Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 02/20

The bankruptcy forms use you and Debtor 1 to refer to a debtor filing alone. A married couple may file a bankruptcy case together—called a 

joint case—and in joint cases, these forms use you to ask for information from both debtors. For example, if a form asks, “Do you own a car,” 

the answer would be yes if either debtor owns a car. When information is needed about the spouses separately, the form uses Debtor 1 and 

Debtor 2 to distinguish between them. In joint cases, one of the spouses must report information as Debtor 1 and the other as Debtor 2. The 

same person must be Debtor 1 in all of the forms.

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: Identify Yourself

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 

1. Your full name

Write the name that is on your

government-issued picture

identification (for example,

your driver’s license or

passport).

Bring your picture

identification to your meeting

with the trustee.

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

___________________________

Suffix (Sr., Jr., II, III)

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

___________________________

Suffix (Sr., Jr., II, III)

2. All other names you

have used in the last 8

years

Include your married or

maiden names.

3. Only the last 4 digits of

your Social Security

number or federal

Individual Taxpayer

Identification number

(ITIN)

xxx – xx – ____ ____ ____ ____

OR

9 xx – xx – ____ ____ ____ ____

xxx – xx – ____ ____ ____ ____

OR

9 xx – xx – ____ ____ ____ ____

United States Bankruptcy Court for the:

____________________ District of _________________

(State) 

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

 Chapter 7 

 Chapter 11

 Chapter 12

 Chapter 13

 Fill in this information to identify your case:

 Check if this is an

amended filing

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 1

Mederos

✔

Raquel

Southern District of Florida

3 7 3 0

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 1 of 58
About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 

4. Any business names

and Employer

Identification Numbers

(EIN) you have used in

the last 8 years

Include trade names and

doing business as names

 I have not used any business names or EINs.

_________________________________________________ 

Business name

_________________________________________________ 

Business name

_________________________________________________

EIN

_________________________________________________

EIN 

 I have not used any business names or EINs.

5. Where you live

_________________________________________________

Number Street

_________________________________________________

_________________________________________________ 

City State ZIP Code 

_________________________________________________

County

If your mailing address is different from the one 

above, fill it in here. Note that the court will send 

any notices to you at this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________ 

City State ZIP Code 

If Debtor 2 lives at a different address:

_________________________________________________

Number Street

_________________________________________________

_________________________________________________

City State ZIP Code 

_________________________________________________

County

If Debtor 2’s mailing address is different from 

yours, fill it in here. Note that the court will send 

any notices to this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________ 

City State ZIP Code

6. Why you are choosing

this district to file for

bankruptcy

Check one:

 Over the last 180 days before filing this petition, I

have lived in this district longer than in any other

district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

Check one:

 Over the last 180 days before filing this petition, I

have lived in this district longer than in any other

district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

_________________________________________________ 

Business name

_________________________________________________ 

Business name

_________________________________________________

EIN

_________________________________________________

EIN 

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 2

Hialeah FL 33015

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✔

Miami-Dade County

6930 Miami Gardens DR #1-403

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 2 of 58
Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the

Bankruptcy Code you

are choosing to file

under

Check one. (For a brief description of each, see Notice Required by 11 U.S.C. § 342(b) for Individuals Filing 

for Bankruptcy (Form 2010)). Also, go to the top of page 1 and check the appropriate box.

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

8. How you will pay the fee  I will pay the entire fee when I file my petition. Please check with the clerk’s office in your

local court for more details about how you may pay. Typically, if you are paying the fee 

yourself, you may pay with cash, cashier’s check, or money order. If your attorney is 

submitting your payment on your behalf, your attorney may pay with a credit card or check 

with a pre-printed address.

 I need to pay the fee in installments. If you choose this option, sign and attach the

Application for Individuals to Pay The Filing Fee in Installments (Official Form 103A).

 I request that my fee be waived (You may request this option only if you are filing for Chapter 7.

By law, a judge may, but is not required to, waive your fee, and may do so only if your income is

less than 150% of the official poverty line that applies to your family size and you are unable to

pay the fee in installments). If you choose this option, you must fill out the Application to Have the

Chapter 7 Filing Fee Waived (Official Form 103B) and file it with your petition.

9. Have you filed for

bankruptcy within the

last 8 years?

 No

 Yes.

10. Are any bankruptcy

cases pending or being

filed by a spouse who is

not filing this case with

you, or by a business

partner, or by an

affiliate?

 No

 Yes.

Debtor _________________________________________________ Relationship to you ________________________ 

District _______________________________________________ When _______________ Case number, if known__________________

Debtor _________________________________________________ Relationship to you ___________________________ 

District _______________________________________________ When _______________ Case number, if known__________________ 

11. Do you rent your

residence?

 No. Go to line 12.

 Yes. Has your landlord obtained an eviction judgment against you?

 No. Go to line 12.

 Yes. Fill out Initial Statement About an Eviction Judgment Against You (Form 101A) and file it with

this bankruptcy petition.

District ____________________________________________ When ______________ Case number __________________

District ____________________________________________ When ______________ Case number __________________

District ____________________________________________ When ______________ Case number __________________

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 3

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Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 3 of 58
Part 3: Report About Any Businesses You Ow n as a Sole Proprietor

12. Are you a sole proprietor

of any full- or part-time

business?

A sole proprietorship is a

business you operate as an

individual, and is not a

separate legal entity such as

a corporation, partnership, or

LLC.

If you have more than one

sole proprietorship, use a

separate sheet and attach it

to this petition.

 No. Go to Part 4.

 Yes. Name and location of business

_______________________________________________________________________________________

Name of business, if any

_______________________________________________________________________________________

Number Street

_______________________________________________________________________________________

_______________________________________________ _______ __________________________

City State ZIP Code

Check the appropriate box to describe your business: 

 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))

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

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

 None of the above

13. Are you filing under

Chapter 11 of the

Bankruptcy Code and

are you a small business

debtor?

For a definition of small

business debtor, see

11 U.S.C. § 101(51D).

If you are filing under Chapter 11, the court must know whether you are a small business debtor so that it 

can set appropriate deadlines. If you indicate that you are a small business debtor, you must attach your

most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or if 

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

 No. I am not filing under Chapter 11.

 No. I am filing under Chapter 11, but I am NOT a small business debtor according to the definition in

the Bankruptcy Code. 

 Yes. I am filing under Chapter 11 and I am a small business debtor according to the definition in the

Bankruptcy Code, and I do not choose to proceed under Subchapter V of Chapter 11.

Part 4: Report if You Ow n or Have Any Hazardous Property or Any Property That Needs Immediate Attention

14. Do you own or have any

property that poses or is

alleged to pose a threat

of imminent and

identifiable hazard to

public health or safety?

Or do you own any

property that needs

immediate attention?

For example, do you own

perishable goods, or livestock

that must be fed, or a building

that needs urgent repairs?

 No

 Yes. What is the hazard?

If immediate attention is needed, why is it needed?

Where is the property? 

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 4

 Yes. I am filing under Chapter 11 and I am a small business debtor according to the definition in the

Bankruptcy Code, and I choose to proceed under Subchapter V of Chapter 11.

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Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 4 of 58
Part 5: Explain Your Efforts to Receive a Briefing About Credit Counseling

15. Tell the court whether

you have received a

briefing about credit

counseling.

The law requires that you

receive a briefing about credit

counseling before you file for

bankruptcy. You must

truthfully check one of the

following choices. If you

cannot do so, you are not

eligible to file.

If you file anyway, the court

can dismiss your case, you

will lose whatever filing fee

you paid, and your creditors

can begin collection activities

again.

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 

You must check one:

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

plan, if any, that you developed with the agency.

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

developed, if any. If you do not do so, your case

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so.

 Active duty. I am currently on active military

duty in a military combat zone.

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

You must check one:

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

plan, if any, that you developed with the agency.

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

developed, if any. If you do not do so, your case

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so.

 Active duty. I am currently on active military

duty in a military combat zone.

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 5

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Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 5 of 58
Part 6: Answ er These Questions for Reporting Purposes

16. What kind of debts do

you have?

16a. Are your debts primarily consumer debts? Consumer debts are defined in 11 U.S.C. § 101(8) 

as “incurred by an individual primarily for a personal, family, or household purpose.”

 No. Go to line 16b.

 Yes. Go to line 17.

16b. Are your debts primarily business debts? Business debts are debts that you incurred to obtain 

money for a business or investment or through the operation of the business or investment.

 No. Go to line 16c.

 Yes. Go to line 17.

16c. State the type of debts you owe that are not consumer debts or business debts. 

_______________________________________________________________

17. Are you filing under

Chapter 7?

Do you estimate that after

any exempt property is

excluded and

administrative expenses

are paid that funds will be

available for distribution

to unsecured creditors?

