Official Form 101

Voluntary Petition for Individuals Filing for Bankruptcy 04/20

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

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

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

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

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

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

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

(if known). Answer every question.

Part 1: Identify Yourself

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

1. Your full name

Write the name that is on your

government-issued picture

identification (for example,

your driver’s license or

passport).

Bring your picture

identification to your meeting

with the trustee.

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

___________________________

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

__________________________________________________

First name

__________________________________________________

Middle name

__________________________________________________

Last name

___________________________

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

2. All other names you

have used in the last 8

years

Include your married or

maiden names.

3. Only the last 4 digits of

your Social Security

number or federal

Individual Taxpayer

Identification number

(ITIN)

xxx – xx – ____ ____ ____ ____

OR

9 xx – xx – ____ ____ ____ ____

xxx – xx – ____ ____ ____ ____

OR

9 xx – xx – ____ ____ ____ ____

United States Bankruptcy Court for the:

____________________ District of _________________

(State) 

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

 Chapter 7 

 Chapter 11

 Chapter 12

 Chapter 13

 Fill in this information to identify your case:

 Check if this is an

amended filing

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

Pena

Alejandra

✔

Southern District of Florida

0 6 4 3

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 1 of 41
About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case): 

4. Any business names

and Employer

Identification Numbers

(EIN) you have used in

the last 8 years

Include trade names and

doing business as names

 I have not used any business names or EINs.

_________________________________________________ 

Business name

_________________________________________________ 

Business name

_________________________________________________

EIN

_________________________________________________

EIN 

 I have not used any business names or EINs.

5. Where you live

_________________________________________________

Number Street

_________________________________________________

_________________________________________________ 

City State ZIP Code 

_________________________________________________

County

If your mailing address is different from the one 

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

any notices to you at this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________ 

City State ZIP Code 

If Debtor 2 lives at a different address:

_________________________________________________

Number Street

_________________________________________________

_________________________________________________

City State ZIP Code 

_________________________________________________

County

If Debtor 2’s mailing address is different from 

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

any notices to this mailing address.

_________________________________________________

Number Street

_________________________________________________

P.O. Box

_________________________________________________ 

City State ZIP Code

6. Why you are choosing

this district to file for

bankruptcy

Check one:

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

have lived in this district longer than in any other

district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

Check one:

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

have lived in this district longer than in any other

district.

 I have another reason. Explain.

(See 28 U.S.C. § 1408.)

_________________________________________________ 

Business name

_________________________________________________ 

Business name

_________________________________________________

EIN

_________________________________________________

EIN 

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

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Alejandra Pena

Miami FL 33175

✔

✔

Miami-Dade County

11855 SW 18th Unit 68

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 2 of 41
Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the

Bankruptcy Code you

are choosing to file

under

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

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

 Chapter 7

 Chapter 11

 Chapter 12

 Chapter 13

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

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

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

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

with a pre-printed address.

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

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

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

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

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

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

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

9. Have you filed for

bankruptcy within the

last 8 years?

 No

 Yes.

10. Are any bankruptcy

cases pending or being

filed by a spouse who is

not filing this case with

you, or by a business

partner, or by an

affiliate?

 No

 Yes.

Debtor _________________________________________________ Relationship to you ________________________ 

District _______________________________________________ When _______________ Case number, if known__________________

Debtor _________________________________________________ Relationship to you ___________________________ 

District _______________________________________________ When _______________ Case number, if known__________________ 

11. Do you rent your

residence?

 No. Go to line 12.

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

 No. Go to line 12.

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

this bankruptcy petition.

District ____________________________________________ When ______________ Case number __________________

District ____________________________________________ When ______________ Case number __________________

District ____________________________________________ When ______________ Case number __________________

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

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

✔

Alejandra Pena

✔

✔

✔

✔

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 3 of 41
Part 3: Report About Any Businesses You Ow n as a Sole Proprietor

12. Are you a sole proprietor

of any full- or part-time

business?

A sole proprietorship is a

business you operate as an

individual, and is not a

separate legal entity such as

a corporation, partnership, or

LLC.

If you have more than one

sole proprietorship, use a

separate sheet and attach it

to this petition.

 No. Go to Part 4.

 Yes. Name and location of business

_______________________________________________________________________________________

Name of business, if any

_______________________________________________________________________________________

Number Street

_______________________________________________________________________________________

_______________________________________________ _______ __________________________

City State ZIP Code

Check the appropriate box to describe your business: 

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

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

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

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

 None of the above

13. Are you filing under

Chapter 11 of the

Bankruptcy Code and

are you a small business

debtor or a debtor as

defined by 11 U.S. C. §

1182(1)?

For a definition of small

business debtor, see

11 U.S.C. § 101(51D).

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

choosing to proceed under Subchapter V so that it can set appropriate deadlines. If you indicate that you

are a small business debtor or you are choosing to proceed under Subchapter V, you must attach your

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

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

 No. I am not filing under Chapter 11.

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

the Bankruptcy Code. 

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

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

14. Do you own or have any

property that poses or is

alleged to pose a threat

of imminent and

identifiable hazard to

public health or safety?

Or do you own any

property that needs

immediate attention?

For example, do you own

perishable goods, or livestock

that must be fed, or a building

that needs urgent repairs?

 No

 Yes. What is the hazard?

If immediate attention is needed, why is it needed?

Where is the property? 

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

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

Bankrutpcy Code, and I choose to proceed under Subchatper V of Chapter 11.

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

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Alejandra Pena

✔

✔

✔

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 4 of 41
Part 5: Explain Your Efforts to Receive a Briefing About Credit Counseling

15. Tell the court whether

you have received a

briefing about credit

counseling.

The law requires that you

receive a briefing about credit

counseling before you file for

bankruptcy. You must

truthfully check one of the

following choices. If you

cannot do so, you are not

eligible to file.

If you file anyway, the court

can dismiss your case, you

will lose whatever filing fee

you paid, and your creditors

can begin collection activities

again.

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

You must check one:

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

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

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

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

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so.

 Active duty. I am currently on active military

duty in a military combat zone.

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

You must check one:

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, and I received a

certificate of completion.

Attach a copy of the certificate and the payment

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

 I received a briefing from an approved credit

counseling agency within the 180 days before I

filed this bankruptcy petition, but I do not have a

certificate of completion.

