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

Official Form 201

Voluntary Petition for Non-Individuals Filing for Bankruptcy 04/20

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

number (if known). For more information, a separate document, Instructions for Bankruptcy Forms for Non-Individuals, is available.

1. Debtor’s name ______________________________________________________________________________________________________

2. All other names debtor used

in the last 8 years

Include any assumed names,

trade names, and doing business

as names

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

3. Debtor’s federal Employer

Identification Number (EIN) ______________________________________

4. Debtor’s address Principal place of business

______________________________________________

Number Street

______________________________________________

______________________________________________ 

City State ZIP Code 

______________________________________________

County 

Mailing address, if different from principal place 

of business

_______________________________________________

Number Street

_______________________________________________

P.O. Box

_______________________________________________ 

City State ZIP Code

Location of principal assets, if different from 

principal place of business

_______________________________________________

Number Street

_______________________________________________

_______________________________________________ 

City State ZIP Code

5. Debtor’s website (URL) ____________________________________________________________________________________________________

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

 Partnership (excluding LLP)

 Other. Specify: __________________________________________________________________

 Check if this is an

amended filing

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:

Miami FL 33131

59-1022077

✔

Southern District of Florida

✔

Suite 903

Miami-Dade County

Pan American Jewelry Exchange of Miami, Inc.

169 East Flagler

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 1 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

7. Describe debtor’s business

A. Check one:

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

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

 Railroad (as defined in 11 U.S.C. § 101(44))

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

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

 Clearing Bank (as defined in 11 U.S.C. § 781(3))

 None of the above

B. Check all that apply:

 Tax-exempt entity (as described in 26 U.S.C. § 501)

 Investment company, including hedge fund or pooled investment vehicle (as defined in 15 U.S.C.

§ 80a-3)

 Investment advisor (as defined in 15 U.S.C. § 80b-2(a)(11))

C. NAICS (North American Industry Classification System) 4-digit code that best describes debtor.

See http://www.naics.com/search/ .

_________

8. Under which chapter of the

Bankruptcy Code is the

debtor filing?

Check one:

9. Were prior bankruptcy cases

filed by or against the debtor

within the last 8 years?

If more than 2 cases, attach a

separate list.

 No

 Yes. District _______________________ When _______________ Case number _________________________

MM / DD / YYYY

District _______________________ When _______________ Case number _________________________

MM / DD / YYYY

10. Are any bankruptcy cases

pending or being filed by a

business partner or an

affiliate of the debtor?

List all cases. If more than 1,

attach a separate list.

 No

 Yes. Debtor _____________________________________________ Relationship _________________________

District _____________________________________________ When __________________ 

MM / DD / YYYY 

Case number, if known ________________________________

A debtor who is a “small business 

debtor” must check the first subbox. A debtor as defined in 

§ 1182(1) who elects to proceed

under subchapter V of chapter 11

(whether or not the debtor is a

“small business debtor”) must

check the second sub-box.

 Chapter 7

 Chapter 9

 Chapter 11. Check all that apply:

 The debtor is a small business debtor as defined in 11 U.S.C. § 101(51D), and its

aggregate noncontingent liquidated debts (excluding debts owed to insiders or

affiliates) are less than $2,725,625. If this sub-box is selected, attach the 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).

 The debtor is a debtor as defined in 11 U.S.C. § 1182(1), its aggregate

noncontingent liquidated debts (excluding debts owed to insiders or affiliates) are

less than $7,500,000, and it chooses to proceed under Subchapter V of

Chapter 11. If this sub-box is selected, attach the 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).

 A plan is being filed with this petition.

 Acceptances of the plan were solicited prepetition from one or more classes of

creditors, in accordance with 11 U.S.C. § 1126(b).

 The debtor is required to file periodic reports (for example, 10K and 10Q) with the

Securities and Exchange Commission according to § 13 or 15(d) of the Securities

Exchange Act of 1934. File the Attachment to Voluntary Petition for Non-Individuals Filing

for Bankruptcy under Chapter 11 (Official Form 201A) with this form.

 The debtor is a shell company as defined in the Securities Exchange Act of 1934 Rule

12b-2.

 Chapter 12

5259

✔

✔

Pan American Jewelry Exchange of Miami, Inc.

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 2 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

11. Why is the case filed in this

district?

Check all that apply:

 Debtor has had its domicile, principal place of business, or principal assets in this district for 180 days

immediately preceding the date of this petition or for a longer part of such 180 days than in any other

district.

 A bankruptcy case concerning debtor’s affiliate, general partner, or partnership is pending in this district.

12. Does the debtor own or have

possession of any real

property or personal property

that needs immediate

attention?

 No

 Yes. Answer below for each property that needs immediate attention. Attach additional sheets if needed.

Why does the property need immediate attention? (Check all that apply.)

 It poses or is alleged to pose a threat of imminent and identifiable hazard to public health or safety.

What is the hazard? _____________________________________________________________________

 It needs to be physically secured or protected from the weather.

 It includes perishable goods or assets that could quickly deteriorate or lose value without

attention (for example, livestock, seasonal goods, meat, dairy, produce, or securities-related

assets or other options).

 Other _______________________________________________________________________________

Where is the property?_____________________________________________________________________

Number Street

____________________________________________________________________

_______________________________________ _______ ________________

City State ZIP Code 

Is the property insured?

 No

 Yes. Insurance agency ____________________________________________________________________

Contact name ____________________________________________________________________

Phone ________________________________ 

Statistical and administrative information

13. Debtor’s estimation of

available funds

Check one:

 Funds will be available for distribution to unsecured creditors.

 After any administrative expenses are paid, no funds will be available for distribution to unsecured creditors.

14. Estimated number of

creditors

 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

15. Estimated assets

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

✔

✔

✔

✔

✔

Pan American Jewelry Exchange of Miami, Inc.

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 3 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

16. Estimated liabilities

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

Request for Relief, Declaration, and Signatures

WARNING -- Bankruptcy fraud is a serious crime. Making a false statement in connection with a bankruptcy case can result in fines up to 

$500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

17. Declaration and signature of

authorized representative of

debtor

The debtor requests relief in accordance with the chapter of title 11, United States Code, specified in this

petition.

I have been authorized to file this petition on behalf of the debtor.

I have examined the information in this petition and have a reasonable belief that the information is true and

correct.