 No. I am not filing under Chapter 7. Go to line 18.

 Yes. I am filing under Chapter 7. Do you estimate that after any exempt property is excluded and

administrative expenses are paid that funds will be available to distribute to unsecured creditors?

 No

 Yes

18. How many creditors do

you estimate that you

owe?

 1-49

 50-99

 100-199

 200-999

 1,000-5,000

 5,001-10,000

 10,001-25,000

 25,001-50,000

 50,001-100,000

 More than 100,000

19. How much do you

estimate your assets to

be worth?

 $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

20. How much do you

estimate your liabilities

to be?

 $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

Part 7: Sign Below

For you

I have examined this petition, and I declare under penalty of perjury that the information provided is true and 

correct. 

If I have chosen to file under Chapter 7, I am aware that I may proceed, if eligible, under Chapter 7, 11,12, or 13 

of title 11, United States Code. I understand the relief available under each chapter, and I choose to proceed 

under Chapter 7.

If no attorney represents me and I did not pay or agree to pay someone who is not an attorney to help me fill out 

this document, I have obtained and read the notice required by 11 U.S.C. § 342(b).

I request relief in accordance with the chapter of title 11, United States Code, specified in this petition.

I understand making a false statement, concealing property, or obtaining money or property by fraud in connection 

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

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

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Executed on _________________ Executed on __________________

MM / DD / YYYY MM / DD / YYYY

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 6

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✔

✔

03/05/2020

/s/ Raquel Mederos

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 6 of 58
For your attorney, if you are 

represented by one

If you are not represented 

by an attorney, you do not 

need to file this page.

I, the attorney for the debtor(s) named in this petition, declare that I have informed the debtor(s) about eligibility 

to proceed under Chapter 7, 11, 12, or 13 of title 11, United States Code, and have explained the relief 

available under each chapter for which the person is eligible. I also certify that I have delivered to the debtor(s) 

the notice required by 11 U.S.C. § 342(b) and, in a case in which § 707(b)(4)(D) applies, certify that I have no 

knowledge after an inquiry that the information in the schedules filed with the petition is incorrect. 

_________________________________ Date _________________ 

Signature of Attorney for Debtor MM / DD / YYYY

_________________________________________________________________________________________________ 

Printed name 

_________________________________________________________________________________________________ 

Firm name 

_________________________________________________________________________________________________ 

Number Street 

_________________________________________________________________________________________________ 

______________________________________________________ ____________ ______________________________ 

City State ZIP Code 

Contact phone ______________________________ Email address _________________________________________ 

______________________________________________________ ____________ 

Bar number State 

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 7

6500 Cowpen Road

3058249800

33014

Richard Adams

Miami lakes FL

FL

#101

/s/ Richard Adams

770434

03/05/2020

Adams & Associates, P.A.

jessica@richardadamslaw.com

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 7 of 58
Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2

Official Form 106Sum 

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

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

information. Fill out all of your schedules first; then complete the information on this form. If you are filing amended schedules after you file 

your original forms, you must fill out a new Summary and check the box at the top of this page. 

Part 1: Summarize Your Assets

Your assets

Value of what you own

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

1a. Copy line 55, Total real estate, from Schedule A/B........................................................................................................

$ ________________

1b. Copy line 62, Total personal property, from Schedule A/B............................................................................................. $ ________________

1c. Copy line 63, Total of all property on Schedule A/B ....................................................................................................... $ ________________

Part 2: Summarize Your Liabilities

Your liabilities

Amount you owe

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

2a. Copy the total you listed in Column A, Amount of claim, at the bottom of the last page of Part 1 of Schedule D ............

$ ________________

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

3a. Copy the total claims from Part 1 (priority unsecured claims) from line 6e of Schedule E/F ...........................................

$ ________________

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F....................................... + $ ________________

Your total liabilities $ ________________

Part 3: Summarize Your Income and Expenses

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

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

$ ________________

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

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

9,522.00

0.00

16,222.00

124,724.59

Southern District of Florida

3,755.00

5,018.45

18,724.59

106,000.00

Raquel Mederos

25,744.00

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 8 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

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

Part 4: Answ er These Questions for Administrative and Statistical Records

6. Are you filing for bankruptcy under Chapters 7, 11, or 13?

 No. You have nothing to report on this part of the form. Check this box and submit this form to the court with your other schedules.

 Yes

7. What kind of debt do you have?

 Your debts are primarily consumer debts. Consumer debts are those “incurred by an individual primarily for a personal,

family, or household purpose.” 11 U.S.C. § 101(8). Fill out lines 8-9g for statistical purposes. 28 U.S.C. § 159.

 Your debts are not primarily consumer debts. You have nothing to report on this part of the form. Check this box and submit

this form to the court with your other schedules.

8. From the Statement of Your Current Monthly Income: Copy your total current monthly income from Official

Form 122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14. $ _________________

9. Copy the following special categories of claims from Part 4, line 6 of Schedule E/F:

Total claim

From Part 4 on Schedule E/F, copy the following:

9a. Domestic support obligations (Copy line 6a.) $_____________________

9b. Taxes and certain other debts you owe the government. (Copy line 6b.) $_____________________

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

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

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

priority claims. (Copy line 6g.)

$_____________________

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

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

✔

0.00

0.00

0.00

0.00

0.00

Raquel Mederos

0.00

0.00

✔

5,568.92

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 9 of 58
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 Ow n 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?

1.1. _________________________________________

Street address, if available, or other description

_________________________________________ 

_________________________________________

City State ZIP Code 

_________________________________________

County

What is the property? Check all that apply.

 Single-family home

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Current value of the 

entire property?

$________________

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this is community property

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

property identification number: 

If you own or have more than one, list here:

1.2. ________________________________________

Street address, if available, or other description

________________________________________ 

________________________________________

City State ZIP Code 

________________________________________

County

What is the property? Check all that apply.

 Single-family home

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$_________________

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

the entireties, or a life estate), if known. 

Who has an interest in the property? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

__________________________________________

 Check if this is community property

(see instructions)

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

property identification number: 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

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

 Check if this is an

amended filing

page 1 of ___

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property:

Describe the nature of your ownership 

interest (such as fee simple, tenancy by

the entireties, or a life estate), if known.

Current value of the

portion you own?

$_________________

__________________________________________

33015

6930 Miami Gardens DR #1-403

106,000.00

Southern District of Florida

✔

Hialeah

Miami-Dade County

106,000.00

✔

Raquel Mederos

✔

10

FL

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 10 of 58
________________________________________ 

Street address, if available, or other description

________________________________________ 

________________________________________

City State ZIP Code 

________________________________________

County

What is the property? Check all that apply.

 Single-family home

 Duplex or multi-unit building

 Condominium or cooperative

 Manufactured or mobile home

 Land

 Investment property

 Timeshare

 Other __________________________________

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$_________________

Describe the nature of your ownership 

interest (such as fee simple, tenancy by 

the entireties, or a life estate), if known. 

Who has an interest in the property? Check one. 

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

__________________________________________

 Check if this is community property

(see instructions)

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

property identification number: 

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

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

$_________________

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

3.1. Make: ____________________________

Model: ____________________________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one. 

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

If you own or have more than one, describe here:

3.2. Make: ____________________________

Model: ____________________________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one. 

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

page ___ of __

1.____

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

6,843.69

Toyota

2

2014

Condition: Poor

✔

106,000.00

6,843.69

✔

Raquel Mederos

70098

Corolla

10

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 11 of 58
____. Make: ____________________________ 

Model: ____________________________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one. 

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

 ____ Make: ____________________________

Model: ____________________________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one. 

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

$________________

Current value of the 

portion you own?

$________________

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

4.1. Make: ____________________________

Model: ____________________________

Year: ____________ 

Other information: 

Who has an interest in the property? Check one. 

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

If you own or have more than one, list here:

4.2. Make: ____________________________

Model: ____________________________

Year: ____________ 

Other information:

Who has an interest in the property? Check one. 

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this is community property (see

instructions)

Do not deduct secured claims or exemptions. Put 

the amount of any secured claims on Schedule D: 

Creditors Who Have Claims Secured by Property.

Current value of the 

entire property?

$________________

Current value of the 

portion you own?

$________________

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 ............................................................................................................................

$_________________

page ___ of __

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

✔

6,843.69

3

Raquel Mederos

10

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 12 of 58
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......... $___________________

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.......... $___________________

12. Jewelry

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

gold, silver

 No

 Yes. Describe.......... $___________________

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 ........................................................................................................................................................

$______________________

page ___ of __

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

4

Sofa, Recliner, Dining table, Chairs, Bar table, Bed, Nightstand, Lamps, Pots & Pans, Cups, Plates,

Microwave, Washer and Dryer, Refrigerator, Television, DVR

Everyday clothing (shirts, pants, shoes, belts, etc).