Within 14 days after you file this bankruptcy petition,

you MUST file a copy of the certificate and payment

plan, if any.

 I certify that I asked for credit counseling

services from an approved agency, but was

unable to obtain those services during the 7

days after I made my request, and exigent

circumstances merit a 30-day temporary waiver

of the requirement.

To ask for a 30-day temporary waiver of the

requirement, attach a separate sheet explaining

what efforts you made to obtain the briefing, why

you were unable to obtain it before you filed for

bankruptcy, and what exigent circumstances

required you to file this case.

Your case may be dismissed if the court is

dissatisfied with your reasons for not receiving a

briefing before you filed for bankruptcy.

If the court is satisfied with your reasons, you must

still receive a briefing within 30 days after you file.

You must file a certificate from the approved

agency, along with a copy of the payment plan you

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

may be dismissed.

Any extension of the 30-day deadline is granted

only for cause and is limited to a maximum of 15

days.

 I am not required to receive a briefing about

credit counseling because of:

 Incapacity. I have a mental illness or a mental

deficiency that makes me

incapable of realizing or making 

rational decisions about finances. 

 Disability. My physical disability causes me

to be unable to participate in a 

briefing in person, by phone, or 

through the internet, even after I 

reasonably tried to do so.

 Active duty. I am currently on active military

duty in a military combat zone.

If you believe you are not required to receive a 

briefing about credit counseling, you must file a 

motion for waiver of credit counseling with the court.

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

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Alejandra Pena

✔

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 5 of 41
Part 6: Answ er These Questions for Reporting Purposes

16. What kind of debts do

you have?

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

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

 No. Go to line 16b.

 Yes. Go to line 17.

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

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

 No. Go to line 16c.

 Yes. Go to line 17.

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

_______________________________________________________________

17. Are you filing under

Chapter 7?

Do you estimate that after

any exempt property is

excluded and

administrative expenses

are paid that funds will be

available for distribution

to unsecured creditors?

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

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

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

 No

 Yes

18. How many creditors do

you estimate that you

owe?

 1-49

 50-99

 100-199

 200-999

 1,000-5,000

 5,001-10,000

 10,001-25,000

 25,001-50,000

 50,001-100,000

 More than 100,000

19. How much do you

estimate your assets to

be worth?

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

20. How much do you

estimate your liabilities

to be?

 $0-$50,000

 $50,001-$100,000

 $100,001-$500,000

 $500,001-$1 million

 $1,000,001-$10 million

 $10,000,001-$50 million

 $50,000,001-$100 million

 $100,000,001-$500 million

 $500,000,001-$1 billion

 $1,000,000,001-$10 billion

 $10,000,000,001-$50 billion

 More than $50 billion

Part 7: Sign Below

For you

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

correct. 

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

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

under Chapter 7.

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

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

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

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

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

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

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Executed on _________________ Executed on __________________

MM / DD / YYYY MM / DD / YYYY

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

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

✔

✔

Alejandra Pena

✔

02/05/2021

✔

/s/ Alejandra Pena

✔

✔

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 6 of 41
For your attorney, if you are 

represented by one

If you are not represented 

by an attorney, you do not 

need to file this page.

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

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

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

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

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

_________________________________ Date _________________ 

Signature of Attorney for Debtor MM / DD / YYYY

_________________________________________________________________________________________________ 

Printed name 

_________________________________________________________________________________________________ 

Firm name 

_________________________________________________________________________________________________ 

Number Street 

_________________________________________________________________________________________________ 

______________________________________________________ ____________ ______________________________ 

City State ZIP Code 

Contact phone ______________________________ Email address _________________________________________ 

______________________________________________________ ____________ 

Bar number State 

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

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

2857 SW 27th Avenue

3059629656

33133

Hector Gonzalez

Miami

Alejandra Pena

FL

FL

/s/ Hector Gonzalez

30326

02/05/2021

Hector Gonzalez Ramirez, PA

hector@hhgonzalez.com

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 7 of 41
Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2

Official Form 106Sum 

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

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

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

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

Part 1: Summarize Your Assets

Your assets

Value of what you own

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

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

$ ________________

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

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

Part 2: Summarize Your Liabilities

Your liabilities

Amount you owe

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

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

$ ________________

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

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

$ ________________

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

Your total liabilities $ ________________

Part 3: Summarize Your Income and Expenses

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

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

$ ________________

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

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

7,419.00

0.00

14,211.00

2,750.00

Southern District of Florida

3,036.00

2,989.70

2,750.00

0.00

Alejandra Pena

21,630.00

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 8 of 41
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

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

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

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

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

 Yes

7. What kind of debt do you have?

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

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

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

this form to the court with your other schedules.

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

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

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

Total claim

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

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

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

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

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

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

priority claims. (Copy line 6g.)

$_____________________

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

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

✔

0.00

0.00

0.00

0.00

0.00

Alejandra Pena

0.00

0.00

✔

3,363.58

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 9 of 41
12/15

3.

4.

6.

7.

1.

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

Debtor 1 Alejandra Pena

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: Southern District of

Florida

Case number

(if know)

Official Form 106A/B

Schedule A/B: Property

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

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

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

case number (if known). Answer every question.

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

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

 No. Go to Part 2

 Yes. Where is the property?

Part 2:

Do you own, lease, or have legal or equitable interest in any vehicles, whether they are registered or not? Include any vehicles

you own that someone else drives. If you lease a vehicle, also report it on Schedule G: Executory Contracts and Unexpired Leases.

Cars, vans, trucks, tractors, sport utility vehicles, motorcycles

 No

 Yes

Watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories

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

 No

 Yes

Part 3:

Current value of the

portion you own?

Household goods and furnishings Do not deduct secured

claims or exemptions.

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

 No

 Yes. Describe...

Electronics

Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music

collections; electronic devices including cell phones, cameras, media players, games

 No

 Yes. Describe...

2 television sets

1 computer

1 cellular

First Name Middle Name Last Name

First Name Middle Name Last Name

Check if this is an

amended filing

Describe Your Vehicles

5.

