r'..1/l 111 t•• ~, 1i./1,n .• , >;) t,,, '1' ,1:Jf\ 1 ,;1 , -~ 1 

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

Official Form 101 

• Chapter? 

• Chapter 11 

• jinapterl2 

fir'" Chapter 13 

... ! 

t · C>l Li.- •.• , 

! • " 

t/:t(> ; ·-i fi,. 

\lCi 

i\f•~ 

Ot~·-· 

-.:ir.:,:, 

,!. t'.:) 

[,.) '1'''''4 u.1,,~ 

c-.,.,1 •·· "'"·'ci u .. 

• Check if this is an 

amended filing 

Voluntary Petition for Individuals Fillng for Bankruptcy 04120 

The bankruptcy forms uae you and Debtor 1 to refer to a debtor filing alone. A married couple may fife a bankruptcy caae together-eafled a 

Joint c:aae-aml In Joint caus, 1heo forms use you to ask for Information from both debtors. For example, if a form asks, "Do you own a car," 

the &l\8Wer would be yv if either debtor awns a car. When Information Is needed about the epouses uparately, the form uses Debtor 1 and 

o.btor 2 to distinguish between them. In joint casH, one of the spo\.lSes must niport Information as Debtor 1 and the other as Debtor 2. Th& 

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

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

lnfonnatlon. ff more space it needed, attach a separate sheet to this form, On the top of any ~itlonal pages, write your name and cue number 

[ff known). Answer every queetlon. 

1111 tclentify YourMff 

i 1. Your full nam4t 

Write lhe name that is on your 

government-issued picture 

identfficatlon (for example, 

your driver's licanse or 

pa5$p()rt). 

Bring your picture 

identification to your meeting 

wiltl the trustee. 

; 2. All other names you 

I have used in the Int 8 

years 

Include yoor married or 

maiden names. 

! a Oniy the Int 4 digits of 

your SOcial Security 

number or federal 

lndivlduat Taxpayer 

ldantffk:ation number 

About Debtor 

Suffix (Sr., Jr., 11, Ill) 

_ __...S/Jme ___ _ First name 

Mlddle name 

Last name 

First name 

Middlenam& 

Lllst name 

XXX 

OR 

9xx - xx --- _____ _ 

.... -lu.Ji.,e__. ___ _ First nan1e 

Middle nrr L ((Jr, //Jet,_, 

Last name 

Sufiix (Sr.. Jr, II, Ill) 

•-------------=•••l!m~ 

Fifstname 

I( 

f/ 

Last <1amo 

XXX -

OR 

9xx - xx - -------- (lTlN} ------------------"~-----""""""""Pl•..,$);""' """"9"-~i~-"1'1~•,rmi"~"~TM----------•--------

Official Form '\01 Voluntary Petition for Individuals Filing for Bankruptcy page 1 

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 1 of 9
Debtor 1 Case rurrlber ,noow,,,_ ____________ _ 

-------------------------------------•=-•,•,l!llll'l"'<~<'' _____________ _, __ _ 

4. Any busineaa names 

and Employer 

Identification Numbers 

(EIN} you have used in 

tha last 8 years 

Include tradtl names and 

doing business as names 

s. Where you live 

&. Why you are choosing 

th/$ dlstrlet to file for 

bankruptcy 

Official Fonn 101 

Business name 

Eif:ilf your malling addreas ls different from the one 

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

any 11otices to you at this maHing address. 

~,_,e __ _ Number Street 

P.OBm 

Clty state ZIP C,xle 

Check one. 

~ver the last 180 di!y& before filing this petition, 

l have lived in lhls district longer than in any 

other district. 

• I have another reason. Explain. 

(See 28 U,S.C. § 1408.) 

About Debtor 2~se0nly In•• Joint CAM): 

• I have not usoo any busines$ names or EINs. 

N} Vf 

Business name { 

auStness name 

If Debtor 2 llves at a different addreu: 

Number Street 

City Slate ZIP Code 

Colmly 

If Debtor 2's mailing addres& ia different from 

yours, fill it in here, Note that the court wiH send 

any nolices to this mailing address, 

__S:~tr.~----

Number Street 

P.O. So,s 

City Slet<0 ZIP Code 

Check one. 