Watch, Wedding band, Everyday earrings

760.00

✔

✔

✔

✔

650.00

✔

0.00

✔

0.00

0.00

0.00

60.00

50.00

0.00

0.00

Raquel Mederos

✔

✔

10

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 13 of 58
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: ....................... $__________________

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

 Yes.....................

17.1. Checking account:

17.2. Checking account: 

17.3. Savings account: 

17.4. Savings account: 

17.5. Certificates of deposit:

Institution name:

___________________________________________________________________________________ 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

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: 

_____________________________________________________________________________________________________ ___________% 

_____________________________________________________________________________________________________ ___________% 

_____________________________________________________________________________________________________ ___________% 

page ___ of __

17.6. Other financial account:

17.7. Other financial account: 

17.8. Other financial account: 

17.9. Other financial account: 

___________________________________________________________________________________ 

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________ 

$__________________

$__________________ 

$__________________ 

$__________________ 

$__________________

$__________________

$__________________

$__________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

TD Bank

TD Bank

Raquel Mederos

5 10

✔

✔

✔

✔

90.00

150.00

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 14 of 58
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:

401(k) or similar plan:

Pension plan: 

IRA: 

Retirement account:

Keogh: 

Additional account:

Additional 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...........................

Electric: 

Gas: 

Heating oil: 

Rental unit:

Prepaid rent: 

Telephone: 

Water: 

 Institution name or individual: 

____________________________________________________________________________________________________ 

____________________________________________________________________________________________________ 

_________________________________________________________________________________________________

____________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Rented furniture: ______________________________________________________________________________________________________ 

Other: ___________________________________________________________________________________________________ 

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:

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

page ___ of __

$__________________

$__________________

$__________________ 

$_________________

$___________________ 

$__________________ $__________________

$_________________

$___________________ 

$_________________

$___________________

$__________________ $__________________ 

$_________________

$___________________ 

$_________________

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________ 

$___________________

$___________________

$___________________

$___________________

$___________________

$__________________ $___________________ _

$__________________ $___________________ _

$__________________ $___________________ _

$__________________ $___________________ _

$__________________

_

$__________________ 

$__________________ 

$__________________ 

$__________________

$__________________

$__________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Walmart 401k Plan

Raquel Mederos

6 10

✔

✔

✔

10,880.90

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 15 of 58
25.





26.





27.





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. ..

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. ..

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. ..

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): 

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

$_________________

$_________________

$_________________

$__________________

$__________________

$__________________

Money or property owed to you? Current value of the 

portion you own?

Do not deduct secured 

claims or exemptions.

28.Tax refunds owed to you

 No

 Yes. Give specific information

about them, including whether 

you already filed the returns 

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

Federal: $_________________

State: $_________________

Local: $_________________

29. Family support

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

 No

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

Alimony: 

Maintenance:

Support: 

Divorce settlement:

Property settlement: 

$________________

$________________

$________________

$________________

$________________

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. ...............

$______________________

page ___ of __

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Raquel Mederos

7 10

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

✔

✔

✔

✔

✔

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 16 of 58
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 ........................................................................................................................................................ $_____________________

Part 5: Describe Any Business-Related Property You Ow n 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.

Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

38. Accounts receivable or commissions you already earned

 No

 Yes. Describe.......

$_____________________

39. Office equipment, furnishings, and supplies

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, electronic devices

 No

 Yes. Describe....... $_____________________

page ___ of __

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Raquel Mederos

8 10

0.00

0.00

0.00

0.00

✔

✔

✔

✔

✔

✔

11,120.90

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 17 of 58
40. Machinery, fixtures, equipment, supplies you use in business, and tools of your trade

 No

 Yes. Describe....... $_____________________

41. Inventory

 No

 Yes. Describe....... $_____________________

42. Interests in partnerships or joint ventures

 No

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

______________________________________________________________________ ________%

______________________________________________________________________ ________%

______________________________________________________________________ ________%

$_____________________

$_____________________

$_____________________

43. Customer lists, mailing lists, or other compilations

 No

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

 No

 Yes. Describe. ........

$____________________

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

 No

 Yes. Give specific

information .........

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

______________________________________________________________________________________ $____________________

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

for Part 5. Write that number here ........................................................................................................................................................

$____________________

Part 6: Describe Any Farm- and Commercial Fishing-Related Property You Ow n 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.

Current value of the 

portion you own?

Do not deduct secured claims 

or exemptions.

47. Farm animals

Examples: Livestock, poultry, farm-raised fish

 No

 Yes...........................

$___________________

page ___ of __

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Raquel Mederos

9 10

✔

0.00

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 18 of 58
48. Crops—either growing or harvested

 No

 Yes. Give specific

information. ............ $___________________

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

 No

 Yes...........................

$___________________ 

50.Farm and fishing supplies, chemicals, and feed

 No

 Yes...........................

$___________________

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

 No

 Yes. Give specific

information. ............ $___________________

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

for Part 6. Write that number here ........................................................................................................................................................

$___________________

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

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

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 ................................................................... $________________

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

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

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

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

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

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

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

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

62.Total personal property. Add lines 56 through 61. ................... $________________ Copy personal property total  + $_________________

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

page ___ of __

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

106,000.00

6,843.69

Raquel Mederos

0.00

0.00

124,724.59

18,724.59 18,724.59

760.00

0.00

0.00

✔

10 10

11,120.90

0.00

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 19 of 58
Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __

Official Form 106C 

Schedule C: T he Property You Claim as Exempt 4/19

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

Using the property you listed on Schedule A/B: Property (Official Form 106A/B) as your source, list the property that you claim as exempt. If more 

space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On the top of any additional pages, write 

your name and case number (if known).

For each item of property you claim as exempt, you must specify the amount of the exemption you claim. One way of doing so is to state a 

specific dollar amount as exempt. Alternatively, you may claim the full fair market value of the property being exempted up to the amount 

of any applicable statutory limit. Some exemptions—such as those for health aids, rights to receive certain benefits, and tax-exempt 

retirement funds—may be unlimited in dollar amount. However, if you claim an exemption of 100% of fair market value under a law that 

limits the exemption to a particular dollar amount and the value of the property is determined to exceed that amount, your exemption 

would be limited to the applicable statutory amount. 

Part 1: Identify the Property You Claim as Exempt

1. Which set of exemptions are you claiming? Check one only, even if your spouse is filing with you.

 You are claiming state and federal nonbankruptcy exemptions. 11 U.S.C. § 522(b)(3)

 You are claiming federal exemptions. 11 U.S.C. § 522(b)(2)

2. For any property you list on Schedule A/B that you claim as exempt, fill in the information below.

Brief description of the property and line on 

Schedule A/B that lists this property

Current value of the 

portion you own

Copy the value from 

Schedule A/B

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description: $________________  $ ____________

Line from 

Schedule A/B:

3. Are you claiming a homestead exemption of more than $170,350?

(Subject to adjustment on 4/01/22 and every 3 years after that for cases filed on or after the date of adjustment.)

 No

 Yes. Did you acquire the property covered by the exemption within 1,215 days before you filed this case?

 No

 Yes 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

Specific laws that allow exemption

 100% of fair market value, up to

any applicable statutory limit 

 100% of fair market value, up to

any applicable statutory limit 

 100% of fair market value, up to

any applicable statutory limit 

Amount of the 

exemption you claim 

Check only one box 

for each exemption

Clothing - Everyday clothing (shirts, pants, shoes,

belts, etc). 60.00

Household goods - Sofa, Recliner, Dining table,

Chairs, Bar table, Bed, Nightstand, Lamps, Pots &

Pans, Cups, Plates, Microwave, Washer and Dryer,

Refrigerator, Television, DVR

650.00

✔

6930 Miami Gardens DR #1-403

106,000.00

✔

Southern District of Florida

✔

✔

✔

1.1

In re Hawkins, 51 B.R. 348 (S.D. Fla.

1985) Fla. Const. Art.10, § 4(a) (2)

6

In re Hawkins, 51 B.R. 348 (S.D. Fla.

1985) Fla. Const. Art.10, § 4(a) (2)

11

Fla. Const. Art. 10, sec. 4(a)(1)

Raquel Mederos

160,000.00

650.00

60.00

2

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 20 of 58
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106C Schedule C: The Property You Claim as Exempt page ___ of __

Part 2: Additional Page

Brief description of the property and line

on Schedule A/B that lists this property

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Specific laws that allow exemption Current value of the 

portion you own 

Copy the value from 

Schedule A/B 

Amount of the 

exemption you claim 

Check only one box 

for each exemption

 100% of fair market value, up to

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

17.1

17.3

21

Walmart 401k Plan

TD Bank (Savings)

TD Bank (Checking)

Jewelry - Watch, Wedding band, Everyday earrings

✔

✔

✔

✔

Fla. Stat. Ann. § 222.21 (2)

In re Hawkins, 51 B.R. 348 (S.D. Fla.