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

you have attached for Part 2. Write that number here...........................................................................................................................................➤ $ 0.00

Describe Your Personal and Household Items

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

Examples:

$ 1,500.00

page 1 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 10 of 41
8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Collectibles of value

Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects;

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

 No

 Yes. Describe...

Equipment for sports and hobbies

Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes

and kayaks; carpentry tools; musical instruments

 No

 Yes. Describe...

Firearms

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

 No

 Yes. Describe...

Clothes

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

 No

 Yes. Describe...

Assorted dresses, skirts, shirts, pants, underwear, and shoes

Jewelry

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

gold, silver

 No

 Yes. Describe...

Assorted costume jewelry

1 ring

Non-farm animals

Examples: Dogs, cats, birds, horses

 No

 Yes. Describe...

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

 No

 Yes. Give specific information...

Part 4:

Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

Cash

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

 No

 Yes.............................................................................................................................................. Cash ...........................

Deposits of money

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

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

 No

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

17.1. Checking account: Chase Bank

Examples:

Examples:

$ 150.00

Examples:

$ 300.00

Add the dollar value of the portion you own for all of your entries from Part 3, including any entries for pages

you have attached for Part 3. Write that number here...........................................................................................................................................➤ $ 1,950.00

Describe Your Financial Assets

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

$ 

Examples:

$ 800.00

Debtor 1 Alejandra Pena Case number(if known)

First Name Middle Name Last Name

page 2 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 11 of 41
18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

Bonds, mutual funds, or publicly traded stocks

Examples: Bond funds, investment accounts with brokerage firms, money market accounts

 No

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

Non-publicly traded stock and interests in incorporated and unincorporated businesses, including an interest in an

LLC, partnership, and joint venture

 No

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

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

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

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

 No

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

Retirement or pension accounts

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

 No

 Yes. List each account separately

Security deposits and prepayments

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

Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications

companies, or others

 No

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

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

 No

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

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

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

 No

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

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

for your benefit

 No

 Yes. Give specific information about them...

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

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

 No

 Yes. Give specific information about them...

Licenses, franchises, and other general intangibles

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

 No

 Yes. Give specific information about them...

Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

Tax refunds owed to you

 No

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

Federal: $ 0.00

State: $ 0.00

Local: $ 0.00

Family support

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

 No

 Yes. Give specific information....

Examples:

Money or property owed to you?

Debtor 1 Alejandra Pena Case number(if known)

First Name Middle Name Last Name

page 3 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 12 of 41
30.

31.

32.

33.

34.

35.

36.

37.

46.

53.

54.

Other amounts someone owes you

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

Social Security benefits; unpaid loans you made to someone else

 No

 Yes. Give specific information....

Interests in insurance policies

 No

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

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

 No

 Yes. Give specific information....

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

 No

 Yes. Give specific information....

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

claims

 No

 Yes. Give specific information....

Any financial assets you did not already list

 No

 Yes. Give specific information...

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

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

 No. Go to Part 6.

 Yes. Go to line 38.

Part 6:

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

 No. Go to Part 7.

 Yes. Go to line 47.

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

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

Examples: Season tickets, country club membership

 No

 Yes. Give specific

Add the dollar value of the portion you own for all of your entries from Part 4, including any entries for pages

you have attached for Part 4. Write that number here...........................................................................................................................................➤ $ 800.00

Describe Any Farm- and Commercial Fishing-Related Prope Describe Any Farm- and Commercial Fishing-Related Property You Own or Have an Interest In. rty You Own or Have an Interest In.

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

information...

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

$ 0.00

Debtor 1 Alejandra Pena Case number(if known)

First Name Middle Name Last Name

page 4 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 13 of 41
Part 8: List the Totals of Each Part of this Form

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

57. Part 3: Total personal and household items, line 15 $ 1,950.00

58. Part 4: Total financial assets, line 36 $ 800.00

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

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

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

62. Total personal property. Add lines 56 through 61 ................... $ 2,750.00 Copy personal property total➤ + $

2,750.00

63. Total of all property on Schedule A/B. Add line 55 + line 62 $ 2,750.00

55. Part 1: Total real estate, line 2............................................................................................................................➤

$ 0.00

+ $ 0.00

Debtor 1 Alejandra Pena Case number(if known)

First Name Middle Name Last Name

page 5 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 14 of 41
Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __

Official Form 106C 

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

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

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

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

your name and case number (if known).

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

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

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

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

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

would be limited to the applicable statutory amount. 

Part 1: Identify the Property You Claim as Exempt

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

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

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

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

Brief description of the property and line on 

Schedule A/B that lists this property

Current value of the 

portion you own

Copy the value from 

Schedule A/B

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description: $________________  $ ____________

Line from 

Schedule A/B:

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

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

 No

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

 No

 Yes 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

Specific laws that allow exemption

 100% of fair market value, up to

any applicable statutory limit 

 100% of fair market value, up to

any applicable statutory limit 

 100% of fair market value, up to

any applicable statutory limit 

Amount of the 

exemption you claim 

Check only one box 

for each exemption

Jewelry - Assorted costume jewelry

1 ring 300.00

Clothing - Assorted dresses, skirts, shirts, pants,

underwear, and shoes 150.00

✔

Electronics - 2 television sets

1 computer

1 cellular 1,500.00

✔

Southern District of Florida

✔

✔

✔

7

Fla. Const. Art.10, § 4(a) (2)

11

Fla. Const. Art.10, § 4(a) (2)

12

Fla. Stat. Ann. § 222.25(4)

Alejandra Pena

1,500.00

150.00

300.00

2

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 15 of 41
Debtor _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

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

Part 2: Additional Page

Brief description of the property and line

on Schedule A/B that lists this property

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Brief 

description:

Line from 

Schedule A/B:

$________________  $ ____________

Specific laws that allow exemption Current value of the 

portion you own 

Copy the value from 

Schedule A/B 

Amount of the 

exemption you claim 

Check only one box 

for each exemption

 100% of fair market value, up to

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

 100% of fair market value, up to 

any applicable statutory limit 

Chase Bank (Checking)

✔

Fla. Stat. Ann. § 222.25(4)

Alejandra Pena

800.00

2

800.00

2

17.1

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 16 of 41
12/15

Fill in this information to identify your case:

Debtor 1 Alejandra Pena

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: Southern District of Florida

Case number

(if know)

Official Form 106D

Schedule D: Creditors Who Have Claims Secured by Prope Schedule D: Creditors Who Have Claims Secured by Property

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

more space is needed, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any additional pages, write your

name and case number (if known).

