Debtor2 

(Spouse, if filing) First Name Middle Name 

United States Bankruptcy Court for the: ~-0 ,,,/-lkt.t,.,oistrict of 

Case number 

(If known) 

1'}-;J..oJ.Ob -r eoR. 

Official Form 107 

D Check if this is an 

amended filing 

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

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

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

number (if known). Answer every question. 

Give Details About Your Marital Status and Where You Lived Before 

1. What is your current marital status? 

D~rried 

!Y'Not married 

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

~o 

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

Debtor 1: 

}J 1~ 

Number Street 

City State ZIP Code 

Number Street 

City State ZIP Code 

Dates Debtor 1 

lived there 

From 

To 

From 

To 

Debtor 2: 

D Same ~s Debtor 1 

Number Street 

City 

D Same as Debtor 1 

Number Street 

City 

State ZIP Code 

State ZIP Code 

Dates Debtor 2 

lived there 

D Same as Debtor 1 

From 

To 

D Same as Debtor 1 

From 

To 

3. Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory? (Community property star and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.) 

~ No 

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

-· •if j Explain ttie Sources of Your Income 

,;, ·'.;,: Official Fo-~ 107 't· .... Statement ofFina~·cial Affairs for Individuals Filing for Ba-.;kruptcy page 1 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 1 of 12
Debtor 1 Case number (ilknown) J.../ ~ J.-O;L06- P/JR First Name Middle Name Last Name 

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

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

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

~:s. Fill in the details. 

From January 1 of current year until 

the date you filed for bankruptcy: 

For last calendar year: 

(January 1 to December 31, ---~ 

yyyy 

For the calendar year before that: 

(January 1 to December 31, ---~ 

yyyy 

Sources of income 

Check all that apply. 

Gross income 

{before deductions and 

exclusions} 

D Wages, commissions, 

bonuses, tips $ ______ _ 

D Operating a business 

D Wages, commissions, 

bonuses, tips 

D Operating a business 

D Wages, commissions, 

bonuses, tips 

D Operating a business 

$ ______ _ 

$ ______ _ 

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

Sources of income 

Check all that apply. 

D Wages, commissions, 

bonuses,tips 

D Operating a business 

D Wages, commissions, 

bonuses, tips 

D Operating a business 

D Wages, commissions, 

bonuses, tips 

D Operating a business 

Gross income 

(before deductions and 

exclusions} 

$ ______ _ 

$ ______ _ 

$ _____ _ 

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. 

0 No 

D Yes. Fill in the details. 

From January 1 of current year until 

the date you filed for bankruptcy: 

For last calendar year: 

(January 1 to December 31, ___ ) yyyy 

For the calendar year before that: 

(January 1 to December 31, ___ ) yyyy 

Sources of income 

Describe below. 

Gross income from 

each source 

{before deductions and . 

exclusions} 

Sources of income 

Describe below. 

$ ________ ----------

$ ________ ----------

$ ________ ----------

$ ________ ----------

$ ________ ----------

$ ________ ----------

$ _______ _ 

$ ________ ----------

$ ________ ----------

Gross income from 

each source 

{before deductions and 

exclusions} 

$ ______ _ 

$ ______ _ 

L 

$ ______ _ 

$ _______ _ 

$ _______ _ 

$ _______ _ 

$ ______ _ 

$ ______ _ 

·, ..... ,~ ..... .,. .... ~ .. , .. -·;on-:1, <.J,,··,.~ ·.e:xnl.'liu th.r· · •'••H· !•::.:orne ~--.-•»~·•·.·~ ,,,_ ... "'.-"""' - . ..,,. · .... {~\ ;-~ •. ,..,;....,.__., .... ,.._,._. ...... ~.,--.:,---,-,.;;.~~~-

: ~--: Explain tt .. Ji·· _-,'B._'.........,.._._, __ _ .. ··- . 

· 1, Official Form 107 ·,f ! · Staterrferit ofFinancial Affairs for Individuals Filing for Bankruptcy ,f 1 <f11;, page 2. 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 2 of 12
Debtor 1 (Y)(Cfl I ifl 0-.,I- 'lf)M b-'Pl>E_ 

Case number {if known)~------------- First Name Middle Name Last Name 

List Certain Payments You Made Before You Filed for Bankruptcy 

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

D 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. 

D 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. 

D 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? 

D No. Go to line 7. 