1985) Fla. Const. Art.10, § 4(a) (2)

In re Hawkins, 51 B.R. 348 (S.D. Fla.

1985) Fla. Const. Art.10, § 4(a) (2)

In re Hawkins, 51 B.R. 348 (S.D. Fla.

1985) Fla. Const. Art.10, § 4(a) (2)

Raquel Mederos

50.00

150.00

90.00

10,880.90

2

10,880.90

90.00

150.00

50.00

2

12

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 21 of 58
Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___

Official Form 106D

Schedule D: Creditors Who Have Claims Secured by Property 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, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any 

additional pages, write your name and case number (if known). 

1. Do any creditors have claims secured by your property?

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

 Yes. Fill in all of the information below.

Part 1: List All Secured Claims

2. List all secured claims. If a creditor has more than one secured claim, list the creditor separately

for each claim. If more than one creditor has a particular claim, list the other creditors in Part 2.

As much as possible, list the claims in alphabetical order according to the creditor’s name.

Column A

Amount of claim 

Do not deduct the 

value of collateral.

Column B

Value of collateral

that supports this 

claim

Column C

Unsecured 

portion

If any

2.1

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

Who owes the debt? Check one.

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim relates to a 

community debt 

Date debt was incurred ____________ Last 4 digits of account number 

2.2 

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________ $____________

Who owes the debt? Check one.

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim relates to a 

community debt 

Date debt was incurred ____________ Last 4 digits of account number 

Add the dollar value of your entries in Column A on this page. Write that number here: $_________________ 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

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















Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

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

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

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















Contingent

Unliquidated

Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or secured 

car loan)

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

Judgment lien from a lawsuit

Other (including a right to offset) ____________________

Ft Worth

2018

1

9,522.00

1000

Santander Consumer Usa

9,522.00

Raquel Mederos

2,678.31

✔

TX 76161

Po Box 961245

2014 Toyota Corolla - $6,843.69

Southern District of Florida

✔

6,843.69

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 22 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

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

Part 2: List Others to Be Notified for a Debt That You Already Listed

Use this page only if you have others to be notified about your bankruptcy for a debt that you already listed in Part 1. For example, if a collection 

agency is trying to collect from you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection agency here. Similarly, if 

you have more than one creditor for any of the debts that you listed in Part 1, list the additional creditors here. If you do not have additional persons to 

be notified for any debts in Part 1, do not fill out or submit this page. 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____ 

Last 4 digits of account number 

1 1

Raquel Mederos

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 23 of 58
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___

Official Form 106E/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 claims and Part 2 for creditors with NONPRIORITY claims.

List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule 

A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any 

creditors with partially secured claims that are listed in Schedule D: Creditors Who Have Claims Secured by Property. If more space is 

needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of 

any additional pages, write your name and case number (if known).

Part 1: List All of Your PRIORITY Unsecured Claims

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

 No. Go to Part 2.

 Yes.

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

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

nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor’s name. If you have more than two priority

unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.

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

Total claim Priority 

amount

Nonpriority 

amount

2.1

Last 4 digits of account number $_____________ $___________ $____________

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were

intoxicated

 Other. Specify

____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Who incurred the debt? Check one.

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt 

Is the claim subject to offset?

 No

 Yes

2.2

____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Who incurred the debt? Check one.  Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Last 4 digits of account number 

When was the debt incurred? ____________ 

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

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were

intoxicated

 Other. Specify 

$_____________ $___________ $____________

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

Southern District of Florida

8

✔

Raquel Mederos

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 24 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: List All of Your NONPRIORITY Unsecured Claims

3. Do any creditors have nonpriority unsecured claims against you?

 No. You have nothing to report in this part. Submit this form to the court with your other schedules.

 Yes

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one

nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured

claims fill out the Continuation Page of Part 2.

Total claim

4.1

$__________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

4.2 Last 4 digits of account number $__________________

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________ 

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

4.3

$_________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________ 

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

15000 Capital One Dr

VA

TX

2016

✔

2015

✔

2016

✔

✔

✔

✔

Bank Of America

Capital One Bank Usa N

Cb/Vicscrt

8

1,960.00

0.00

534.00

✔

✔

✔

✔

23238

El Paso 79998

0935

Richmond

****

2

0787

Raquel Mederos

Po Box 982238

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 25 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: List All of Your NONPRIORITY Unsecured Claims

3. Do any creditors have nonpriority unsecured claims against you?

 No. You have nothing to report in this part. Submit this form to the court with your other schedules.

 Yes

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one

nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured

claims fill out the Continuation Page of Part 2.

Total claim

$__________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Last 4 digits of account number $__________________

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________ 

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

$_________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Po Box 182789

Po Box 98875

NV

OH

OH

2016

✔

2016

✔

2017

✔

4.4

4.5

4.6

✔

✔

✔

Comenitybank/Ny&Co

Comenitybank/Victoria

Credit One Bank Na

8

542.00

534.00

0.00

✔

✔

✔

✔

89193

43218

Columbus 43218

3126

Columbus

 

3

Las Vegas

4041

Raquel Mederos

Po Box 182789

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 26 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: List All of Your NONPRIORITY Unsecured Claims

3. Do any creditors have nonpriority unsecured claims against you?

 No. You have nothing to report in this part. Submit this form to the court with your other schedules.

 Yes

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one

nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured

claims fill out the Continuation Page of Part 2.

Total claim

$__________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Last 4 digits of account number $__________________

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________ 

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

$_________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Po Box 1269

Po Box 6189

SD

SC

SC

1982

✔

2018

✔

2018

✔

4.7

4.8

4.9

✔

✔

✔

Lvnv Funding Llc

Lvnv Funding Llc

Sears/Cbna

8

2,303.00

1,073.00

0.00

✔

✔

✔

✔

57117

29602

Greenville 29602

4952

Greenville

4041

4

Sioux Falls

** **

Raquel Mederos

Po Box 1269

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 27 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: List All of Your NONPRIORITY Unsecured Claims

3. Do any creditors have nonpriority unsecured claims against you?

 No. You have nothing to report in this part. Submit this form to the court with your other schedules.

 Yes

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one

nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured

claims fill out the Continuation Page of Part 2.

Total claim

$__________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Last 4 digits of account number $__________________

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________ 

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

$_________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Po Box 91614

4125 Windward Plaza

GA

AL

AL

2014

✔

2013

✔

2015

✔

4.10

4.11

4.12

✔

✔

✔

Setf/Wofc

Setoyota Fin Dba Of Wo

Syncb/Onav

8

7,042.00

0.00

0.00

Toyota vehicle repossessed in 2018

✔

✔

✔

✔

30005

36691

Mobile 36691-1817

2672

Mobile

2056

5

Alpharetta

 

Raquel Mederos

P.O. Box 991817

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 28 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: List All of Your NONPRIORITY Unsecured Claims

3. Do any creditors have nonpriority unsecured claims against you?

 No. You have nothing to report in this part. Submit this form to the court with your other schedules.

 Yes

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one

nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured

claims fill out the Continuation Page of Part 2.

Total claim

$__________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Last 4 digits of account number $__________________

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________ 

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street 

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

$_________________

Last 4 digits of account number 

When was the debt incurred? ____________

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce 

that you did not report as priority claims

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

 Other. Specify

_____________________________________________________________

Nonpriority Creditor’s Name 

_____________________________________________________________ 

Number Street

_______________________________________________________________________

_____________________________________________________________ 

City State ZIP Code

Who incurred the debt? Check one. 

 Debtor 1 only 

 Debtor 2 only 

 Debtor 1 and Debtor 2 only 

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes 

Po Box 6497

Credit Bureau Dispute Resoluti Po Box 14517

IA

SD

2013

✔

2014

✔

2014

✔

4.13

4.14

4.15

✔

✔

✔

Syncb/Wlmrtd

Thd/Cbna

Wells Fargo

8

0.00

2,234.00

0.00

✔

✔

✔

✔

50306

57117

** **

Sioux Falls

9114

6

Des Moines

5924

Raquel Mederos Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 29 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 3: List Others to Be Notified About a Debt That You Already Listed

5. Use this page only if you have others to be notified about your bankruptcy, for a debt that you already listed in Parts 1 or 2. For

example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or

2, then list the collection agency here. Similarly, if you have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the

additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill out or submit this page.

