(s) Chapter 11

VERIFICATION OF CREDITOR MATRIX

I, the Manager of the corporation named as the debtor in this case, hereby verify that the attached list of creditors is true and correct to

the best of my knowledge.

Date: August 14, 2019 /s/ Dr. Amos O. Dare

Dr. Amos O. Dare/Manager

Signer/Title

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Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 38 of 40
}bk1{Credito AresMatix}bk{

American Horizon Financial

5571 N University Dr

Suite 104

Pompano Beach, FL 33067

Carecentric Investments I, LLC

3091 Governors Lake Drive

Suite 500

Norcross, GA 30071

Echelon Medical Capital

Lockbox Services 206136

2975 Regent Boulevard

Irving, TX 75063

Hamsa Hand Holdings LLC,

2700 West Cypress Creek Road, Suite C-10

Fort Lauderdale, FL 33309

LITVAK BEASLEY WILSON & BALL, LLP

226 East Government Street

Birmingham, AL 35202

Med-Link Medical Financial Group

8833 Perimeter Park Boulevard

Suite 804

Jacksonville, FL 32216

Momentum Funding

6001 Broken Sound Parkway

Suite 150

Boca Raton, FL 33487

Northern Trust Company

PO Box 75965

Chicago, IL 60675

Palm Beach County - Tax Collector

301 North Olive Avenue

West Palm Beach, FL 33401

Well States Healthcare

333 Perry Street

Suite 302

Castle Rock, CO 80104

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 39 of 40
Wells Fargo As CTL AGT

P.O Box 9000

Lutherville Timonium, MD 21094

Case 19-20831-MAM Doc 1 Filed 08/14/19 Page 40 of 40