Part 1: List All Secured Claims

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

First Name Middle Name Last Name

First Name Middle Name Last Name

Check if this is an

amended filing

Do any creditors have claims secured by your property?

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

 Yes. Fill in all of the information below.

1.

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

more than one creditor has a particular claim, list the other creditors in Part 2. As much as possible, list the claims in

alphabetical order according to the creditor’s name.

Column B

Value of collateral

that supports this

claim

Column C

Unsecured

portion If any

Column A

Amount of claim

Do not deduct the

value of collateral.

2.1 Describe the property that secures the claim: $ 7,419.00 $ 0.00 $ 7,419.00

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim relates to a community

debt

Date debt was incurred 2017

- $0.00

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

apply.

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

An agreement you made (such as mortgage or

secured car loan)

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

 Judgment lien from a lawsuit

 Other (including a right to offset) 

Setf/Wofc

Creditor’s Name

P.O. Box 991817

Number Street

Mobile

City

AL

State

36691-1817

ZIP Code

Last 4 digits of account number 5904

Add the dollar value of your entries in Column A on this page. Write that number here: $ 7,419.00

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

you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection agency here. Similarly, if you have more than one creditor for any of the debts that

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

Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of 1

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 17 of 41
12/15

Fill in this information to identify your case:

Debtor 1 Alejandra Pena

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: Southern District of Florida

Case number

(if know)

Official Form 106E/F

Schedule E/F: Creditors Who Have Unsecured Claims

Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY claims and Part 2 for creditors with NONPRIORITY claims. List the other party to any executory

contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts

and Unexpired Leases (Official Form 106G). Do not include any creditors with partially secured claims that are listed in Schedule D: Creditors Who Have Claims Secured by

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

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

Part 1: List All of Your PRIORITY Unsecured Claims

Part 2: List All of Your NONPRIORITY Unsecured Claims

First Name Middle Name Last Name

First Name Middle Name Last Name

Check if this is an

amended filing

Do any creditors have priority unsecured claims against you?

 No. Go to Part 2.

 Yes.

1.

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

creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already included in Part 1. If more than one creditor holds a particular claim,

list the other creditors in Part 3.If you have more than three nonpriority unsecured claims fill out the Continuation Page of Part 2.

Total claim

Do any creditors have nonpriority unsecured claims against you?

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

 Yes. Fill in all of the information below.

3.

4.1 $ 5,685.00

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim relates to a community

debt

Is the claim subject to offset?

 No

 Yes

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

debts

 Other. Specify 

Bank Of America

Nonpriority Creditor's Name

Po Box 982238

Number Street

El Paso

City

TX

State

79998

ZIP Code

Last 4 digits of account number 1739

When was the debt incurred? 2015

4.2 $ 3,454.00

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim relates to a community

debt

Is the claim subject to offset?

 No

 Yes

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

debts

 Other. Specify 

Cbna

Nonpriority Creditor's Name

50 Northwest Point Road

Number Street

Elk Grove Village

City

IL

State

60007

ZIP Code

Last 4 digits of account number 1423

When was the debt incurred? 2016

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of 3

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 18 of 41
4.3 $ 1,282.00

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim relates to a community

debt

Is the claim subject to offset?

 No

 Yes

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

debts

 Other. Specify 

Convergent Outsourcing

Nonpriority Creditor's Name

800 Sw 39th St

Number Street

Renton

City

WA

State

98057

ZIP Code

Last 4 digits of account number 38**

When was the debt incurred? 2020

4.4 $ 801.00

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim relates to a community

debt

Is the claim subject to offset?

 No

 Yes

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

debts

 Other. Specify 

Lvnv Funding Llc

Nonpriority Creditor's Name

Po Box 1269

Number Street

Greenville

City

SC

State

29602

ZIP Code

Last 4 digits of account number 7774

When was the debt incurred? 2018

4.5 $ 205.00

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim relates to a community

debt

Is the claim subject to offset?

 No

 Yes

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

debts

 Other. Specify 

Receivable Management

Nonpriority Creditor's Name

240 Emery St

Number Street

Bethlehem

City

PA

State

18015

ZIP Code

Last 4 digits of account number  

When was the debt incurred? 2019

Debtor Alejandra Pena Case number(if known)

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 2 of 3

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 19 of 41
Part 3: List Others to Be Notified About a Debt That You Already Listed

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

4.6 $ 2,784.00

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

Check if this claim relates to a community

debt

Is the claim subject to offset?

 No

 Yes

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

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

Student loans

Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

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

debts

 Other. Specify 

Syncb/Jcp

Nonpriority Creditor's Name

Number Street

.

City

.

State

.

ZIP Code

Last 4 digits of account number ** **

When was the debt incurred? 2015

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

collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or 2, then list the collection agency here. Similarly, if you have more than one creditor

for any of the debts that you listed in Parts 1 or 2, list the additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill

out or submit this page.

5.

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

Add the amounts for each type of unsecured claim.

6.

Total claim

6a. Domestic support obligations 6a. $ 0.00

6b. Taxes and certain other debts you owe the government 6b. $ 0.00

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

intoxicated

6c. $ 0.00

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

amount here.

6d. $ 0.00

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

$ 0.00

Total claims

from Part 1

Total claim

6f. Student loans 6f. $ 0.00

6g. Obligations arising out of a separation agreement or

divorce that you did not report as priority claims

6g. $ 0.00

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

debts

6h. $ 0.00

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

amount here.

6i. $ 14,211.00

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

$ 14,211.00

Total claims

from Part 2

Debtor Alejandra Pena Case number(if known)

First Name Middle Name Last Name

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 3 of 3

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 20 of 41
12/15

Fill in this information to identify your case:

Debtor 1 Alejandra Pena

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: Southern District of Florida

Case number

(if know)

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases

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

information. If more space is needed, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any

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

First Name Middle Name Last Name

First Name Middle Name Last Name

Check if this is an

amended filing

Do you have any executory contracts or unexpired leases?

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

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

1.

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

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

and unexpired leases.