CD'over the last 180 days before filing this petition, 

I have 11ved in this district longer than in any 

other district 

D I have another reason. Explain. 

(See 28 U.S.C. § 1408.) 

--------·- Voluntary Petition for Individuals Flllng for Bankruptcy page 2 

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 2 of 9
Debl0f1 Case numbert>'>Mwf!), ___________ _ 

f H Teff the Court About Your a-kruptcy Caae 

1. The chapter of the 

Bankruptcy Code you 

are choosing to file 

under 

Check one. (For a brief description of each. see Notrce Required by 1 t U.S.C. § 342(b) for frldwiduals Filing 

for Bankruptcy (Fom1 2010)). Also. go to the top of page 1 and check the appropriate box. · 

• Chapter7 

• Chapter 11 

• Chapter 12 

___ , __ ,..,"'"-~ Chapl~~-~""'" ., , -··--"· 

a. 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 detans about how you may pay. Typically, if you are paying the fee 

yourself, you may pay with cash, cashier's cneck, 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 addres.c;. 

11. Have you flied for 

bankruptcy within the 

last 8 years? 

• 10. Ara any bankrup~y 

cases pending or being 

flied by a spouse who l& 

not filing this case with 

you. or by a business 

partner, or by an 

afflllate? 

11. Do you nmt your 

residence? 

Official Form 101 

,need to pay the fee in installment&. If you choose this option. sign and attach the 

Application for Individuals to Pay The Filing Foo in Installments {Official Form 103A). 

• I request that my fee be waived {You may request this optlon 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 ln installments). If you choose this option, you must fill out the Application to Have the 

Chapter 7 Filing Fn Waived (Official Fom, 103B) and file a with your pe@on. 

Oi&lrict _________ When _____ Case number ________ _ 

MM1 00/YYYY 

• Yes. Oeb!Of __________________ R<;~alloost"P to you 

Distriet _________ Whoo _____ Case nLimi:,er, if l<nowr, ______ _ 

MM 100 IYYYY 

Oeblor _________________ Relationship to you 

District _________ When _____ Case number, if known ______ _ 

MM iDOiYYYY 

,,.l.o. Go to line 12, 

0 Yes. Has your landlord obtained an eviction Judgment agemst you? 

0 No. Go to line 12. 

0 Yes. FU! out Initial Statement About an Eviction Judgment Againsf You (Fann 10·1 A) and file it as 

part of this bankruptcy petition. 

Volumary Petition for lodivlduals Filing for Bankruptcy page 3 

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 3 of 9
I. 

. . 

Case number ,if-•l ____________ _ 

fHH Rctport About Anr ~ You Own a, a Sot. Proprietor 

. 12. Ara you a sole proprietor ~-Go to Part 4. 

· of any full- or part-time 

business? • Yes. Name and location of business 

A sole proprietorship ts a 

business you operate as an Individual, and is not a Name of bu&ir>ess, if any 

separate klga! entity such as 

a corporation, partnership, or LLC. Number S1reet 

If you have more than one 

sole proprietorship, use a 

separate sheet and attach it 

to this petition. 

11. Are you filing under 

Chapter 11 of the 

Bankruptcy Cod&, and 

are you a small business 

debtor or a debtor as 

defined by 11 U.S. C. § 

1182(1)? 

For a definition of small 

businass debtor, see 

11 u.s.c. § 101(510). 

Official Fomi 101 

City State 

Check the appropriate bo)( to describe your business: 

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

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

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

• Commodity Broker (as defined in 11 U.$.C. § i01(6)J 

0 None of the above 

ZIP Code 

If you are filing under Chapter 11, the court must !<now whether you are a small business debtor or a debtor 

choosing to procaed under Subchapter V so that it can sat appropriate deadlines. If you indicate that you 

are a small bu&iness debtor or you are choosing to proceed under Subchapler V, you must attach your 

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

if an),"f these documents do not exist, follow ttie procedure in 11 l!.S.C. § 1116(1 )(8). 

fiYNo. I am not tiling under Chapter 11. 