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

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

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

Creditor"s Name 

Number Street 

City State 

Creditor"s Name 

Number Street 

City State 

Creditor's Name 

Number Street 

City State 

ZIP Code 

ZIP Code 

ZIP Code 

Dates of 

payment 

Total amount paid Amount you still owe 

$ _______ $ ______ _ 

$ ________ $ _______ _ 

$ ________ $ _______ _ 

.. ~. ..... · .. · 

.... · .... , ... ,,_ 

Official Form 1 fr'.ifr Statement of Financial Affairs for Individuals Filing for Bankruptcy'. 

Was this payment for ... 

D Mortgage 

Dear 

D Credit card 

D Loan repayment 

D Suppliers or vendors 

D Other ____ _ 

D Mortgage 

Dear 

D Credit card 

D Loan repayment 

D Suppliers or vendors 

Dother ___ _ 

• Mortgage 

Dear 

D Credit card 

D Loan repayment 

D Suppliers or vendors 

Dother ___ _ 

page3 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 3 of 12
Debtor 1 ~lo M~dleName 

Casenumber(rtknown):J../- J,()~6 _,. Pp,€ 

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

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

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

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

such as child support and alimony. 

~o 

0 Yes. List all payments to an insider. 

Insider's Name 

Number Street 

City State ZIP Code 

Insider's Name 

Number Street 

City State ZIP Code 

Dates of 

payment 

Total amount 

paid 

$ ____ _ 

Amount you still Reason for this payment 

owe 

$ _____ _ 

I 

$ ______ $ ____ _ 

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

an insider? 

Include payments on debts guaranteed or cosigned by an insider. 

~o 

0 Yes. List all payments that benefited an insider. 

Insider's Name 

Number Street 

City State ZIP Code 

Dates of 

payment 

Total amount 

paid 

Amount you still 

owe 

$ _____ $ ____ _ 

Reason for this payment 

Include creditor's name __ _ 

I 

i 

I ----- ---- - --- ------- ---, 

Insider's Name 

Number Street 

City 

· ·:i" Official Fofittt"107,·" 

$ _____ $ _____ _ 

State ZIP Code 

Statement of Financial Affairs foflndividuals Filjng for Bankruptcy-· page4 

I 

I 

. .-· ~~ .. _, 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 4 of 12
Debtor 1 Case number (if known) 1.J -J,J}t-Ob-pl)R First Name Middle Name ---------------

Identify Legal Actions, Repossessions, and Foreclosures 

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

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

and contract disputes. 

rJ/No 

0 Yes. Fill in the details. 

Nature of the case Court or agency 

Case title. ___________ _ Court Name 

Number Street 

Case number 

Casetitle ____________ 1-

City 

Court Name 

Number Street 

Case number ---------1 ! City 

L _____ --------------------------- .... 

State ZIP Code 

State ZIP Code 

Status of the case 

D Pending 

D On appeal 

D Concluded 

D Pending 

D On appeal 

D Concluded 

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

Check all that apply and fill in the details below. 

[) .t-Jo. Go to line 11. 

rrves. Fill in the information below. 

/JLf!). 

State 

Describe the property 

Explain what happened 

D yroperty was repossessed. 

c:!" Property was foreclosed. 

D Property was garnished. 

0 Property was attached, seized, or levied. 

Describe the property 

-Cred-itor"s-Nam-e ----1 ---- -- Number Street 

City State ZIP Code 

Explain what happened 

D Property was repossessed. 

D Property was foreclosed. 

D Property was garnished. 

D Property was attached, seized, or levied. 

Statement of Firiancia.l'Affairsrfor Individuals Filing for Bankruptcy 

Date Value of the property 

Date Value of the propertJ 

$ _____ _ 

· ·,;•,page-5 "'W~-

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 5 of 12
Debtor 1 Middle Name Last Name 

Case number (if known) ')_/-JJJ ;.,o 6 --J'L)I? First Name 

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

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

ijZI No 

0 Yes. Fill in the details. 

Creditor's Name 

Number Street 

City State ZIP Code 

Describe the action the creditor took 

Last 4 digits of account number: XXXX-___ _ 

Date action 

was taken 

Amount 

$ ______ _ 

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

cre~rs, a court-appointed receiver, a custodian, or another official? 

l:J""No 

0 Yes 

•Mil List Certain Gifts and Contributions 

13. Wit_?in 2 years before you filed for b~nkruptcy, did you give any gifts with a total value of more than $600 per p~rson? 