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured Claims

Last 4 digits of account number 

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured

Claims

Last 4 digits of account number 

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured

Claims

Last 4 digits of account number 

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured

Claims

Last 4 digits of account number

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured

Claims

Last 4 digits of account number 

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured

Claims

Last 4 digits of account number

_____________________________________________________

Name

_____________________________________________________

Number Street

_____________________________________________________

_____________________________________________________

City State ZIP Code

On which entry in Part 1 or Part 2 did you list the original creditor?

Line _____ of (Check one):  Part 1: Creditors with Priority Unsecured Claims

 Part 2: Creditors with Nonpriority Unsecured

Claims

Last 4 digits of account number

PO BOX 546 4.1

8

Hazelwood MO 63042

✔

4307

Credit Control, LLC

7

Raquel Mederos Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 30 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 4: Add the Amounts for Each Type of Unsecured Claim

6. Total the amounts of certain types of unsecured claims. This information is for statistical reporting purposes only. 28 U.S.C. § 159.

Add the amounts for each type of unsecured claim.

Total claim

Total claims 

from Part 1

6a. Domestic support obligations 6a. $_________________________

6b. Taxes and certain other debts you owe the 

government 6b. $_________________________

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

intoxicated 6c. $_________________________

6d. Other. Add all other priority unsecured claims. 

Write that amount here. 6d. +$_________________________

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

$_________________________

Total claim

Total claims 

from Part 2

6f. Student loans 6f.

$_________________________

6g. Obligations arising out of a separation agreement 

or divorce that you did not report as priority 

claims 6g. $_________________________

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

similar debts 6h. $_________________________

6i. Other. Add all other nonpriority unsecured claims. 

Write that amount here. 6i. + $_________________________

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

$_________________________

8

0.00

0.00

0.00

16,222.00

0.00

0.00

8

16,222.00

Raquel Mederos

0.00

0.00

0.00

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 31 of 58
Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___

Official Form 106G 

Schedule G: Executory Contracts and Unexpired Leases 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, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any 

additional pages, write your name and case number (if known). 

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

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

 Yes. Fill in all of the information below even if the contracts or leases are listed on Schedule A/B: Property (Official Form 106A/B).

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

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

unexpired leases.

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

2.1

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

City State ZIP Code

2.2 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

City State ZIP Code

2.3 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

City State ZIP Code

2.4 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

City State ZIP Code

2.5 

_____________________________________________________________________

Name

_____________________________________________________________________ 

Street 

_____________________________________________________________________

City State ZIP Code

Debtor __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse If filing) First Name Middle Name Last Name

United States Bankruptcy Court for the:______________________ District of ________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

✔

Southern District of Florida

Raquel Mederos

1

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 32 of 58
Official Form 106H Schedule H: Your Codebtors page 1 of ___

Official Form 106H 

Schedule H: Your Codebtors 12/15

Codebtors are people or entities who are also liable for any debts you may have. Be as complete and accurate as possible. If two married people 

are filing together, both are equally responsible for supplying correct information. If more space is needed, copy the Additional Page, fill it out, 

and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and 

case number (if known). Answer every question.

1. Do you have any codebtors? (If you are filing a joint case, do not list either spouse as a codebtor.)

 No

 Yes

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

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

 No. Go to line 3.

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

 No

 Yes. In which community state or territory did you live? __________________. Fill in the name and current address of that person.

______________________________________________________________________ 

Name of your spouse, former spouse, or legal equivalent 

______________________________________________________________________ 

Number Street

______________________________________________________________________

City State ZIP Code 

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

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

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

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

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

Check all schedules that apply:

3.1

________________________________________________________________________________ 

Name

________________________________________________________________________________

Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

3.2

________________________________________________________________________________ 

Name

________________________________________________________________________________ 

Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

3.3

________________________________________________________________________________ 

Name

________________________________________________________________________________ 

Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

 Schedule E/F, line ______

 Schedule G, line ______

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the:_______________________ District of ________

(State) 

Case number ____________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

Southern District of Florida

Raquel Mederos

✔

1

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 33 of 58
Official Form 106I Schedule I: Your Income page 1

Official Form 106I 

Schedule I: Your Income 12/15

Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for 

supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your spouse.

If you are separated and your spouse is not filing with you, do not include information about your spouse. If more space is needed, attach a 

separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Describe Employment

1. Fill in your employment

information.

If you have more than one job,

attach a separate page with

information about additional

employers.

Include part-time, seasonal, or

self-employed work.

Occupation may include student

or homemaker, if it applies.

Debtor 1 Debtor 2 or non-filing spouse

Employment status  Employed

 Not employed

 Employed

 Not employed

Occupation __________________________________ __________________________________

Employer’s name __________________________________ __________________________________

Employer’s address _______________________________________

Number Street

_______________________________________ 

_______________________________________ 

_______________________________________ 

City State ZIP Code

________________________________________

Number Street

________________________________________ 

________________________________________ 

________________________________________ 

City State ZIP Code

Part 2: Give Details About Monthly Income

Estimate monthly income as of the date you file this form. If you have nothing to report for any line, write $0 in the space. Include your non-filing 

spouse unless you are separated. 

If you or your non-filing spouse have more than one employer, combine the information for all employers for that person on the lines 

below. If you need more space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or 

non-filing spouse

2. List monthly gross wages, salary, and commissions (before all payroll

deductions). If not paid monthly, calculate what the monthly wage would be. 2. $___________ $____________

3. Estimate and list monthly overtime pay. 3. +$___________ + $____________

4. Calculate gross income. Add line 2 + line 3. 4. $__________ $____________

Debtor 1 ____________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ____________________________________________________________________ 

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

United States Bankruptcy Court for the: ______________________ District 

tate) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is: 

 An amended filing

 A supplement showing postpetition chapter 13

income as of the following date:

________________

MM / DD / YYYY

How long employed there?________________________ ________________________

4581 Weston Rd

Suite 211

Fort Lauderdale, FL 33331

Southern District of Florida

885.51

0.00

885.51

Hialeah, FL 33012

Manager

1 year

400 W 49 ST

Cashier

Suntech Plumbing and

Mechanical Cor

4,364.08

0.00

4,364.08

✔ ✔

Raquel Mederos

8 years

Walmart

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 34 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106I Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or 

non-filing spouse

Copy line 4 here............................................................................................ 4. $___________ $_____________

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a. $____________ $_____________

5b. Mandatory contributions for retirement plans 5b. $____________ $_____________

5c. Voluntary contributions for retirement plans 5c. $____________ $_____________

5d. Required repayments of retirement fund loans 5d. $____________ $_____________

5e. Insurance 5e. $____________ $_____________

5f. Domestic support obligations 5f. $____________ $_____________

5g. Union dues 5g. $____________ $_____________

+ $_____________

6.

5h. Other deductions. Specify: __________________________________ 5h. + $____________

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $____________

8. List all other income regularly received:

8a. Net income from rental property and from operating a business,

profession, or farm

Attach a statement for each property and business showing gross 

receipts, ordinary and necessary business expenses, and the total 

monthly net income. 8a.

$____________ $_____________

8b. Interest and dividends 8b. $____________ $_____________

8c. Family support payments that you, a non-filing spouse, or a dependent 

regularly receive

Include alimony, spousal support, child support, maintenance, divorce 

settlement, and property settlement. 8c.

$____________ $_____________

8d. Unemployment compensation 8d. $____________ $_____________

8e. Social Security 8e. $____________ $_____________

8f. Other government assistance that you regularly receive

Include cash assistance and the value (if known) of any non-cash assistance 

that you receive, such as food stamps (benefits under the Supplemental 

Nutrition Assistance Program) or housing subsidies.

Specify: ___________________________________________________ 8f. $____________ $_____________

8g. Pension or retirement income 8g. $____________ $_____________

8h. Other monthly income. Specify: _______________________________ 8h. + $____________ + $_____________

9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h. 9. $____________ $_____________

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

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

$___________ + $_____________ = $_____________

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

Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and other

friends or relatives.

Do not include any amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J.

Specify: _______________________________________________________________________________ 11. + $_____________

12. $_____________

Combined 

monthly income

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

Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies

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

 No.

 Yes. Explain: 

Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

$____________

$____________

$____________

6. $____________

$____________

$____________

$____________

$____________

$____________

0.00

317.66

2.80

1.47

0.00

451.54

433.97

958.00

0.00

0.00

0.00

29.79

5,018.45

0.00

99.82

3,626.48

0.00

0.00

0.00

0.00

0.00

0.00

0.00 0.00

958.00

0.00

0.00

1,391.97

0.00

0.00

0.00

0.00

74.97

0.00

0.00

5,018.45

0.00

3,626.48

737.60

885.51

✔

662.63

0.00

0.00

4,364.08

Raquel Mederos

IMS AD&D U

Accident

0.00

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 35 of 58
Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J 

Schedule J: Your Expenses 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 another 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 Your Household

1. Is this a joint case?

 No. Go to line 2.