2.

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

2.1 Apartment Lessee

Alfredo Izaguirre

Name

11855 SW 18th Unit 68

Street

Miami

City

FL

State

33175

ZIP Code

Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of 1

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 21 of 41
12/15

Fill in this information to identify your case:

Debtor 1 Alejandra Pena

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: Southern District of Florida

Case number

(if know)

Official Form 106H

Schedule H: Your Codebtors

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

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

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

name and case number (if known). Answer every question.

First Name Middle Name Last Name

First Name Middle Name Last Name

Check if this is an

amended filing

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

 No

 Yes

1.

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

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

 No. Go to line 3.

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

2.

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

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

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

out Column 2.

3.

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

Check all schedules that apply:

Official Form 106H Schedule H: Your Codebtors page 1 of 1

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 22 of 41
Official Form 106I Schedule I: Your Income page 1

Official Form 106I 

Schedule I: Your Income 12/15

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

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

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

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

Part 1: Describe Employment

1. Fill in your employment

information.

If you have more than one job,

attach a separate page with

information about additional

employers.

Include part-time, seasonal, or

self-employed work.

Occupation may include student

or homemaker, if it applies.

Debtor 1 Debtor 2 or non-filing spouse

Employment status  Employed

 Not employed

 Employed

 Not employed

Occupation __________________________________ __________________________________

Employer’s name __________________________________ __________________________________

Employer’s address _______________________________________

Number Street

_______________________________________ 

_______________________________________ 

_______________________________________ 

City State ZIP Code

________________________________________

Number Street

________________________________________ 

________________________________________ 

________________________________________ 

City State ZIP Code

Part 2: Give Details About Monthly Income

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

spouse unless you are separated. 

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

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

For Debtor 1 For Debtor 2 or 

non-filing spouse

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

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

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

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

Debtor 1 ____________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ____________________________________________________________________ 

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

United States Bankruptcy Court for the: ______________________ District 

tate) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is: 

 An amended filing

 A supplement showing postpetition chapter 13

income as of the following date:

________________

MM / DD / YYYY

How long employed there?________________________ ________________________

Southern District of Florida

3,363.58

0.00

3,363.58

Lewes, DE 19958

16192 Coastal Hwy

Customer Service

✔

Alejandra Pena

2 years

Netbus Inc

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 23 of 41
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106I Schedule I: Your Income page 2

For Debtor 1 For Debtor 2 or 

non-filing spouse

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

5. List all payroll deductions:

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

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

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

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

5e. Insurance 5e. $____________ $_____________

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

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

+ $_____________

6.

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

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

8. List all other income regularly received:

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

profession, or farm

Attach a statement for each property and business showing gross 

receipts, ordinary and necessary business expenses, and the total 

monthly net income. 8a.

$____________ $_____________

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

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

regularly receive

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

settlement, and property settlement. 8c.

$____________ $_____________

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

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

8f. Other government assistance that you regularly receive

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

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

Nutrition Assistance Program) or housing subsidies.

Specify: ___________________________________________________ 8f. $____________ $_____________

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

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

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

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

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

$___________ + $_____________ = $_____________

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

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

friends or relatives.

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

Specify: _______________________________________________________________________________ 11. + $_____________

12. $_____________

Combined 

monthly income

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

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

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

 No.

 Yes. Explain: 

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

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

$____________

$____________

$____________

6. $____________

$____________

$____________

$____________

$____________

$____________

0.00

352.21

0.00

0.00

373.88

2,989.70

0.00

0.00

0.00

2,989.70

0.00

0.00

21.67

0.00

0.00

0.00

2,989.70

0.00

0.00

0.00

0.00

2,989.70

3,363.58

✔

0.00

Alejandra Pena Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 24 of 41
Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J 

Schedule J: Your Expenses 12/15 

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

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

(if known). Answer every question. 

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

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

 No

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

2. Do you have dependents?

Do not list Debtor 1 and

Debtor 2.

Do not state the dependents’

names.

 No

 Yes. Fill out this information for

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

Dependent’s relationship to 

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent live 

with you?

_________________________ ________

 No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

_________________________ ________  No

 Yes

3. Do your expenses include

expenses of people other than

yourself and your dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

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

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

applicable date.

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

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

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

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

If not included in line 4:

4a. Real estate taxes 4a. $_____________________

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

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

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

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

Check if this is: 

 An amended filing

 A supplement showing postpetition chapter 13

expenses as of the following date:

________________

MM / DD / YYYY

Southern District of Florida

1,550.00

0.00

0.00

30.00

0.00

✔

✔

✔

✔

Alejandra Pena

Daughter

Daughter 14

12

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 25 of 41
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106J Schedule J: Your Expenses page 2

Your expenses

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

6. Utilities:

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

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

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

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

7. Food and housekeeping supplies 7. $_____________________

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

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

10. Personal care products and services 10. $_____________________

11. Medical and dental expenses 11. $_____________________

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

Do not include car payments. 12.

$_____________________

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

14. Charitable contributions and religious donations 14. $_____________________

15. Insurance.

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

1

15a. Life insurance 15a. $_____________________

15b. Health insurance 15b. $_____________________

15c. Vehicle insurance 15c. $_____________________

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

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

Specify: ________________________________________________________ 16. $_____________________

17. Installment or lease payments:

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

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

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

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

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

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

$_____________________

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

Specify:_______________________________________________________ 19. $_____________________

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

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

20b. Real estate taxes 20b. $_____________________

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

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

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

100.00

600.00

0.00

100.00

0.00

100.00

0.00

0.00

38.00

30.00

50.00

0.00

178.00

180.00

0.00

0.00

80.00

0.00

Alejandra Pena

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 26 of 41
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ 

First Name Middle Name Last Name

Official Form 106J Schedule J: Your Expenses page 3

21. +$_____________________

22a.

22b.

21. Other. Specify:______________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

22. Calculate your monthly expenses.

22a. Add lines 4 through 21.

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

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

$_____________________

$_____________________

$_____________________

23. Calculate your monthly net income.

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

$_____________________

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

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

The result is your monthly net income. 23c.

$_____________________

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

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

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

 No.