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

Executed on _________________

MM / DD / YYYY

_____________________________________________ _______________________________________________

Signature of authorized representative of debtor Printed name

Title _________________________________________ 

18. Signature of attorney _____________________________________________ 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

hross@hjrlaw.com

FL

Eugene R. Berkey

Boca Raton

Law Office of Harry J. Ross

846228

FL

✔

33434

561-482-2400

/s/ Harry Ross

02/25/2021

02/25/2021

Harry Ross

6100 Glades Road Suite 211

/s/ Eugene R. Berkey

President

Pan American Jewelry Exchange of Miami, Inc.

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 4 of 37
Official Form 206Sum Summary of Assets and Liabilities for Non-Individuals page 1

Official Form 206Sum

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

Part 1: Summary of Assets

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

1a. Real property:

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

$ __________________

1b. Total personal property:

Copy line 91A from Schedule A/B........................................................................................................................................

$ __________________

1c. Total of all property:

Copy line 92 from Schedule A/B ..........................................................................................................................................

$ __________________

Part 2: Summary of Liabilities 

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

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

$ __________________ 

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

3a. Total claim amounts of priority unsecured claims:

Copy the total claims from Part 1 from line 6a of Schedule E/F.........................................................................................

$ __________________ 

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

Copy the total of the amount of claims from Part 2 from line 6b of Schedule E/F .............................................................

+$ __________________

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

Lines 2 + 3a + 3b

$ __________________

Debtor name _________________________________________________________________ 

United States Bankruptcy Court for the:_______________________ District of ________

(State) 

Case number (If known): _________________________ 

 Fill in this information to identify the case:

 Check if this is an

amended filing

31,151.00

Southern District of Florida

0.00

Pan American Jewelry Exchange of Miami, Inc.

22,605.77

0.00

327,799.04

350,404.81

31,151.00

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 5 of 37
Official Form 206A/B Schedule A/B: Assets  Real and Personal Property page 1

Official Form 206A/B

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

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

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

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

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

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

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

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

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

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

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

Part 1: Cash and cash equivalents

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

 No. Go to Part 2.

 Yes. Fill in the information below.

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

interest

2. Cash on hand $______________________

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

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

3.1. _________________________________________________ ______________________ ____ ____ ____ ____

3.2. _________________________________________________ ______________________ ____ ____ ____ ____

$______________________

$______________________

4. Other cash equivalents (Identify all)

4.1. _____________________________________________________________________________________________________ $______________________

4.2. _____________________________________________________________________________________________________ $______________________

5. Total of Part 1

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

$______________________

Part 2: Deposits and prepayments

6. Does the debtor have any deposits or prepayments?

 No. Go to Part 3.

 Yes. Fill in the information below.

Current value of 

debtor’s interest

7. Deposits, including security deposits and utility deposits

Description, including name of holder of deposit

7.1. ________________________________________________________________________________________________________

7.2._________________________________________________________________________________________________________

$______________________

$_______________________

Debtor name __________________________________________________________________ 

United States Bankruptcy Court for the:_______________________________ 

Case number (If known): _________________________ 

 Fill in this information to identify the case:

 Check if this is an

amended filing

✔

✔

5 7 8 5

51.00

Unknown

51.00

0.00

Southern District of Florida

Regions Bank

Regions Bank

3 5 3 9

Pan American Jewelry Exchange of Miami, Inc.

Checking

Checking

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 6 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

8. Prepayments, including prepayments on executory contracts, leases, insurance, taxes, and rent

Description, including name of holder of prepayment

8.1.___________________________________________________________________________________________________________

8.2.___________________________________________________________________________________________________________

$______________________

$_______________________

9. Total of Part 2.

Add lines 7 through 8. Copy the total to line 81.

$______________________

Part 3: Accounts receivable

10. Does the debtor have any accounts receivable?

 No. Go to Part 4.

 Yes. Fill in the information below.

Current value of debtor’s 

interest

11. Accounts receivable

11a. 90 days old or less: ____________________________ – ___________________________ = ........

face amount doubtful or uncollectible accounts

$______________________

11b. Over 90 days old: ___________________________ – ___________________________ = ........

face amount doubtful or uncollectible accounts

$______________________

12. Total of Part 3

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

$______________________

Part 4: Investments

13. Does the debtor own any investments?

 No. Go to Part 5.

 Yes. Fill in the information below.

Valuation method

used for current value

Current value of debtor’s 

interest

14. Mutual funds or publicly traded stocks not included in Part 1

Name of fund or stock:

14.1. ________________________________________________________________________________

14.2. ________________________________________________________________________________

_____________________

_____________________

$________________________

$________________________

15. Non-publicly traded stock and interests in incorporated and unincorporated businesses,

including any interest in an LLC, partnership, or joint venture

Name of entity: % of ownership:

15.1._______________________________________________________________ ________%

15.2._______________________________________________________________ ________%

_____________________

_____________________

$________________________

$________________________

16. Government bonds, corporate bonds, and other negotiable and non-negotiable

instruments not included in Part 1

Describe:

16.1.________________________________________________________________________________

16.2.________________________________________________________________________________

______________________

______________________ 

$_______________________

$_______________________

17. Total of Part 4

Add lines 14 through 16. Copy the total to line 83.

$______________________

100.00

100.00

✔

✔

0.00

0.00

0.00

100.00

100.00

Pan American Jewelry Exchange of Miami, Inc.

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 7 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

Part 5: Inventory, excluding agriculture assets

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

 No. Go to Part 6.

 Yes. Fill in the information below.

General description Date of the last 

physical inventory

Net book value of 

debtor's interest 

(Where available)

Valuation method used 

for current value

Current value of 

debtor’s interest

19. Raw materials

________________________________________

______________

MM / DD / YYYY $__________________ ______________________ $______________________

20. Work in progress

________________________________________

______________

MM / DD / YYYY $__________________ ______________________ $______________________

21. Finished goods, including goods held for resale

________________________________________

______________

MM / DD / YYYY $__________________ ______________________ $______________________

22. Other inventory or supplies

________________________________________

______________

MM / DD / YYYY $__________________ ______________________ $______________________

23. Total of Part 5

Add lines 19 through 22. Copy the total to line 84.

$______________________

24. Is any of the property listed in Part 5 perishable?

 No

 Yes

25. Has any of the property listed in Part 5 been purchased within 20 days before the bankruptcy was filed?

 No

 Yes. Book value _______________ Valuation method____________________ Current value______________

26. Has any of the property listed in Part 5 been appraised by a professional within the last year?

 No

 Yes

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

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

 No. Go to Part 7.