 Yes. Does Debtor 2 live in a separate household?

 No

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

2. Do you have dependents?

Do not list Debtor 1 and

Debtor 2.

Do not state the dependents’

names.

 No

 Yes. Fill out this information for

each dependent.......................... 

Dependent’s relationship to 

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent live 

with you?

_________________________ ________

 No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

3. Do your expenses include

expenses of people other than

yourself and your dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

Estimate your expenses as of your bankruptcy filing date unless you are using this form as a supplement in a Chapter 13 case to report 

expenses as of a date after the bankruptcy is filed. If this is a supplemental Schedule J, check the box at the top of the form and fill in the 

applicable date.

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

such assistance and have included it on Schedule I: Your Income (Official Form 106I.) Your expenses

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

any rent for the ground or lot. 4. $_____________________

If not included in line 4:

4a. Real estate taxes 4a. $_____________________

4b. Property, homeowner’s, or renter’s insurance 4b. $_____________________

4c. Home maintenance, repair, and upkeep expenses 4c. $_____________________

4d. Homeowner’s association or condominium dues 4d. $_____________________

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is: 

 An amended filing

 A supplement showing postpetition chapter 13

expenses as of the following date:

________________

MM / DD / YYYY

Southern District of Florida

0.00

15.00

0.00

100.00

385.00

✔

✔

Raquel Mederos

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 36 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106J Schedule J: Your Expenses page 2

Your expenses

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

6. Utilities:

6a. Electricity, heat, natural gas 6a. $_____________________

6b. Water, sewer, garbage collection 6b. $_____________________

6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $_____________________

6d. Other. Specify: _______________________________________________ 6d. $_____________________

7. Food and housekeeping supplies 7. $_____________________

8. Childcare and children’s education costs 8. $_____________________

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

10. Personal care products and services 10. $_____________________

11. Medical and dental expenses 11. $_____________________

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

Do not include car payments. 12.

$_____________________

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $_____________________

14. Charitable contributions and religious donations 14. $_____________________

15. Insurance.

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

1

15a. Life insurance 15a. $_____________________

15b. Health insurance 15b. $_____________________

15c. Vehicle insurance 15c. $_____________________

15d. Other insurance. Specify:_______________________________________ 15d. $_____________________

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

Specify: ________________________________________________________ 16. $_____________________

17. Installment or lease payments:

17a. Car payments for Vehicle 1 17a. $_____________________

17b. Car payments for Vehicle 2 17b. $_____________________

17c. Other. Specify:_______________________________________________ 17c. $_____________________

17d. Other. Specify:_______________________________________________ 17d. $_____________________

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

your pay on line 5, Schedule I, Your Income (Official Form 106I). 18.

$_____________________

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

Specify:_______________________________________________________ 19. $_____________________

20. Other real property expenses not included in lines 4 or 5 of this form or on Schedule I: Your Income.

20a. Mortgages on other property 20a. $_____________________

20b. Real estate taxes 20b. $_____________________

20c. Property, homeowner’s, or renter’s insurance 20c. $_____________________

20d. Maintenance, repair, and upkeep expenses 20d. $_____________________

20e. Homeowner’s association or condominium dues 20e. $_____________________

100.00

780.00

0.00

310.00

215.00

0.00

315.00

0.00

0.00

180.00

210.00

75.00

350.00

180.00

0.00

0.00

Raquel Mederos

180.00

360.00

0.00

0.00

0.00

0.00

0.00

Additional Car Payments

0.00

0.00

0.00

0.00

0.00

0.00

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 37 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106J Schedule J: Your Expenses page 3

21. +$_____________________

22a.

22b.

21. Other. Specify:______________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

22. Calculate your monthly expenses.

22a. Add lines 4 through 21.

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

and 22b. The result is your monthly expenses. 22c.

$_____________________

$_____________________

$_____________________

23. Calculate your monthly net income.

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

$_____________________

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

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

The result is your monthly net income. 23c.

$_____________________

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

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

mortgage payment to increase or decrease because of a modification to the terms of your mortgage?

 No.

 Yes. Explain here: 

 +$_____________________

 +$_____________________

0.00

✔

3,755.00

3,755.00

Raquel Mederos

3,755.00

5,018.45

1,263.45

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 38 of 58
Official Form 106Dec Declaration About an Individual Debtor’s Schedules 

Official Form 106Dec

Declaration About an Individual Debtor’s Schedules 12/15

If two married people are filing together, both are equally responsible for supplying correct information. 

You must file this form whenever you file bankruptcy schedules or amended schedules. Making a false statement, concealing property, or 

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

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

Sign Below

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

 No

 Yes. Name of person__________________________________________________. Attach Bankruptcy Petition Preparer’s Notice, Declaration, and 

Signature (Official Form 119).

Under penalty of perjury, I declare that I have read the summary and schedules filed with this declaration and 

that they are true and correct.

______________________________________________  _____________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

Southern District of Florida

03/05/2020

✔

Raquel Mederos

/s/ Raquel Mederos

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 39 of 58
Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

Official Form 107 

Statement of Financial Affairs for Individuals Filing for Bankruptcy 4/19

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

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

number (if known). Answer every question.

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

1. What is your current marital status?

 Married

 Not married

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

 No

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

Debtor 1: Dates Debtor 1 

lived there 

Debtor 2: Dates Debtor 2 

lived there 

__________________________________________

Number Street

__________________________________________

__________________________________________ 

City State ZIP Code

From ________

To __________

 Same as Debtor 1

___________________________________________

Number Street

___________________________________________

___________________________________________ 

City State ZIP Code

 Same as Debtor 1

From ________

To ________

__________________________________________

Number Street

__________________________________________

__________________________________________ 

City State ZIP Code

From ________

To ________

 Same as Debtor 1

___________________________________________

Number Street

___________________________________________

___________________________________________ 

City State ZIP Code

 Same as Debtor 1

From ________

To ________

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

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

 No

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of ______________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

 

Raquel Mederos

Southern District of Florida

✔

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 40 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

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

 No

 Yes. Fill in the details.

Debtor 1 Debtor 2 

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

Sources of income

Check all that apply.

Gross income 

(before deductions and 

exclusions)

From January 1 of current year until 

the date you filed for bankruptcy: 

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

For last calendar year:

(January 1 to December 31, _________)

YYYY

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

For the calendar year before that: 

(January 1 to December 31, _________)

YYYY

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

 Wages, commissions, 

bonuses, tips

 Operating a business

$________________

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

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

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

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

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

 No

 Yes. Fill in the details.

Debtor 2 

Sources of income

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

Sources of income 

Describe below.

Gross income from 

each source

(before deductions and 

exclusions)

From January 1 of current 

year until the date you 

filed for bankruptcy: 

_________________________

_________________________ 

_________________________

For last calendar year:

(January 1 to 

December 31, _________)

$________________

$________________

$_________________ 

Part 2: Explain the Sources of Your Income 

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________ 

_________________________

_________________________

_________________________ 

_________________________

$________________

$________________

$_________________ 

$________________

$________________

$_________________ 

$________________

$________________

$_________________ 

$________________

$________________

$_________________ 

$________________

$________________

$_________________ 

Debtor 1

For the calendar year 

before that: 

(January 1 to 

December 31, _________)

✔

Raquel Mederos

✔

1,770.58

17,454.85

47,166.00

2019

2018

✔

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 41 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 3: List Certain Payments You Made Before You Filed for Bankruptcy 

6. Are either Debtor 1’s or Debtor 2’s debts primarily consumer debts?

 No. Neither Debtor 1 nor Debtor 2 has primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8) as

“incurred by an individual primarily for a personal, family, or household purpose.” 

During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,825* or more? 

 No. Go to line 7.

 Yes. List below each creditor to whom you paid a total of $6,825* or more in one or more payments and

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

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

* Subject to adjustment on 4/01/22 and every 3 years after that for cases filed on or after the date of adjustment.

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

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

 No. Go to line 7.

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

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

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

____________________________________

Creditor’s Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Dates of 

payment

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

_________

_________

_________

$_________________ $__________________  Mortgage 

 Car 

 Credit card 

 Loan repayment 

 Suppliers or vendors 

 Other ______________ 

____________________________________

Creditor’s Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________  Mortgage 

 Car 

 Credit card 

 Loan repayment 

 Suppliers or vendors 

 Other ______________

____________________________________

Creditor’s Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

_________

_________

_________

$_________________ $__________________  Mortgage 

 Car 

 Credit card 

 Loan repayment 

 Suppliers or vendors 

 Other _______________

Raquel Mederos

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 42 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

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

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

such as child support and alimony.

 No

 Yes. List all payments to an insider.

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

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

an insider?

Include payments on debts guaranteed or cosigned by an insider.

 No

 Yes. List all payments that benefited an insider.