0 No. I am fling 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, I am a small business debtor 1:1ccording to the definition in the Bankruptcy 

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

• Yes. I am filing under Chapter 11, I am a debtor according to the definition In§ 1182(1) of the 

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

Voluntary Petition for Individuals Filing for Bankruptcy page4 

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 4 of 9
Debtor 1 

14. Do you own or have any 

property that pons or Is 

alleged to pose a threat 

of lmmhwnt and 

ldenttflable hazard to 

publtc health or safety? 

Or do you own any 

property that nffds 

lmmed1ate attention? 

For example, do you own 

perishable goods, or ltvestook 

that must be fed, or a building 

that llffda urgent repairs? 

Official Form 101 

r~1se nu,nt>flr t11(:-!'o>'I-M'l'~, ___________ _ 

• Yes. What is the hazard? 

If immediate attention is needed, why is it needed? _______________ _ 

When is the property? _______________________ _ 

Number Street 

City 

Voluntary Petition for l ndlvlduals Filing for Bankruptcy page 5 

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 5 of 9
Debtor 1 

Explain Yoar Efforts to -.0.lve a Bf'leflng About Credit CounaeUng 

1s. Tell the court whether 

you haw nteelved a 

brfeflng about credit 

counseling. 

The law requires that yoo 

receive a briefing about credit 

counseling before yoo file ror 

bankmptcy. Youmust 

truthfully check one of the 

following chotees. If you 

cannot do $0, you 8fe not 

ellg!bltl to (de. 

If you file anyway, the court 

can dismiss your case, you 

will loae whatever filing fee 

you paid, and your creditors 

can begin collectlon activities 

again. 

Otbtot1: 

You ,?1st check one: 

~ received a brleffng from an approved credlt 

counHtlng agency within the 180 days before I 

ffled this bankruptcy P41titton, and t 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 bafore I 

flied this bankruptcy petition, but I do not have a 

certificate of completion. 

Within 14 days after you me this bankruptcy petition, 

you MUST file a mpy of the certificate and payment 

plan, if any. 

• l cartlfy that I asked for credit counseling 

urvlca. from an approved agency, but was 

unable to obtaln those servtces during the 7 

days attar I ma my request, and exigent 

ctrcumstances 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 

yoo were unable to obtain it before you filed for 

bat'lkruptcy, and what exigent cif'Cl.llnatances 

required you lo me !hls case. 

Your case may be dismissed if the court is 

diSsatiSfled w,h your re8$00S for oot receiving a 

briefmg before you f~ed for bankruptcy. 

If the court is saUsfied with your reasons, you must 

stil receive a briefing within 30 days after you file. 

You must file a certlfieate 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 exteosiOn 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 counseltng 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 

duly it1 a mffitary combat zone. 

If you believe you are not required to re<'.eive a 

brief111g about credit counseling, you must file a 

motiol'l for wai,er of credit counseling with the court. 

About Debtor 2 (Spo._. Only in a Joint Cau): 

Vov must check one. 

• I received a briefing from an approved crvdit 

counseling agency within the 180 days before I 

filed this bankruptcy petition, and I received a 

certificate of completion. 

Altach 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 

servk:es from an approll'ed agency, but was 

unable to obtain those services during the 7 

days after I made my rvqueat, arid exigent 

clrcumstanc&S merit a'30-day temporary waiver 

of the requirement. 

To ask for a 30-day tempo~ waiver ot the 

requirement, attach a separate sheet explaining 

what efforts you made to obtain the briefing, Ylly 

you were unable to obtain it before you fited for 

bankruptcy, and what exigent circumstances 

required you to me this case. 

Y<lur case may be dismissed if the court is 

dissatIsfted with your reasons for not receiving a 

briefing before you tied for bankruptcy. 

If the court is satisfied with your reasons, you must 

still receive a briefing within 30 days after you file, 

You must fie a certificate from the app!'O\led 

agency, along with a copy of the payment plan you 

developed, if any. If you do nol do so, your case 

may be dism,ssed. 

Any extension of the 3(k:lay deadline ts granted 

only for cause and ls 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 Hlness or a mental 

deficiency that makes me 

incapable of realizing or making 

rational der..isionS aoout finances. 