 Yes. Fill in the information below.

General description Net book value of 

debtor's interest 

(Where available)

Valuation method used 

for current value

Current value of debtor’s 

interest

28. Crops—either planted or harvested

______________________________________________________________ $________________ ____________________ $______________________

29. Farm animals Examples: Livestock, poultry, farm-raised fish

______________________________________________________________ $________________ ____________________ $______________________

30. Farm machinery and equipment (Other than titled motor vehicles)

______________________________________________________________ $________________ ____________________ $______________________

31. Farm and fishing supplies, chemicals, and feed

______________________________________________________________ $________________ ____________________ $______________________

32. Other farming and fishing-related property not already listed in Part 6

______________________________________________________________ $________________ ____________________ $______________________

✔

25,000.00

Non precious stones and accesories

✔

✔

✔

12/31/2020

✔

25,000.00

Pan American Jewelry Exchange of Miami, Inc.

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 8 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

33. Total of Part 6.

Add lines 28 through 32. Copy the total to line 85.

$______________________

34. Is the debtor a member of an agricultural cooperative?

 No

 Yes. Is any of the debtor’s property stored at the cooperative?

 No

 Yes

35. Has any of the property listed in Part 6 been purchased within 20 days before the bankruptcy was filed?

 No

 Yes. Book value $_______________ Valuation method ____________________ Current value $________________

36. Is a depreciation schedule available for any of the property listed in Part 6?

 No

 Yes

37. Has any of the property listed in Part 6 been appraised by a professional within the last year?

 No

 Yes

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

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

 No. Go to Part 8.

 Yes. Fill in the information below.

General description Net book value of 

debtor's interest 

(Where available)

Valuation method

used for current value

Current value of debtor’s 

interest

$________________ ____________________ $______________________

$________________ ____________________ $______________________

$________________ ____________________ $______________________

$________________ ____________________ $______________________

$________________ ____________________ $______________________

$________________ ____________________ $______________________

$______________________

39. Office furniture

40. Office fixtures

41. Office equipment, including all computer equipment and

communication systems equipment and software

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

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

or baseball card collections; other collections, memorabilia, or collectibles

42.1___________________________________________________________ 

42.2___________________________________________________________ 

42.3___________________________________________________________

43. Total of Part 7.

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

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

 No

 Yes

 No

 Yes

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

✔

100.00

100.00

Desk, 1 Desk Chair, File Cabinet, Shelving, Small Refrigerator,

Microwave, 2 Chairs

Pan American Jewelry Exchange of Miami, Inc.

✔

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 9 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

Part 8: Machinery, equipment, and vehicles

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

 No. Go to Part 9.

 Yes. Fill in the information below.

General description

Include year, make, model, and identification numbers (i.e., VIN, 

HIN, or N-number)

Net book value of 

debtor's interest 

(Where available)

Valuation method used 

for current value

Current value of 

debtor’s interest

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

47.1___________________________________________________________ $________________ ____________________ $______________________

47.2___________________________________________________________ $________________ ____________________ $______________________

47.3___________________________________________________________ $________________ ____________________ $______________________

47.4___________________________________________________________ $________________ ____________________ $______________________

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

trailers, motors, floating homes, personal watercraft, and fishing vessels

48.1__________________________________________________________ $________________ ____________________ $______________________

48.2__________________________________________________________ $________________ ____________________ $______________________

$________________ ____________________ $______________________

$________________ ____________________ $______________________

$________________ ____________________ $______________________

$______________________

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

49. Aircraft and accessories

49.1__________________________________________________________

49.2__________________________________________________________

50. Other machinery, fixtures, and equipment 

______________________________________________________________

51. Total of Part 8.

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

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

 No

 Yes

 No

 Yes 

(excluding farm machinery and equipment)

✔

Office Safe ** Extremly heavy **

✔

6,000.00

6,000.00

Pan American Jewelry Exchange of Miami, Inc.

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 10 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

Part 9: Real property

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

 No. Go to Part 10.

 Yes. Fill in the information below.

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

Description and location of property 

Include street address or other description such as 

Assessor Parcel Number (APN), and type of property 

(for example, acreage, factory, warehouse, apartment 

or office building), if available.

Nature and extent

of debtor’s interest 

in property

Net book value of 

debtor's interest 

(Where available)

Valuation method used 

for current value

Current value of 

debtor’s interest

55.1 

$_______________

55.2 

$_______________

____________________ $_____________________

55.3 

$_______________

____________________ $_____________________

____________________ $_____________________

56. Total of Part 9.

Add the current value on lines 55.1 through 55.6 and entries from any additional sheets. Copy the total to line 88.

$_____________________

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

 No

 Yes

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

 No

 Yes

Part 10: Intangibles and intellectual property

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

 No. Go to Part 11.

 Yes. Fill in the information below.

General description Net book value of 

debtor's interest 

(Where available)

Valuation method

used for current value

Current value of 

debtor’s interest

60. Patents, copyrights, trademarks, and trade secrets

______________________________________________________________ $_________________ ______________________ $____________________

61. Internet domain names and websites

______________________________________________________________ $_________________ ______________________ $____________________

62. Licenses, franchises, and royalties

______________________________________________________________ $_________________ ______________________ $____________________

63. Customer lists, mailing lists, or other compilations

______________________________________________________________ $_________________ ______________________ $____________________

64. Other intangibles, or intellectual property

______________________________________________________________ $________________ _____________________ $____________________

65. Goodwill

______________________________________________________________

$________________ _____________________ $____________________

66. Total of Part 10.

Add lines 60 through 65. Copy the total to line 89.

$____________________

✔

✔

Pan American Jewelry Exchange of Miami, Inc. Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 11 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

67. Do your lists or records include personally identifiable information of customers (as defined in 11 U.S.C. §§ 101(41A) and 107)?

 No

 Yes

68. Is there an amortization or other similar schedule available for any of the property listed in Part 10?

 No

 Yes

69. Has any of the property listed in Part 10 been appraised by a professional within the last year?

 No

 Yes

Part 11: All other assets

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

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

 No. Go to Part 12.

 Yes. Fill in the information below.