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

Dates of 

payment

Total amount 

paid

Amount you still 

owe

Reason for this payment

Include creditor’s name

_________

_________

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

____________________________________________

City State ZIP Code

_________

_________

_________

$____________ $____________

Raquel Mederos

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 43 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

 Part 4: Identify Legal Actions, Repossessions, and Foreclosures

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

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

and contract disputes.

 No

 Yes. Fill in the details.

Case title:

Case number ________________________ 

Nature of the case Court or agency Status of the case

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

 Pending 

 On appeal

 Concluded

Case title:

Case number ________________________

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

 Pending 

 On appeal

 Concluded

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

Check all that apply and fill in the details below.

 No. Go to line 11.

 Yes. Fill in the information below.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized, or levied.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized, or levied.

Miami

✔

Raquel Mederos

73 W. Flagler

✔

FL 33130

11th Judicial Circuit Miami-Dade County

LVNV FUNDING LLC V. RAQUEL

MEDEROS ✔

2019-022771-SP-05

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 44 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

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

 No

 Yes. Fill in the details.

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

______________________________________

City State ZIP Code

Describe the action the creditor took Date action 

was taken

Amount

____________ $________________

Last 4 digits of account number: XXXX– 

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

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

 No

 Yes

Part 5: List Certain Gifts and Contributions 

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

 No

 Yes. Fill in the details for each gift.

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

Number Street

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

Gifts with a total value of more than $600 

per person

Describe the gifts Dates you gave 

the gifts

Value 

______________________________________

Person to Whom You Gave the Gift 

______________________________________

______________________________________

Number Street

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

_________

$_____________

$_____________

✔

Raquel Mederos

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 45 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

 No

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

Gifts or contributions to charities 

that total more than $600

Describe what you contributed Date you 

contributed

Value 

_____________________________________

Charity’s Name

_____________________________________

_____________________________________

Number Street

_____________________________________

City State ZIP Code

_________

_________

$_____________

$_____________

Part 6: List Certain Losses 

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

or gambling?

 No

 Yes. Fill in the details.

Describe the property you lost and how 

the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending insurance 

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

Date of your loss Value of property 

lost

_________ $_____________

Part 7: List Certain Payments or Transfers 

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

consulted about seeking bankruptcy or preparing a bankruptcy petition?

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

 No

 Yes. Fill in the details.

___________________________________

Person Who Was Paid 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

____________________________________________ 

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

Raquel Mederos

✔

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 46 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 8

____________________________________

Person Who Was Paid 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

________________________________________________ 

Email or website address

Description and value of any property transferred Date payment or 

transfer was made 

Amount of 

payment

_________

_________

$_____________

$_____________

___________________________________

Person Who Made the Payment, if Not You

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

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

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

 No

 Yes. Fill in the details.

____________________________________

Person Who Was Paid 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code 

Description and value of any property transferred Date payment or 

transfer was made

Amount of payment

_________

_________

$____________

$____________

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

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

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

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

 No

 Yes. Fill in the details.

___________________________________

Person Who Received Transfer 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Description and value of property 

transferred

Describe any property or payments received 

or debts paid in exchange

Date transfer 

was made

_________

Person’s relationship to you _____________

___________________________________

Person Who Received Transfer 

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

_________

Person’s relationship to you _____________

✔

Raquel Mederos

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 47 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 9

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

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

 No

 Yes. Fill in the details.

Name of trust 

Description and value of the property transferred Date transfer 

was made

_________

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

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

closed, sold, moved, or transferred?

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

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

 No

 Yes. Fill in the details.

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code 

Last 4 digits of account number Type of account or 

instrument

Date account was 

closed, sold, moved, 

or transferred

Last balance before 

closing or transfer

XXXX–___ ___ ___ ___  Checking

 Savings

 Money market

 Brokerage 

 Other__________

_________ $___________

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

XXXX–___ ___ ___ ___  Checking

 Savings

 Money market

 Brokerage 

 Other__________

_________ $___________

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

securities, cash, or other valuables?

 No

 Yes. Fill in the details.

____________________________________

Name of Financial Institution 

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

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

have it?

_______________________________________

Name 

_______________________________________

Number Street

_______________________________________

City State ZIP Code

 No

 Yes

Raquel Mederos

✔

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 48 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 10

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

 No

 Yes. Fill in the details.

___________________________________

Name of Storage Facility

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

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

have it?

_______________________________________

Name 

_______________________________________

Number Street

_______________________________________

CityState ZIP Code

 No

 Yes

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

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

or hold in trust for someone.

 No

 Yes. Fill in the details.

___________________________________

Owner’s Name

___________________________________

Number Street

___________________________________

___________________________________

City State ZIP Code

Where is the property? Describe the property Value

_________________________________________

Number Street

_________________________________________

_________________________________________

City State ZIP Code

$__________

Part 10: Give Details About Environmental Information

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

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

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

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

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

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

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

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

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

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

 No

 Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

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

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

✔

Raquel Mederos

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 49 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 11

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

 No

 Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

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

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

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

 No

 Yes. Fill in the details.

Case title 

Case number 

Court or agency Nature of the case Status of the 

case

________________________________

Court Name

________________________________

Number Street

________________________________

City State ZIP Code

 Pending 

 On appeal 

 Concluded

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

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

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

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

 A partner in a partnership

 An officer, director, or managing executive of a corporation

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

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

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

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

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

Name of accountant or bookkeeper 

Dates business existed

From _______ To _______ 

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

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

Name of accountant or bookkeeper

Dates business existed

From _______ To _______ 

✔

Raquel Mederos

✔

✔

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 50 of 58
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 12

____________________________________

Business Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

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

Name of accountant or bookkeeper

Dates business existed

From _______ To _______ 

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

institutions, creditors, or other parties.

 No

 Yes. Fill in the details below.

____________________________________

Name

____________________________________

Number Street

____________________________________

____________________________________

City State ZIP Code

Date issued

____________ 

MM / DD / YYYY

Part 12: Sign Below

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

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

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

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

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Date ________________ Date _________________

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

 No

 Yes

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

 No

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

Declaration, and Signature (Official Form 119).

✔

✔

Raquel Mederos

03/05/2020

/s/ Raquel Mederos

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 51 of 58
Bank Of America

Po Box 982238

El Paso, TX 79998

Capital One Bank Usa N

15000 Capital One Dr

Richmond, VA 23238

Cb/Vicscrt

Comenitybank/Ny&Co

Po Box 182789

Columbus, OH 43218

Comenitybank/Victoria

Po Box 182789

Columbus, OH 43218

Credit Control, LLC

PO BOX 546

Hazelwood, MO 63042

Credit One Bank Na

Po Box 98875

Las Vegas, NV 89193

Lvnv Funding Llc

Po Box 1269

Greenville, SC 29602

Santander Consumer Usa

Po Box 961245

Ft Worth, TX 76161

Sears/Cbna

Po Box 6189

Sioux Falls, SD 57117

Setf/Wofc

P.O. Box 991817

Mobile, AL 36691-1817

Setoyota Fin Dba Of Wo

Po Box 91614

Mobile, AL 36691

Syncb/Onav

4125 Windward Plaza

Alpharetta, GA 30005

Syncb/Wlmrtd

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 52 of 58
Thd/Cbna

Po Box 6497

Sioux Falls, SD 57117

Wells Fargo

Credit Bureau Dispute Resoluti Po Box 14

Des Moines, IA 50306

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 53 of 58
United States Bankruptcy Court

In re: Case No.

Chapter

Debtor(s)

Verification of Creditor Matrix

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

true and correct to the best of their knowledge.

Date:

Signature of Debtor

Signature of Joint Debtor

13

Southern District of Florida

03/05/2020 /s/ Raquel Mederos

Raquel Mederos

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 54 of 58
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 1

Notice Required by 11 U.S.C. § 342(b) for 

Individuals Filing for Bankruptcy (Form 2010)

This notice is for you if:

 You are an individual filing for bankruptcy, 

and 

 Your debts are primarily consumer debts.

Consumer debts are defined in 11 U.S.C. 

§ 101(8) as “incurred by an individual 

primarily for a personal, family, or 

household purpose.” 

The types of bankruptcy that are 

available to individuals

Individuals who meet the qualifications may file 

under one of four different chapters of the 

Bankruptcy Code: 

 Chapter 7 — Liquidation 

 Chapter 11 — Reorganization 

 Chapter 12 — Voluntary repayment plan 

for family farmers or 

fishermen

 Chapter 13 — Voluntary repayment plan 

for individuals with regular 

income 

You should have an attorney review your 

decision to file for bankruptcy and the choice of 

chapter. 