 Yes. Explain here: 

 +$_____________________

 +$_____________________

0.00

✔

3,036.00

3,036.00

Alejandra Pena

3,036.00

2,989.70

-46.30

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 27 of 41
Official Form 106Dec Declaration About an Individual Debtor’s Schedules 

Official Form 106Dec

Declaration About an Individual Debtor’s Schedules 12/15

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

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

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

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

Sign Below

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

 No

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

Signature (Official Form 119).

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

that they are true and correct.

______________________________________________  _____________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

 Fill in this information to identify your case:

 Check if this is an

amended filing

Southern District of Florida

02/05/2021

✔

Alejandra Pena

/s/ Alejandra Pena

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 28 of 41
4/19

Fill in this information to identify your case:

Debtor 1 Alejandra Pena

Debtor 2

(Spouse, if filing)

United States Bankruptcy Court for the: Southern District of Florida

Case number

(if know)

Official Form 107

Statement of Financial Affairs for Individuals Filing fo Statement of Financial Affairs for Individuals Filing for Bankruptcy r Bankruptcy

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

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

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

Part 2: Explain the Sources of Your Income

First Name Middle Name Last Name

First Name Middle Name Last Name

Check if this is an

amended filing

What is your current marital status?

 Married

 Not married

1.

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

 No

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

2.

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

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

 No

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

3.

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

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

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

 No

 Yes. Fill in the details.

Debtor 1

Sources of income

Check all that apply

Gross income

(before deductions and

exclusions)

Debtor 2

Sources of income

Check all that apply

Gross income

(before deductions and

exclusions)

4.

From January 1 of current year until the date you filed

for bankruptcy: Wages, commissions,

bonuses, tips

Operating a business

$ 2,998.83 Wages, commissions,

bonuses, tips

 Operating a business

$ 

For last calendar year:

(January 1 to December 31, 2020

Wages, commissions,

bonuses, tips

Operating a business

$ 20,502.82 Wages, commissions,

bonuses, tips

 Operating a business

$ 

For the calendar year before that:

(January 1 to December 31, 2019

Wages, commissions,

bonuses, tips

Operating a business

$ 31,166.87 Wages, commissions,

bonuses, tips

 Operating a business

$ 

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

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

benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and gambling and lottery winnings. If you are filing a joint case

and you have income that you received together, list it only once under Debtor 1.

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

 No

 Yes. Fill in the details.

5.

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 29 of 41
Part 3: List Certain Payments You Made Before You Filed for Bankruptcy

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

Part 5: List Certain Gifts and Contributions

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

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

as

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

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

 No. Go to line 7.

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

and

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

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

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

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

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

 No. Go to line 7.

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

that

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

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

6.

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

relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer,

director, person in control, or owner of 20% or more of their voting securities; and any managing agent, including one for a business you operate as a sole

proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations, such as child support and alimony.

 No.

 Yes. List all payments to an insider.

7.

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

Include payments on debts guaranteed or cosigned by an insider.

 No.

 Yes. List all payments that benefited an insider.

8.

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

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

 No

 Yes. Fill in the details.

9.

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

Check all that apply and fill in the details below.

 No. Go to line 11.

 Yes. Fill in the information below.

10.

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

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

 No

 Yes. Fill in the details

11.

Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of creditors, a courtappointed receiver, a custodian, or another official?

 No

 Yes

12.

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

 No

 Yes. Fill in the details for each gift.

13.

Debtor Alejandra Pena Case number(if known)

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 2 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 30 of 41
Part 6: List Certain Losses

Part 7: List Certain Payments or Transfers

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

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

 No

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

14.

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

 No

 Yes. Fill in the details.

15.

Description and value of any property transferred Date payment or

transfer was made

Amount of

payment

Funds 09/09/2020 $ 1,200.00

$ 1,200.00

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

consulted about seeking bankruptcy or preparing a bankruptcy petition?

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

 No

 Yes. Fill in the details.

16.

Hector Gonzalez

Person Who Was Paid

2857 SW 27th avenue

Number Street

Miami

City

FL

State

33133

ZIP Code

www.hhgonzalez.com

Email or website address

Person Who Made the Payment, if Not You

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

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

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

 No

 Yes. Fill in the details.

17.

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

in the ordinary course of your business or financial affairs?

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

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

 No

 Yes. Fill in the details.

18.

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

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

 No

 Yes. Fill in the details.

19.

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

closed, sold, moved, or transferred?

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

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

 No

 Yes. Fill in the details.

20.

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

securities, cash, or other valuables?

 No

 Yes. Fill in the details.

21.

Debtor Alejandra Pena Case number(if known)

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 31 of 41
Part 9: Identify Property You Hold or Control for Someone Else

Part 10: Give Details About Environmental Information

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

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

 No

 Yes. Fill in the details.

22.

Where is the property? Describe the property Value

Assorted furniture $ Unknown

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

or hold in trust for someone.

 No

 Yes. Fill in the details.

23.

Alfredo Izaguirre

Owner’s Name

11855 SW 18th Unit 68

Number Street

Miami

City

FL

State

33175

ZIP Code

11855 SW 18 Terrace Unit 68

Number Street

Miami

City

FL

State

33175

ZIP Code

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

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

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

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

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

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

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

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

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

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

 No

 Yes. Fill in the details.

24.

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

 No

 Yes. Fill in the details.

25.

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

 No

 Yes. Fill in the details.

26.

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

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

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

 A partner in a partnership

 An officer, director, or managing executive of a corporation

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

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

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

27.

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

institutions, creditors, or other parties.

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

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

28.

Debtor Alejandra Pena Case number(if known)

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 4 of 5

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 32 of 41
Part 12: Sign Below

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

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

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

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

Date 02/05/2021

/s/ Alejandra Pena

Signature of Debtor 1

Date 

Signature of Debtor 2

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

 No

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

Declaration, and Signature (Official Form 119).

Debtor Alejandra Pena Case number(if known)

First Name Middle Name Last Name

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

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 33 of 41
Official Form 108 Statement of Intention for Individuals Filing Under Chapter 7 page 1 

Official Form 108

Statement of Intention for Individuals Filing Under Chapter 7 12/15

If you are an individual filing under chapter 7, you must fill out this form if:

 creditors have claims secured by your property, or

 you have leased personal property and the lease has not expired.