Current value of 

debtor’s interest

71. Notes receivable

Description (include name of obligor)

______________________________________________________

_______________ – __________________________ = 

Total face amount doubtful or uncollectible amount

$_____________________

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

Description (for example, federal, state, local)

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Tax year ___________

Tax year ___________

Tax year ___________

$_____________________ 

$_____________________

$_____________________

73. Interests in insurance policies or annuities

______________________________________________________________ $_______________________

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

has been filed)

______________________________________________________________ $_______________________

Nature of claim ___________________________________

Amount requested $________________

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

every nature, including counterclaims of the debtor and rights to

set off claims

______________________________________________________________ $_______________________

Nature of claim ___________________________________

Amount requested $________________

76. Trusts, equitable or future interests in property 

______________________________________________________________ $_____________________

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

country club membership

____________________________________________________________

____________________________________________________________

$_____________________

$_____________________

78. Total of Part 11.

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

$_____________________

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

 No

 Yes

✔

Pan American Jewelry Exchange of Miami, Inc.

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 12 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

Part 12: Summary

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

Type of property Current value of 

personal property

Current value 

of real property

80. Cash, cash equivalents, and financial assets. Copy line 5, Part 1. $_______________

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

82. Accounts receivable. Copy line 12, Part 3. $_______________

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

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

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

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

Copy line 43, Part 7.

$_______________

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

88. Real property. Copy line 56, Part 9. . ..................................................................................  $________________

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

90. All other assets. Copy line 78, Part 11. + $_______________

91. Total. Add lines 80 through 90 for each column. ...........................91a. $_______________ + 91b.

$________________

92. Total of all property on Schedule A/B. Lines 91a + 91b = 92. ........................................................................................... $__________________

0.00

0.00

0.00

31,151.00 0.00

31,151.00 31,151.00

Pan American Jewelry Exchange of Miami, Inc.

51.00

0.00

0.00

0.00

25,000.00

0.00

100.00

6,000.00

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 13 of 37
Official Form 206D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___

Official Form 206D 

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

Be as complete and accurate as possible.

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

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

 Yes. Fill in all of the information below.

Part 1: List Creditors Who Have Secured Claims 

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

secured claim, list the creditor separately for each claim.

Column A

Amount of claim 

Do not deduct the value 

of collateral.

Column B

Value of collateral 

that supports this 

2.1 Creditor’s name Describe debtor’s property that is subject to a lien claim

__________________________________________ $__________________ $_________________ 

Creditor’s mailing address

________________________________________________________

________________________________________________________

Creditor’s email address, if known

_________________________________________

 No

 Yes

Date debt was incurred __________________

Last 4 digits of account 

number _________________ Is anyone else liable on this claim?

 No

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

Do multiple creditors have an interest in the 

same property?

 No

 Yes. Specify each creditor, including this creditor, As of the petition filing date, the claim is: 

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

2.2 Creditor’s name Describe debtor’s property that is subject to a lien

__________________________________________

Creditor’s mailing address

________________________________________________________ 

________________________________________________________

Creditor’s email address, if known 

_________________________________________ 

Date debt was incurred __________________

Last 4 digits of account 

number _________________

Do multiple creditors have an interest in the 

same property?

 No

 Yes. Have you already specified the relative 

priority?

 No. Specify each creditor, including this

creditor, and its relative priority. 

3. Total of the dollar amounts from Part 1, Column A, including the amounts from the Additional $________________ 

Debtor name __________________________________________________________________ 

United States Bankruptcy Court for the: _______________________________________

Case number (If known): _________________________ 

 Fill in this information to identify the case:

 Check if this is an

amended filing

Describe the lien

_________________________________________________ 

Is the creditor an insider or related party? 

Page, if any.

 Yes. The relative priority of creditors is

specified on lines _____

$__________________ $_________________ 









No

Yes

Is anyone else liable on this claim?

No

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

As of the petition filing date, the claim is: 

Check all that apply. 







Contingent

Unliquidated

Disputed

Describe the lien

_________________________________________________ 

Is the creditor an insider or related party? 

100.00

0.00

✔

✔

Statutory

3000 Marcus Avenue

c/o T Jewell Law, PLLC

Taryn@tljlawesq.com

✔

✔

PO Box 899, Holbrook, NY 11741

Suite 2W15, New Hyde Park, NY 11042

22,605.77

12/14/2020

02/12/2021

Desk, 1 Desk Chair, File Cabinet,

Shelving, Small Refrigerator, Microwave, 2

Chairs

Unknown

22,605.77

Pan American Jewelry Exchange of Miami, Inc.

Southern District of Florida

The LCF Group

Spark Funding, LLC dba Fundamental

Capital

✔

2

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 14 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________

Name

Form 206D Official Part 2 of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___

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

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

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

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

Name and address On which line in Part 1 

did you enter the 

related creditor? 

Last 4 digits of 

account number 

for this entity

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Line 2. __ _________________

Pan American Jewelry Exchange of Miami, Inc.

2

2 2

Marcella G. rabinovich, Esq.

147 Willis Avenue

Mineola, NY, 11501

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 15 of 37
Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___

Official Form 206E/F

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

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

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

on Schedule A/B: Assets - Real and Personal Property (Official Form 206A/B) and on Schedule G: Executory Contracts and Unexpired Leases

(Official Form 206G). Number the entries in Parts 1 and 2 in the boxes on the left. If more space is needed for Part 1 or Part 2, fill out and attach 

the Additional Page of that Part included in this form. 

Part 1: List All Creditors w ith PRIORITY Unsecured Claims

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

 No. Go to Part 2.

 Yes. Go to line 2.

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

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

Total claim Priority amount

2.1 As of the petition filing date, the claim is:

Check all that apply. 

$______________________ $_________________ 

 Contingent

 Unliquidated

 Disputed

Basis for the claim:

Priority creditor’s name and mailing address

Date or dates debt was incurred 

_________________________________ 

Last 4 digits of account 

number _______________________

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) (_____)

2.2 As of the petition filing date, the claim is:

Check all that apply. 

$______________________ $_________________ 

 Contingent

 Unliquidated

 Disputed

Basis for the claim:

2.3 As of the petition filing date, the claim is:

Check all that apply. 

$______________________ $_________________ 

 Contingent

 Unliquidated

 Disputed

Basis for the claim:

Debtor __________________________________________________________________ 

United States Bankruptcy Court for the: ________________________________ 

Case number ___________________________________________

(If known)

Fill in this information to identify the case:

 Check if this is an

amended filing

Is the claim subject to offset? 