Chapter 7: Liquidation 

$245 filing fee

 $75 administrative fee

+ $15 trustee surcharge

$335 total fee

Chapter 7 is for individuals who have financial 

difficulty preventing them from paying their 

debts and who are willing to allow their nonexempt property to be used to pay their 

creditors. The primary purpose of filing under 

chapter 7 is to have your debts discharged. The 

bankruptcy discharge relieves you after 

bankruptcy from having to pay many of your 

pre-bankruptcy debts. Exceptions exist for 

particular debts, and liens on property may still 

be enforced after discharge. For example, a 

creditor may have the right to foreclose a home 

mortgage or repossess an automobile. 

However, if the court finds that you have 

committed certain kinds of improper conduct 

described in the Bankruptcy Code, the court 

may deny your discharge. 

You should know that even if you file 

chapter 7 and you receive a discharge, some 

debts are not discharged under the law. 

Therefore, you may still be responsible to pay: 

 most taxes; 

 most student loans; 

 domestic support and property settlement 

obligations; 

 

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 55 of 58
 

Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 2

 most fines, penalties, forfeitures, and 

criminal restitution obligations; and 

 certain debts that are not listed in your 

bankruptcy papers. 

You may also be required to pay debts arising 

from:

 fraud or theft;

 fraud or defalcation while acting in breach 

of fiduciary capacity; 

 intentional injuries that you inflicted; and 

 death or personal injury caused by 

operating a motor vehicle, vessel, or 

aircraft while intoxicated from alcohol or 

drugs. 

If your debts are primarily consumer debts, the 

court can dismiss your chapter 7 case if it finds 

that you have enough income to repay 

creditors a certain amount. You must file 

Chapter 7 Statement of Your Current Monthly 

Income (Official Form 122A–1) if you are an 

individual filing for bankruptcy under 

chapter 7. This form will determine your 

current monthly income and compare whether 

your income is more than the median income 

that applies in your state. 

If your income is not above the median for 

your state, you will not have to complete the 

other chapter 7 form, the Chapter 7 Means 

Test Calculation (Official Form 122A–2). 

If your income is above the median for your 

state, you must file a second form —the 

Chapter 7 Means Test Calculation (Official 

Form 122A–2). The calculations on the form—

sometimes called the Means Test—deduct 

from your income living expenses and 

payments on certain debts to determine any 

amount available to pay unsecured creditors. If

your income is more than the median income 

for your state of residence and family size, 

depending on the results of the Means Test, the 

U.S. trustee, bankruptcy administrator, or 

creditors can file a motion to dismiss your case 

under § 707(b) of the Bankruptcy Code. If a 

motion is filed, the court will decide if your 

case should be dismissed. To avoid dismissal, 

you may choose to proceed under another 

chapter of the Bankruptcy Code.

If you are an individual filing for chapter 7 

bankruptcy, the trustee may sell your property 

to pay your debts, subject to your right to 

exempt the property or a portion of the 

proceeds from the sale of the property. The 

property, and the proceeds from property that 

your bankruptcy trustee sells or liquidates that 

you are entitled to, is called exempt property. 

Exemptions may enable you to keep your 

home, a car, clothing, and household items or 

to receive some of the proceeds if the property 

is sold. 

Exemptions are not automatic. To exempt 

property, you must list it on Schedule C: The 

Property You Claim as Exempt (Official Form 

106C). If you do not list the property, the 

trustee may sell it and pay all of the proceeds 

to your creditors.

Chapter 11: Reorganization 

$1,167 filing fee

+ $550 administrative fee

$1,717 total fee

Chapter 11 is often used for reorganizing a 

business, but is also available to individuals. 

The provisions of chapter 11 are too 

complicated to summarize briefly. 

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 56 of 58
 

Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 3

Chapter 12: Repayment plan for family 

farmers or fishermen

$200 filing fee

+ $75 administrative fee

$275 total fee

Similar to chapter 13, chapter 12 permits 

family farmers and fishermen to repay their 

debts over a period of time using future 

earnings and to discharge some debts that are 

not paid. 

Chapter 13: Repayment plan for 

individuals with regular 

income

$235 filing fee

+ $75 administrative fee

$310 total fee

Chapter 13 is for individuals who have regular 

income and would like to pay all or part of 

their debts in installments over a period of time

and to discharge some debts that are not paid. 

You are eligible for chapter 13 only if your 

debts are not more than certain dollar amounts 

set forth in 11 U.S.C. § 109. 

Under chapter 13, you must file with the court 

a plan to repay your creditors all or part of the 

money that you owe them, usually using your 

future earnings. If the court approves your 

plan, the court will allow you to repay your 

debts, as adjusted by the plan, within 3 years or 

5 years, depending on your income and other 

factors.

After you make all the payments under your 

plan, many of your debts are discharged. The

debts that are not discharged and that you may 

still be responsible to pay include: 

 domestic support obligations, 

 most student loans, 

 certain taxes, 

 debts for fraud or theft,

 debts for fraud or defalcation while acting 

in a fiduciary capacity,

 most criminal fines and restitution 

obligations, 

 certain debts that are not listed in your 

bankruptcy papers, 

 certain debts for acts that caused death or 

personal injury, and 

 certain long-term secured debts. 

Read These Important Warnings 

Because bankruptcy can have serious long-term financial and legal consequences, including loss of 

your property, you should hire an attorney and carefully consider all of your options before you file. 

Only an attorney can give you legal advice about what can happen as a result of filing for bankruptcy 

and what your options are. If you do file for bankruptcy, an attorney can help you fill out the forms 

properly and protect you, your family, your home, and your possessions. 

Although the law allows you to represent yourself in bankruptcy court, you should understand that 

many people find it difficult to represent themselves successfully. The rules are technical, and a 

mistake or inaction may harm you. If you file without an attorney, you are still responsible for knowing 

and following all of the legal requirements. 

You should not file for bankruptcy if you are not eligible to file or if you do not intend to file the 

necessary documents.

Bankruptcy fraud is a serious crime; you could be fined and imprisoned if you commit fraud in your 

bankruptcy case. Making a false statement, concealing property, or obtaining money or property by 

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

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

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 57 of 58
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 4

Bankruptcy crimes have serious 

consequences

 If you knowingly and fraudulently conceal 

assets or make a false oath or statement 

under penalty of perjury—either orally or 

in writing—in connection with a 

bankruptcy case, you may be fined, 

imprisoned, or both. 

 All information you supply in connection 

with a bankruptcy case is subject to 

examination by the Attorney General acting 

through the Office of the U.S. Trustee, the 

Office of the U.S. Attorney, and other 

offices and employees of the U.S. 

Department of Justice.

Make sure the court has your 

mailing address

The bankruptcy court sends notices to the 

mailing address you list on Voluntary Petition 

for Individuals Filing for Bankruptcy (Official 

Form 101). To ensure that you receive 

information about your case, Bankruptcy 

Rule 4002 requires that you notify the court of 

any changes in your address. 

A married couple may file a bankruptcy case 

together—called a joint case. If you file a joint 

case and each spouse lists the same mailing 

address on the bankruptcy petition, the 

bankruptcy court generally will mail you and 

your spouse one copy of each notice, unless 

you file a statement with the court asking that 

each spouse receive separate copies.

Understand w hich services you 

could receive from credit 

counseling agencies

The law generally requires that you receive a 

credit counseling briefing from an approved 

credit counseling agency. 11 U.S.C. § 109(h). 

If you are filing a joint case, both spouses must 

receive the briefing. With limited exceptions, 

you must receive it within the 180 days before

you file your bankruptcy petition. This briefing 

is usually conducted by telephone or on the 

Internet. 

In addition, after filing a bankruptcy case, you 

generally must complete a financial 

management instructional course before you 

can receive a discharge. If you are filing a joint 

case, both spouses must complete the course. 

You can obtain the list of agencies approved to 

provide both the briefing and the instructional 

course from: 

http://justice.gov/ust/eo/hapcpa/ccde/cc_approved.html. 

In Alabama and North Carolina, go to: 

http://www.uscourts.gov/FederalCourts/Bankruptcy/

BankruptcyResources/ApprovedCredit 

AndDebtCounselors.aspx. 

If you do not have access to a computer, the 

clerk of the bankruptcy court may be able to 

help you obtain the list.

Warning: File Your Forms on Time

Section 521(a)(1) of the Bankruptcy Code 

requires that you promptly file detailed information 

about your creditors, assets, liabilities, income, 

expenses and general financial condition. The 

court may dismiss your bankruptcy case if you do 

not file this information within the deadlines set by 

the Bankruptcy Code, the Bankruptcy Rules, and 

the local rules of the court. 

For more information about the documents and 

their deadlines, go to: 

http://www.uscourts.gov/bkforms/bankruptcy_form

s.html#procedure. 

Case 20-13111-RAM Doc 1 Filed 03/05/20 Page 58 of 58