You must file this form with the court within 30 days after you file your bankruptcy petition or by the date set for the meeting of creditors, 

whichever is earlier, unless the court extends the time for cause. You must also send copies to the creditors and lessors you list on the form. 

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

Both debtors must sign and date the form. 

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

write your name and case number (if known).

Part 1: List Your Creditors Who Have Secured Claims

1. For any creditors that you listed in Part 1 of Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D), fill in the

information below.

Identify the creditor and the property that is collateral What do you intend to do with the property that 

secures a debt?

Did you claim the property 

as exempt on Schedule C?

Creditor’s 

name:

 Surrender the property.

 Retain the property and redeem it. 

 Retain the property and enter into a

Reaffirmation Agreement.

 Retain the property and [explain]:

______________________________________

 No

 Yes

Description of 

property 

securing debt: 

Creditor’s 

name:

 Surrender the property.

 Retain the property and redeem it.

 Retain the property and enter into a

Reaffirmation Agreement.

 Retain the property and [explain]:

______________________________________

 No

 Yes

Description of 

property 

securing debt: 

Creditor’s 

name:

 Surrender the property.

 Retain the property and redeem it.

 Retain the property and enter into a

Reaffirmation Agreement.

 Retain the property and [explain]:

______________________________________

 No

 Yes

Description of 

property 

securing debt: 

Creditor’s 

name:

 Surrender the property.

 Retain the property and redeem it.

 Retain the property and enter into a

Reaffirmation Agreement.

 Retain the property and [explain]:

______________________________________

 No

 Yes

Description of 

property 

securing debt: 

Debtor 1 __________________________________________________________________ 

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

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

United States Bankruptcy Court for the: ______________________ District of __________

(State) 

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

 Check if this is an

amended filing

Southern District of Florida

Setf/Wofc

Alejandra Pena

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 34 of 41
Debtor ______________________________________________________ Case number (If known)_____________________________________

Official Form 108 Statement of Intention for Individuals Filing Under Chapter 7 page 2 

Part 2: List Your Unexpired Personal Property Leases

For any unexpired personal property lease that you listed in Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G), 

fill in the information below. Do not list real estate leases. Unexpired leases are leases that are still in effect; the lease period has not yet 

ended. You may assume an unexpired personal property lease if the trustee does not assume it. 11 U.S.C. § 365(p)(2).

Describe your unexpired personal property leases Will the lease be assumed? 

Lessor’s name:  No

 Yes Description of leased 

property: 

Lessor’s name:  No

 Yes Description of leased 

property: 

Lessor’s name:  No

Description of leased  Yes

property: 

Lessor’s name:  No

 Yes

Description of leased 

property: 

Lessor’s name:  No

 Yes

Description of leased 

property: 

Lessor’s name:  No

 Yes

Description of leased 

property: 

Lessor’s name:  No

 Yes

Description of leased 

property: 

Part 3: Sign Below

Under penalty of perjury, I declare that I have indicated my intention about any property of my estate that secures a debt and any 

personal property that is subject to an unexpired lease.

___________________________________________ ___________________________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

/s/ Alejandra Pena

02/05/2021

Alejandra Pena

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 35 of 41
Alfredo Izaguirre

11855 SW 18th Unit 68

Miami, FL 33175

Bank Of America

Po Box 982238

El Paso, TX 79998

Cbna

50 Northwest Point Road

Elk Grove Village, IL 60007

Convergent Outsourcing

800 Sw 39th St

Renton, WA 98057

Lvnv Funding Llc

Po Box 1269

Greenville, SC 29602

Receivable Management

240 Emery St

Bethlehem, PA 18015

Setf/Wofc

P.O. Box 991817

Mobile, AL 36691-1817

Syncb/Jcp

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 36 of 41
United States Bankruptcy Court

In re: Case No.

Chapter

Debtor(s)

Verification of Creditor Matrix

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

true and correct to the best of their knowledge.

Date:

Signature of Debtor

Signature of Joint Debtor

7

Southern District of Florida

02/05/2021 /s/ Alejandra Pena

Alejandra Pena

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 37 of 41
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 1

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

Individuals Filing for Bankruptcy (Form 2010)

This notice is for you if:

You are an individual filing for bankruptcy, 

and 

Your debts are primarily consumer debts.

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

§ 101(8) as “incurred by an individual 

primarily for a personal, family, or 

household purpose.”

The types of bankruptcy that are 

available to individuals 

Individuals who meet the qualifications may file 

under one of four different chapters of the 

Bankruptcy Code:

 Chapter 7 — Liquidation

 Chapter 11 — Reorganization

 Chapter 12 — Voluntary repayment plan 

for family farmers or 

fishermen

 Chapter 13 — Voluntary repayment plan 

for individuals with regular 

income

You should have an attorney review your 

decision to file for bankruptcy and the choice of 

chapter. 

Chapter 7: Liquidation 

$245 filing fee

 $78 administrative fee

+ $15 trustee surcharge

$338 total fee

Chapter 7 is for individuals who have financial 

difficulty preventing them from paying their 

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

creditors. The primary purpose of filing under 

chapter 7 is to have your debts discharged. The 

bankruptcy discharge relieves you after 

bankruptcy from having to pay many of your 

pre-bankruptcy debts. Exceptions exist for

particular debts, and liens on property may still 

be enforced after discharge. For example, a 

creditor may have the right to foreclose a home 

mortgage or repossess an automobile.

However, if the court finds that you have 

committed certain kinds of improper conduct 

described in the Bankruptcy Code, the court 

may deny your discharge. 

You should know that even if you file 

chapter 7 and you receive a discharge, some 

debts are not discharged under the law. 

Therefore, you may still be responsible to pay:

 most taxes; 

 most student loans; 

 domestic support and property settlement 

obligations; 

 

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 38 of 41
 

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

 most fines, penalties, forfeitures, and 

criminal restitution obligations; and

 certain debts that are not listed in your 

bankruptcy papers. 

You may also be required to pay debts arising 

from: 

 fraud or theft;

 fraud or defalcation while acting in breach 

of fiduciary capacity; 

 intentional injuries that you inflicted; and 

 death or personal injury caused by 

operating a motor vehicle, vessel, or 

aircraft while intoxicated from alcohol or 

drugs. 