No

Yes

Is the claim subject to offset? 





No

Yes

Is the claim subject to offset? 





No

Yes

Priority creditor’s name and mailing address

Date or dates debt was incurred 

_________________________________ 

Last 4 digits of account 

number _______________________

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) (_____)

Priority creditor’s name and mailing address

Date or dates debt was incurred 

_________________________________ 

Last 4 digits of account 

number _______________________

Specify Code subsection of PRIORITY unsecured 

claim: 11 U.S.C. § 507(a) (_____)

Pan American Jewelry Exchange of Miami, Inc.

Undetermined

Undetermined

2021

12/31/2020

Taxes & Other Government Units

Taxes & Other Government Units

5

✔

✔

Internal Revenue Service

Special Procedures - Insolvency Unit

7850 SW 6th Court, Room 165

Fort Lauderdale, FL, 33324

State of Florida

Tallahassee, FL

✔

Southern District of Florida

8

8

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 16 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: List All Creditors w ith NONPRIORITY Unsecured Claims

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

Amount of claim

3.1

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

unsecured claims, fill out and attach the Additional Page of Part 2.

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

___________________

3.2 As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

__________________

Is the claim subject to offset? 

3.3 As of the petition filing date, the claim is:

Check all that apply. $________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

__________________

3.4 As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

__________________

Is the claim subject to offset? 





No

Yes

3.5 As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________ 

__________________

Is the claim subject to offset? 

3.6 As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________ 

___________________

Is the claim subject to offset? 





No

Yes

Basis for the claim:

Is the claim subject to offset? 

Is the claim subject to offset? 

Basis for the claim:

Basis for the claim:

 Contingent

 Unliquidated

 Disputed

 No

 Yes

Basis for the claim:

Basis for the claim:





No

Yes

Basis for the claim:





No

Yes





No

Yes

Bank Of America

Po Box 982238

El Paso, TX, 79998

5

Amex

Po Box 297871

Fort Lauderdale, FL, 33329

American Express Merchant Financing

POB 53773

Phoenix, AZ, 85072

Alfred I. Dupont Building Partnership, LLP

169 E. Flagler Street

Miami, FL, 33131

Advance Merchant Services, LLC

116 Nassau Street

Suit 804

New York, NY, 10038

55,463.00

2,911.92

135,000.00

12,791.00

0.00

102.00

Deficiency Balance

Commercial Lease Rent

Deficiency Balance

Credit Card Debt

Credit Card Debt

Credit Card Debt

2

0365

4907

2203

0868

2077

2009

2003

1996

06/12/2020

05/22/2018

01/21/2021

✔

✔

✔

✔

✔

✔

Pan American Jewelry Exchange of Miami, Inc.

Citi

Po Box 6190

Sioux Falls, SD, 57117

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 17 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Additional Page

Copy this page only if more space is needed. Continue numbering the lines sequentially from the 

previous page. If no additional NONPRIORITY creditors exist, do not fill out or submit this page.

Amount of claim

3.___ As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

___________________

Basis for the claim:

Is the claim subject to offset? 

 No

 Yes

3.___

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

___________________

Basis for the claim:

 No

 Yes

3.___

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

__________________

Basis for the claim:

 No

 Yes

3.___

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

___________________

Basis for the claim:

 No

 Yes

3.___

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

____________________

___________________

Basis for the claim:

 No

 Yes

Is the claim subject to offset? 

Is the claim subject to offset? 

Is the claim subject to offset? 

Is the claim subject to offset? 

5

 

8228

4,837.00

8,494.00

13,799.12

✔

✔

Credit Card Debt

Credit Card Debt

Credit Card Debt

1976

2019

10

3

11

** **

****

First Nat

5750 Sunset Dr South

Miami, FL, 33143-5396

Jpmcb Card

Po Box 15369

Wilmington, DE, 19850

Credit Card Debt

Credit Card Debt

68,660.00

170.00

2017

2017

✔

✔

✔

9

8

7

Pan American Jewelry Exchange of Miami, Inc.

Elavon

7300Chapman Highway

Knoxville, TN, 37920-6612

Discover Fin Svcs Llc

Po Box 15316

Wilmington, DE, 19850

Citicards Cbna

Po Box 6241

Sioux Falls, SD, 57117

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 18 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Part 2: Additional Page

Copy this page only if more space is needed. Continue numbering the lines sequentially from the 

previous page. If no additional NONPRIORITY creditors exist, do not fill out or submit this page.

Amount of claim

3.___ As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

___________________

Basis for the claim:

Is the claim subject to offset? 

 No

 Yes

3.___

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

___________________

Basis for the claim:

 No

 Yes

3.___

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

__________________

Basis for the claim:

 No

 Yes

3.___

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

___________________

___________________

Basis for the claim:

 No

 Yes

3.___

As of the petition filing date, the claim is:

Check all that apply. 

 Contingent

 Unliquidated

 Disputed

$________________________________

Nonpriority creditor’s name and mailing address

Date or dates debt was incurred

Last 4 digits of account number

____________________

___________________

Basis for the claim:

 No

 Yes

Is the claim subject to offset? 

Is the claim subject to offset? 

Is the claim subject to offset? 

Is the claim subject to offset? 

5

14,800.00

10,500.00

271.00

Deficiency Balance

Deficiency Balance

Credit Card Debt

4

4393

8334127100

2077

1990

05/04/2020

10/07/2020

✔

✔

✔

14

13

12

Pan American Jewelry Exchange of Miami, Inc.

Usaa Savings Bank

Po Box 47504

San Antonio, TX, 78265

U.S. Small Business Administration

409 3rd Street

Washington, DC, 20416

Mantis Funding, LLC

64 Beaver Street

#344

New York, NJ, 10004

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 19 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

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

Total of claim amounts

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

5b. Total claims from Part 2 5b. + $_____________________________

5c. Total of Parts 1 and 2

Lines 5a + 5b = 5c.

5c. $_____________________________

5

327,799.04

327,799.04

0.00

Pan American Jewelry Exchange of Miami, Inc.

5

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 20 of 37
Official Form 206G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___

Official Form 206G 

Schedule G: Executory Contracts and Unexpired Leases 12/15

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

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

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

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

Form 206A/B).