• Disability. My pf;lySical disability causes me 

to be unable to participate in a 

briefing in persc,n, by phone. er 

through th$ Internet, even after I 

reasonably tried to do so. 

• Aetlve duty. I am currently on acttve military 

dllty in a militaty combat zone. 

If you believe you are not required to receive a 

briefing aoout c-.mdit counseling, you must file a 

motion for waivl:lf of credit counseling with th& court. 

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

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 6 of 9
Debtor 1 Case numoer(lf/;r,qwoi ____________ _ 

HI• Amlwer ~ .. Gu••tlons tor Reporting PurpoHs 

11. What kind of debts do 

you have? 

11. Are you filing under . Chapter?? 

Do you estimate that after 

any exempt property is 

•xcluded and 

admlnlatratM• expenses . are paid that funds wHI be 

available for distribution 

to unaecured creditors? 

• 1a. How many creditors do 

you estimate that you 

owe? 

1t. How much do you 

estimate your assets to 

beworth7 

18a. Are your debts primarily consumer debts? Consumer debts are defined in 11 u.s.c. § 101(8) 

as "incurred by an indMdual primarily for a persona!, famHy, or household purpose." 

• )lo. Go lo line 16b. 

Clir Yes. Go to hne 17. 

i6b. Are your debts primarily business debts? Busin&ss debts are debta that you incurred to obtain 

money for a t>usiness or investment or through the operation of the t>usiness or investment. 

• No. Go to line 16c. 

0 Yes. Goto line 17. 

16c. State the type of debts you owe !hat are not consumer debts or t>usi ness debts. 

~o. I am not filing under Chapter 7. Go to line 18. 

• Yes. I am filing under Chapter 7, Do you estimate that after any exernpt property ls exr;luded an<! 

administratilftl expenses are paid t11at funds will be available to distribute lo unsecured creditors? 

• No 

• Yes 

ii<.49 

• 50-99 

• 100-199 

• 200-999 

• 1,000-5.000 

• 5,001-10,000 

0 10,001-25,000 

• SO-SS0,000 D $1,000,001-$10million 

• $50,001-$100,000 • $10,000,001-$50 million 

0 }100,001-$500,000 D $50,000,001-$100 mithon 

CB' S500,001-$1 miflion • $100,000,001-SSOO million 

• 25,001-50,000 

• 50,001-100.000 

• More than 100,000 

• $500,000,001-$1 billion 

• $1,000,000,001-$10 biUion 

• $10,000,000,001-$50 biH1on 

• More than $50 bdl!on 

·---------,. .. ,.__,_,._ ·----- 20. How much do you 

estimate your liabilities 

to be? 

'"'* For you .... Below 

• $0-$50,000 

• $50,001-$100,000 

Ofi100,001-$5oo.ooo 

if $500,001-$1 mHlion 

• $1,000,001-$10 milf:on 

D $'10,000,001-$50 million 

• $50.000,001·$100 million 

D $100.000,001-$500 million 

• $500,000,001-$1 billion 

• $1,000,000,001-$10 bi!Hon 

• $10,000,000,001-$50 billion 

• More than $50 billion 

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 Ct1apter 7, 11,12, or 1a 

of title 11, United States Cock>. I understand the relief a'/8llable under each chapter, aoo I choose to proceed 

un<ler Chapter 7. 

If no attorney rep, e&ents me and I did not pay or agree to pay someone who is not an attorney to help me fill out 

this doet.ment, I "lave obtained and read the notice requiroo by 11 U.S.C. § 342{b). 

I ,.quest relief in accordance with the chapter of title 1 i, United States Code, specified in this petition. 

I un<lerstand 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 impusonment for up to 20 years. or both. 

:U-~,;:1, 1519. and 3571. ~ 

Signature 

~~---of Debtor ~ 1 x~~ Signature of Debtor 2 ~ 

Executed on iD-'"2:2--7.-1 

MM I 00 /YYYY 

Executed on f 0-~ZL 

MM I DO IYYYY 

------------lllll(llllilllli< ___ , .... __ ... , ... !ll!Ob oo;r llllitfft;IIIW ___ ,..,H ....... , .... -l.'!'t~~~!l~, ... ll!llll!ll __ ........ , ... , ... ! __ ..,, ... ,ffiliffflft!ffil!Oi·, ... mnllllll_ ............. ,"',H:l!ill!JHIWl.-i1'l!. --------

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page7 

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 7 of 9
For you if you are fifing this 

• bankruptcy without an 

• attomey 

If you are represented by 

an attorney, you do not 

need to file this pag,. 