If your debts are primarily consumer debts, the 

court can dismiss your chapter 7 case if it finds 

that you have enough income to repay 

creditors a certain amount. You must file 

Chapter 7 Statement of Your Current Monthly 

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

individual filing for bankruptcy under 

chapter 7. This form will determine your 

current monthly income and compare whether 

your income is more than the median income 

that applies in your state. 

If your income is not above the median for 

your state, you will not have to complete the 

other chapter 7 form, the Chapter 7 Means 

Test Calculation (Official Form 122A–2). 

If your income is above the median for your 

state, you must file a second form —the 

Chapter 7 Means Test Calculation (Official 

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

sometimes called the Means Test—deduct 

from your income living expenses and 

payments on certain debts to determine any

amount available to pay unsecured creditors. If 

your income is more than the median income 

for your state of residence and family size, 

depending on the results of the Means Test, the 

U.S. trustee, bankruptcy administrator, or 

creditors can file a motion to dismiss your case

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

motion is filed, the court will decide if your 

case should be dismissed. To avoid dismissal, 

you may choose to proceed under another 

chapter of the Bankruptcy Code.

If you are an individual filing for chapter 7 

bankruptcy, the trustee may sell your property

to pay your debts, subject to your right to 

exempt the property or a portion of the 

proceeds from the sale of the property. The 

property, and the proceeds from property that 

your bankruptcy trustee sells or liquidates that 

you are entitled to, is called exempt property. 

Exemptions may enable you to keep your 

home, a car, clothing, and household items or 

to receive some of the proceeds if the property 

is sold. 

Exemptions are not automatic. To exempt

property, you must list it on Schedule C: The 

Property You Claim as Exempt (Official Form 

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

trustee may sell it and pay all of the proceeds 

to your creditors.

Chapter 11: Reorganization 

$1,167 filing fee

+ $571 administrative fee

$1,738 total fee

Chapter 11 is often used for reorganizing a 

business, but is also available to individuals. 

The provisions of chapter 11 are too 

complicated to summarize briefly. 

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 39 of 41
 

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

Chapter 12: Repayment plan for family 

farmers or fishermen

$200 filing fee

+ $78 administrative fee

$278 total fee

Similar to chapter 13, chapter 12 permits 

family farmers and fishermen to repay their 

debts over a period of time using future 

earnings and to discharge some debts that are 

not paid. 

Chapter 13: Repayment plan for 

individuals with regular 

income

$235 filing fee

+ $78 administrative fee

$313 total fee

Chapter 13 is for individuals who have regular 

income and would like to pay all or part of 

their debts in installments over a period of time

and to discharge some debts that are not paid. 

You are eligible for chapter 13 only if your 

debts are not more than certain dollar amounts 

set forth in 11 U.S.C. § 109. 

Under chapter 13, you must file with the court 

a plan to repay your creditors all or part of the 

money that you owe them, usually using your 

future earnings. If the court approves your 

plan, the court will allow you to repay your 

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

5 years, depending on your income and other 

factors.

After you make all the payments under your 

plan, many of your debts are discharged. The 

debts that are not discharged and that you may 

still be responsible to pay include: 

 domestic support obligations, 

 most student loans, 

 certain taxes, 

 debts for fraud or theft,

 debts for fraud or defalcation while acting 

in a fiduciary capacity,

 most criminal fines and restitution 

obligations, 

 certain debts that are not listed in your 

bankruptcy papers, 

 certain debts for acts that caused death or 

personal injury, and 

 certain long-term secured debts. 

Read These Important Warnings

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

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

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

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

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

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

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

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

and following all of the legal requirements. 

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

necessary documents.

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

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

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

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

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 40 of 41
Notice Required by 11 U.S.C. U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 4

Bankruptcy crimes have serious 

consequences 

 If you knowingly and fraudulently conceal 

assets or make a false oath or statement 

under penalty of perjury—either orally or 

in writing—in connection with a 

bankruptcy case, you may be fined, 

imprisoned, or both. 

 All information you supply in connection 

with a bankruptcy case is subject to 

examination by the Attorney General acting 

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

Office of the U.S. Attorney, and other 

offices and employees of the U.S. 

Department of Justice.

Make sure the court has your 

mailing address

The bankruptcy court sends notices to the 

mailing address you list on Voluntary Petition 

for Individuals Filing for Bankruptcy (Official 

Form 101). To ensure that you receive 

information about your case, Bankruptcy 

Rule 4002 requires that you notify the court of 

any changes in your address.

A married couple may file a bankruptcy case 

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

case and each spouse lists the same mailing 

address on the bankruptcy petition, the 

bankruptcy court generally will mail you and 

your spouse one copy of each notice, unless 

you file a statement with the court asking that 

each spouse receive separate copies.

Understand which services you 

could receive from credit 

counseling agencies 

The law generally requires that you receive a 

credit counseling briefing from an approved 

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

If you are filing a joint case, both spouses must 

receive the briefing. With limited exceptions, 

you must receive it within the 180 days before

you file your bankruptcy petition. This briefing

is usually conducted by telephone or on the 

Internet. 

In addition, after filing a bankruptcy case, you 

generally must complete a financial 

management instructional course before you 

can receive a discharge. If you are filing a joint 

case, both spouses must complete the course. 

You can obtain the list of agencies approved to 

provide both the briefing and the instructional 

course from: http://www.uscourts.gov/servicesforms/bankruptcy/credit-counseling-and-debtoreducation-courses. 

In Alabama and North Carolina, go to: 

http://www.uscourts.gov/servicesforms/bankruptcy/credit-counseling-anddebtor-education-courses. 

If you do not have access to a computer, the 

clerk of the bankruptcy court may be able to 

help you obtain the list.

Warning: File Your Forms on Time

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

requires that you promptly file detailed information 

about your creditors, assets, liabilities, income, 

expenses and general financial condition. The 

court may dismiss your bankruptcy case if you do 

not file this information within the deadlines set by 

the Bankruptcy Code, the Bankruptcy Rules, and 

the local rules of the court. 

For more information about the documents and 

their deadlines, go to: 

http://www.uscourts.gov/forms/bankruptcy-forms

Case 21-11134-LMI Doc 1 Filed 02/05/21 Page 41 of 41