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

whom the debtor has an executory contract or unexpired lease

2.1

State what the contract or 

lease is for and the nature 

of the debtor’s interest

State the term remaining 

List the contract number of 

any government contract

2.2

State what the contract or 

lease is for and the nature 

of the debtor’s interest

State the term remaining 

List the contract number of 

any government contract

2.3

State what the contract or 

lease is for and the nature 

of the debtor’s interest

State the term remaining 

List the contract number of 

any government contract

2.4

State what the contract or 

lease is for and the nature 

of the debtor’s interest

State the term remaining 

List the contract number of 

any government contract

2.5

State what the contract or 

lease is for and the nature 

of the debtor’s interest

State the term remaining 

List the contract number of 

any government contract

Debtor name __________________________________________________________________ 

United States Bankruptcy Court for the:______________________

Case number (If known): _________________________ Chapter _____

Fill in this information to identify the case:

 Check if this is an

amended filing

Pan American Jewelry Exchange of Miami, Inc.

1

05/2021

Alfred I. DuPont Building Partnership, LLC

169 E. Flagler Street

903

Miami, FL, 33131

Commercial Lease

Lessee

7

Southern District of Florida

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 21 of 37
Official Form 206H Schedule H: Codebtors page 1 of ___

Official Form 206H 

Schedule H: Codebtors 12/15

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

the Additional Page to this page. 

1. Does the debtor have any codebtors?

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

 Yes

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

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

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

Column 1: Codebtor Column 2: Creditor 

Name Name Check all schedules 

that apply:

2.1 

Mailing address 

_____________________  D

 E/F

 G

2.2

_____________________  D

 E/F

 G

2.3

_____________________  D

 E/F

 G

2.4 

_____________________  D

 E/F

 G

2.5 

_____________________  D

 E/F

 G

2.6 

_____________________  D

 E/F

 G

Debtor name __________________________________________________________________ 

United States Bankruptcy Court for the:_______________________________ 

Case number (If known): _________________________ 

Fill in this information to identify the case:

 Check if this is an

amended filing

Pan American Jewelry Exchange of Miami, Inc.

Eugene R. Berkey

1

Eugene R. Berkey

169 E. Flagler Street

903

Miami, FL 33131

Alfred I. Dupont Building Partnership, LLP

✔

✔

Southern District of Florida

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 22 of 37
 Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 1

Official Form 207 

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

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

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

Part 1: Income 

1. Gross revenue from business

 None

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

may be a calendar year

Sources of revenue 

Check all that apply 

From the beginning of the 

fiscal year to filing date: From ___________ to Filing date

MM / DD / YYYY 





For prior year: From ___________ to ___________

MM / DD / YYYY MM / DD / YYYY





For the year before that: From ___________ to ___________

MM / DD / YYYY MM / DD / YYYY





Gross revenue 

(before deductions and 

exclusions)

$_____________________

$_____________________

$_____________________

2. Non-business revenue

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

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

 None

Description of sources of revenue Gross revenue from each 

source 

(before deductions and 

exclusions)

From the beginning of the 

fiscal year to filing date: From ___________ to Filing date

MM / DD / YYYY 

___________________________ $__________________

For prior year: From ___________ to ___________

MM / DD / YYYY MM / DD / YYYY ___________________________ $__________________

For the year before that: From ___________ to ___________

MM / DD / YYYY MM / DD / YYYY ___________________________ $__________________

 Check if this is an

amended filing

Debtor name __________________________________________________________________ 

United States Bankruptcy Court for the: ______________________ District of _________ 

(State) 

Case number (If known): _________________________ ___________________________________________

 Fill in this information to identify the case: 

Operating a business 

Operating a business 

Operating a business 

Other

Other

Other

917,734.00

742,193.00

45,039.49

01/01/2019

01/01/2020

01/01/2021

Pan American Jewelry Exchange of Miami, Inc.

12/31/2019

12/31/2020

0.00

0.00

0.00

01/01/2019

01/01/2020

01/01/2021

12/31/2019

12/31/2020

✔

✔

✔

Southern District of Florida

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 23 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

Part 2: List Certain Transfers Made Before Filing for Bankruptcy 

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

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

days before filing this case unless the aggregate value of all property transferred to that creditor is less than $6,825. (This amount may be 

adjusted on 4/01/22 and every 3 years after that with respect to cases filed on or after the date of adjustment.)

 None

Dates Total amount or value Reasons for payment or transfer 

Check all that apply 

3.1.

________ 

________ 

________ 

$_________________  Secured debt 

 Unsecured loan repayments 

 Suppliers or vendors 

 Services 

 Other _______________________________

3.2.

Creditor’s name and address 

__________________________________________ 

Creditor’s name 

__________________________________________ 

Creditor’s name 

________ 

________ 

________ 

$_________________  Secured debt 

 Unsecured loan repayments 

 Suppliers or vendors 

 Services 

 Other _______________________________

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

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

guaranteed or cosigned by an insider unless the aggregate value of all property transferred to or for the benefit of the insider is less than

$6,825. (This amount may be adjusted on 4/01/22 and every 3 years after that with respect to cases filed on or after the date of adjustment.) 

Do not include any payments listed in line 3. Insiders include officers, directors, and anyone in control of a corporate debtor and their 

relatives; general partners of a partnership debtor and their relatives; affiliates of the debtor and insiders of such affiliates; and any managing 

agent of the debtor. 11 U.S.C. § 101(31).

 None

Dates Total amount or value Reasons for payment or transfer

4.1.

_________ 

_________ 

_________

$__________________

4.2.

Insider’s name and address 

__________________________________________ 

Insider’s name 

Relationship to debtor 

__________________________________________ 

__________________________________________ 

Insider’s name 

_________ 

_________ 

_________

$__________________

Relationship to debtor 

__________________________________________ 

350.00

1,900.00

State of Florida

Alfred I. Dupont Building Partnership, LLP

Other

Pan American Jewelry Exchange of Miami, Inc.

✔

✔

✔

169 E. Flagler Street

Miami, FL 33131

Tallahassee, FL

01/01/2021

350.00

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 24 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

5. Repossessions, foreclosures, and returns

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

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

 None

Creditor’s name and address Description of the property Date Value of property

5.1.

______________ $___________

5.2.