Official Fonn 101 

Case number f#•'-")'--------------

The law allows you, as an individual, to represent yourself in bankruptcy court, but you 

should und.arstand that many people find it extremely difficult to represent 

themselves successfully, Because bankruptcy has long-term financial and leg.al 

consequences, you are strongly urged to hire a qualified attorney. 

To be successful, you must correctly file and handle your bankruptcy case. The rules are very 

technical, and a mistake or inaction may affect your rights. For example, your case may be 

dismissed because you did not file a required document, pay a fee on time, attend a meeting or 

hearing, or cooperate with the c-..ourt, case trustee. U.S. trustee, bankruptcy administrator, or audit 

firm if your case ls selected for audit. If that happens, you could lose your right to file another 

case, or you may lose protections, including the benefit of the automatic stay. 

You must list all your property and debts in the schedules that you are required to file with the 

court. Even if you plan to pay a particular debt outside of your bankruptcy, you must list that debt 

in your schedules. If you do not list a debt, the debt may not be discharged. If you do not list 

property or properly claim it as exempt, you may not be able to keep the property. The judge can 

also deny you a discharge of all your debts if you do something dishonest in your bankruptcy 

case, such as destroying 1)r hiding property, falsifying records, or lying. Individual bankruptcy 

cases are randomly audited to determine if debtors have been accurate. truttlful,,and complete. 

Bankruptcy fraud la a serious crime; you could be fined and Imprisoned. 

If you decide to flle wil.hout an attorney, the court expects you to follow the rules as if you had 

hired an attorney. The court will not treat you differently because you are filing for yourself. To be 

successtu:, you mus I be familiar with the United States Bankruptcy Code. the Federal Rules of 

Bankruptcy Procedure. and the local rules of the court in which your case is flied. You must also 

be fammar with any state exemption laws that apply. 

Are you aware that tiling for bankruptcy is a serious action with long-term financial and legal 

consequences? 

~ Are you aware that bankruptcy fraud is a serious crime and that if your bankruptcy forms are 

inaccurate or incomplete, you could be fined or imprisoned? 

• J40 

0"ves 

Dio/l'ou pay m agree to pay someone who is not an attorney to help you fill out your bankruptcy forms? 

151 No • Yes. Name of Person, __________________ --::-:::-~=--:-:-:::-

Attach Bankruptcy Petition Preparer's Notice, Declaration, and Signature {Official Form 119), 

By signing here, I acknowledge that I understand the risks involved in filing without an attorney. I 

have read and understood this notice, and I am aware that filing a bankmptcy case without an 

attorney may cause me to lose my rights or property if I do not properly handle the case. 

x-lfl);;_:::::, x t'~&P!-~ 

S,gnatvre of Dehtt>r 1 Signature of Debtor 2 

Date iO--C..~'<..,f .. MM/ DD IYYYY 

Cootl!ci pnone :t:54~'.L L Y:<t{JtCell phone 

Ema» address 

Date .,o:-z..-cJZ/ 

Contact phone 

Cell phone 

MM/ DD IYYYY 

Voluntary Petition tor Individuals Filing for Bankruptcy page 9 

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 8 of 9
::,(ja; '1 . ]( : . F~d~1tn rYl o,--to~q__ .addr=: si£o 6f/o""'-'£ c~ 1?1VJ) 

Geff'el 1) TX) 1SDI? 

_'.J>f'C t?e:.1"1 >, : l'7 oo rv w // f'tth <;,.f-- rn,~:n, · FL- s:s 11,e; 

1V '. 2a n-K IL. Jf; <;;E I -q-t!1 s+ Rf- ~i!<erJo. k Fl sD I 6 

Case 21-20206-PDR Doc 1 Filed 10/25/21 Page 9 of 9