__________________________________________ 

Creditor’s name 

__________________________________________ 

Creditor’s name _______________ $___________

6. Setoffs

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

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

 None

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

taken 

Amount 

__________________________________________ 

Creditor’s name 

_______________ $___________

Last 4 digits of account number: XXXX– ________ 

 Part 3: Legal Actions or Assignments

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

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

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

 None

7.1.

Case title Nature of case Court or agency’s name and address Status of case 

 Pending 

 On appeal 

Case number  Concluded

_________________________________ 

7.2. 

Case title Court or agency’s name and address  Pending 

 On appeal 

 Concluded

Case number 

_________________________________ 

02/2021 Unknown

c/o T Jewell Law, PLLC

PO Box 899

Holbrook, NY 11741

Spark Funding, LLC dba Fundamental Capital

✔

Pan American Jewelry Exchange of Miami, Inc.

Arbitration

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 25 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

8. Assignments and receivership

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

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

 None

Custodian’s name and address Description of the property Value 

__________________________________________ 

Custodian’s name 

______________________________________ $_____________

Case title Court name and address 

______________________________________ __________________________________________ 

Name 

Case number

______________________________________ 

Date of order or assignment

______________________________________ 

Part 4: Certain Gifts and Charitable Contributions 

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

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

 None

9.1.

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

__________________________________________ 

Recipient’s name 

_________________ $__________

Recipient’s relationship to debtor 

__________________________________________

9.2.

__________________________________________ 

Recipient’s name 

_________________ $__________

Recipient’s relationship to debtor 

__________________________________________

Part 5: Certain Losses 

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

 None

Description of the property lost and how the loss

occurred

Amount of payments received for the loss

If you have received payments to cover the loss, for 

example, from insurance, government compensation, or 

tort liability, list the total received. 

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

Assets – Real and Personal Property).

Date of loss Value of property 

lost 

___________________________________________ _________________ $__________

_________________ $__________

_________________ $__________

✔

✔

Pan American Jewelry Exchange of Miami, Inc.

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 26 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

Part 6: Certain Payments or Transfers 

11. Payments related to bankruptcy

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

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

seeking bankruptcy relief, or filing a bankruptcy case.

 None

Who was paid or who received the transfer? If not money, describe any property transferred Dates Total amount or 

value 

11.1.

______________ $_________

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

value 

11.2.

______________ $_________

__________________________________________ 

Address 

Email or website address 

_________________________________ 

Who made the payment, if not debtor? 

__________________________________________ 

Who was paid or who received the transfer? 

__________________________________________ 

Address 

Email or website address 

__________________________________________ 

Who made the payment, if not debtor? 

__________________________________________

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

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

a self-settled trust or similar device.

Do not include transfers already listed on this statement.

 None

Name of trust or device Describe any property transferred Dates transfers 

were made 

Total amount or 

value 

__________________________________________ 

______________ $_________

Trustee 

__________________________________________ 

6100 Glades Road

211

Boca Raton, FL 33434

Eugene R. Berkey

✔

3,500.00

Pan American Jewelry Exchange of Miami, Inc.

Harry J. Ross

02/2021

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 27 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

13. Transfers not already listed on this statement

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

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

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

 None

Who received transfer? Description of property transferred or payments received

or debts paid in exchange 

Date transfer 

was made 

Total amount or 

value 

13.1. ________________ $_________

________________ $_________

13.2.

__________________________________________ 

Address 

Relationship to debtor 

__________________________________________ 

Who received transfer? 

__________________________________________ 

Address 

Relationship to debtor 

__________________________________________ 

Part 7: Previous Locations 

14.Previous addresses

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

 Does not apply

Address Dates of occupancy 

14.1. From ____________ To ____________

14.2. From ____________ To ____________

✔

✔

Pan American Jewelry Exchange of Miami, Inc.

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 28 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

Part 8: Health Care Bankruptcies 

15. Health Care bankruptcies

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

 diagnosing or treating injury, deformity, or disease, or

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

 No. Go to Part 9.

 Yes. Fill in the information below.

Facility name and address If debtor provides meals 

and housing, number of 

patients in debtor’s care 

15.1. ____________________

How are records kept?

Nature of the business operation, including type of services the 

debtor provides 

Location where patient records are maintained (if different from facility 

address). If electronic, identify any service provider.

Check all that apply: 

 Electronically

 Paper

If debtor provides meals 

and housing, number of 

patients in debtor’s care 

15.2.

________________________________________ 

Facility name 

Facility name and address 

________________________________________ 

Facility name 

____________________

How are records kept?

Nature of the business operation, including type of services the 

debtor provides 

Location where patient records are maintained (if different from facility 

address). If electronic, identify any service provider.

Check all that apply: 

 Electronically

Paper

Part 9: Personally Identifiable Information 

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

 No.

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

Does the debtor have a privacy policy about that information? 

 No

 Yes

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

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

 No. Go to Part 10.

Yes. Does the debtor serve as plan administrator?

 No. Go to Part 10.

 Yes. Fill in below:

Name of plan

_______________________________________________________________________ 

Employer identification number of the plan 

EIN: ___________________________________

Has the plan been terminated? 

 No

 Yes

✔

✔

Pan American Jewelry Exchange of Miami, Inc.

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 29 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

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

18. Closed financial accounts

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

moved, or transferred?

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

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

 None

Last 4 digits of account 

number 

Type of account Date account was 

closed, sold, moved, 

or transferred 

Last balance 

before closing or 

transfer 

18.1. XXXX–__________ Checking 

 Savings 

 Money market 

 Brokerage 

 Other______________

___________________ $__________

18.2.

Financial institution name and address

______________________________________ 

Name 

______________________________________ 

Name 

XXXX–__________ Checking 

 Savings 

 Money market 

 Brokerage 

 Other______________

___________________ $__________

19. Safe deposit boxes

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

 None

Names of anyone with access to it Description of the contents Does debtor 

still have it? Depository institution name and address 

______________________________________ 

Name 

 No

 Yes

Address 

20.Off-premises storage

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

which the debtor does business.

 None

Facility name and address Names of anyone with access to it Description of the contents Does debtor 

still have it? 

______________________________________ 

Name 

 No

 Yes

Address 

✔

✔

Miami, FL

Unknown 5785 11/08/2020

Pan American Jewelry Exchange of Miami, Inc.

✔

Regions Bank

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 30 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

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

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

21. Property held for another

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

trust. Do not list leased or rented property.

 None

Owner’s name and address Location of the property Value 

______________________________________ 

Name 

Description of the property 

$_________

Part 12: Details About Environmental Information 

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

 Environmental law means any statute or governmental regulation that concerns pollution, contamination, or hazardous material,

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

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

formerly owned, operated, or utilized.

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

or a similarly harmful substance.

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

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

 No

 Yes. Provide details below.

Case title Status of case 

_________________________________ 

Court or agency name and address 

_____________________________________ 

Name 

Nature of the case 

 Pending 

 On appeal 

 Concluded

Case number 

_________________________________ 

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

environmental law?

 No

 Yes. Provide details below.

Site name and address Date of notice

__________________________________ 

Name 

Governmental unit name and address 

_____________________________________ 

Name 

Environmental law, if known

__________

Pan American Jewelry Exchange of Miami, Inc.

✔

✔

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 31 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 10

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

 No

 Yes. Provide details below.

Site name and address Date of notice

__________________________________ 

Name 

Governmental unit name and address 

______________________________________ 

Name 

Environmental law, if known

__________

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

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

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

Include this information even if already listed in the Schedules.

 None

25.1.

Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ________________________

Dates business existed

From ___________ To ____________

25.2.

Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ________________________ 

Dates business existed

25.3.

Business name and address

__________________________________ 

Name 

Business name and address

__________________________________ 

Name 

Business name and address

__________________________________ 

Name 

Describe the nature of the business 

Describe the nature of the business 

Describe the nature of the business Employer Identification number 

Do not include Social Security number or ITIN.

EIN: ________________________ 

Dates business existed

From ___________ To ____________

From ___________ To ____________

Pan American Jewelry Exchange of Miami, Inc.

✔

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 32 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 11

26. Books, records, and financial statements

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

 None

Dates of service

26a.1.

From _______

To _______

Dates of service

26a.2.

Name and address 

__________________________________________________________________________________ 

Name 

Name and address 

__________________________________________________________________________________ 

Name 

From _______

To _______

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

statement within 2 years before filing this case. 

 None

Name and address Dates of service

26b.1.

From _______

To _______

Dates of service

26b.2.

From _______

To _______

______________________________________________________________________________ 

Name 

Name and address 

______________________________________________________________________________ 

Name 

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

 None

Name and address 

26c.1. ______________________________________________________________________________ 

Name 

If any books of account and records are 

unavailable, explain why

Michael Zimmerman, CPA

✔

01/01/2019

02/25/2021

Pan American Jewelry Exchange of Miami, Inc.

Michael Zimmerman, CPA (Records Keeper)

12002 SW 128 Court, Suite 106, Miami, FL 33186

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 33 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 12

26c.2.

If any books of account and records are 

unavailable, explain why Name and address 

______________________________________________________________________________ 

Name 

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

within 2 years before filing this case. 

 None

26d.1.

26d.2.

Name and address 

______________________________________________________________________________ 

Name 

Name and address 

______________________________________________________________________________ 

Name 

27. Inventories

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

 No

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

Name of the person who supervised the taking of the inventory Date of 

inventory

The dollar amount and basis (cost, market, or 

other basis) of each inventory

______________________________________________________________________ _______ $___________________

27.1.

Name and address of the person who has possession of inventory records

______________________________________________________________________ 

Name 

Pan American Jewelry Exchange of Miami, Inc.

✔

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 34 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 13

Name of the person who supervised the taking of the inventory Date of 

inventory

The dollar amount and basis (cost, market, or 

other basis) of each inventory

______________________________________________________________________ _______ $___________________

27.2.

Name and address of the person who has possession of inventory records

______________________________________________________________________ 

Name 

 Yes. Identify below. 

Address 

30.1. _________________________ _____________

_____________

_____________

______________________________________________________________ 

Name 

Relationship to debtor _____________

______________________________________________________________ _____________

Position and nature of any 

interest 

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

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

Name Address Position and nature of any interest % of interest, if any 

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

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

 No

Period during which position 

or interest was held

Name

30.



Payments, distributions, or withdrawals credited or given to insiders

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

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

No

 Yes. Identify below.

Name and address of recipient

Amount of money or description 

and value of property 

Dates Reason for providing 

the value 

_________ To _________

_________ To _________

_________ To _________

_________ To _________

✔

Pan American Jewelry Exchange of Miami, Inc.

✔

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 35 of 37
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

Name

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 14

__________________________ _____________

30.2

_____________

_____________

_____________

_____________

Name and address of recipient

______________________________________________________________ 

Name 

Relationship to debtor 

______________________________________________________________

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

 No

 Yes. Identify below.

Name of the parent corporation Employer Identification number of the parent 

corporation 

______________________________________________________________ EIN: ____________________________

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

 No

 Yes. Identify below.

Name of the pension fund

______________________________________________________________ 

Employer Identification number of the pension fund 

EIN: ____________________________

Part 14: Signature and Declaration 

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

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

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

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

is true and correct. 

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

Executed on _________________ 

MM / DD / YYYY 

___________________________________________________________ Printed name _________________________________________________ 

Signature of individual signing on behalf of the debtor 

Position or relationship to debtor ____________________________________ 

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

 No

 Yes

/s/ Eugene R. Berkey

✔

Pan American Jewelry Exchange of Miami, Inc.

✔

Eugene R. Berkey

02/25/2021

✔

President

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 36 of 37
Official Form 202 Declaration Under Penalty of Perjury for Non-Individual Debtors

Official Form 202 

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

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

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

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

document, and the date. Bankruptcy Rules 1008 and 9011. 

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

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

1519, and 3571.

Declaration and signature

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

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

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

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

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

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

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

 Schedule H: Codebtors (Official Form 206H)

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

 Amended Schedule ____

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

 Other document that requires a declaration__________________________________________________________________________________ 

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

Executed on ______________ _________________________________________________________________________

MM / DD / YYYY Signature of individual signing on behalf of debtor

________________________________________________________________________

Printed name

______________________________________

Position or relationship to debtor

Debtor Name __________________________________________________________________ 

United States Bankruptcy Court for the: ________________________________ 

Case number (If known): _________________________ 

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

✔

✔

✔

Southern District of Florida

✔

✔

Eugene R. Berkey

02/25/2021

✔

/s/ Eugene R. Berkey

President

Pan American Jewelry Exchange of Miami, Inc.

Case 21-11799-RAM Doc 1 Filed 02/25/21 Page 37 of 37