(B" No 

0 Yes. Fill in the details for each gift. 

Gifts with a total value of more than $600 

per person 

Person to Whom You Gave the Gift 

Number Street 

City State ZIP Code 

Person's relationship to you 

Gifts with a total value of more than $600 

per person 

Person to Whom You Gave the Gift 

Number Street 

City State ZIP Code 

Person's relationship to you _____ _ 

Describe the gifts 

Describe the gifts 

Official Form 107 "?•Statement ofiFinancial Affairs•for Individuals Filing for Bankruptcy 

Dates you gave 

the gifts 

Dates you gave 

the gifts 

··11~-

Value 

$ ____ _ 

$ _____ _ 

Value 

$ _____ _ 

$ _____ _ 

··'>f-. -page6 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 6 of 12
Debtor 1 Case number (if known) 'J./ -'J.., 0 ;J,, {l {; - f D /<, First Name Middle Name Last Name 

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

~o 

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

Gifts or contributions to charities 

that total more than $600 

Charity's Name 

Number Street 

City State ZIP Code 

•,,, List Certain Losses 

Describe what you contributed Date you 

contributed 

Value 

$ ____ _ 

$ _____ _ 

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

disaster, or gambling? 

r(No . 

0 Yes. Fill in the details. 

Describe the properly you lost and 

how the loss occurred 

Describe any insurance coverage for the loss Date of your 

loss 

Include the amount that insurance has paid. List pending insurance 

claims on line 33 of Schedule AIB: Property. 

•::..-:,•-- List Certain Payments or Transfers 

Value of property 

lost 

$ _____ _ 

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

you consulted about seeking bankruptcy or preparing a bankruptcy petition? 

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

rj{No 

0 Yes. Fill in the details. 

Description and value of any property transferred Date payment or Amount of payment 

transfer was 

Person Who Was Paid -~----~----------------·--·--·------------ made 

Number Street $ _____ _ 

$ ____ _ 

City State ZIP Code 

Email or website address 

f~?n Who M@_dl' the f,'.ayment, if Not You 

Official Form 107 '~" ,:if'· ·Statement ofFinancral Affairs for Individuals Filing for Bankruptcy -.•<;F· pl'@e 7 -· 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 7 of 12
Debtor 1 Case number (if known) l/-~~ ,. P/J/2. First Name Middle Name 

----------------------------... ----------------·--

Description and value of any property transferred Date payment or Amount of 

transfer was made payment 

Person Who Was Paid 

$ _____ _ 

Number Street 

$ ____ _ 

City State ZIP Code 

Email or website address 

Person Who Made the Payment, ~ Not You 

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

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

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

~o 

D Yes. Fill in the details. 

Description and value of any property transferred Date payment or Amount of payment 

transfer was 

made 

Person Who Was Paid 

Number Street 

$ ____ _ 

-C-ity ________ S_t-at_e __ Z_I_P_C-od_e ____________________________ -----·- ----··-··------ j 

$ ____ _ 

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

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

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

Do ..!)'it include gifts and transfers that you have already listed on this statement. 

lil'No 

D Yes. Fill in the details. 

Person Who Received Transfer 

Number Street 

City State ZIP Code 

Person's relationship to you _____ _ 

Person Who Received Transfer 

Number Street 

City. State ZIP Code 

·Person's relationship to you _____ _ 

Description and value of property 

transferred 

--------·--------,-------, .-, •-= 

Describe any property or payments received 

or debts paid in exchange 

... ,.~,.-, -----------·-···--·--··--------

Official Form 107fri: Statement of Financial Affairs for Individuals Filing·:fdr Bankruptcy 

Date transfer 

was made 

pages 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 8 of 12
Debtor 1 Case number (if known) 11,. First Name Middle Name Last Name 

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

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

~o 

D Yes. Fill in the details. 

Description and value of the property transferred 

Name of trust __ I

--L _____________ -------------------- -- 0' • :F.Ti•:i:i List Certain Financial Accounts, Instruments, Safe Deposit Boxes, and Storage Units 

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

closed, sold, moved, or transferred? 

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

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

0 No 

0 Yes. Fill in the details. 

Last 4 digits of account number 

Name of Financial Institution XXXX-_ __ _ 

Number Street 

City State ZIP Code 

Type of account or 

instrument 

0 Checking 

0 Savings 

0 Money market 

0 Brokerage 

00ther""""=-c== 

Date account was Last balance before 

closed, sold, moved, closing or transfer 

or transferred 

$ ___ _ 

XXXX-___ _ 0 Checking 

0 Savings 

$ ____ _ 

Name of Financial Institution 

Number Street 

City State ZIP Code 

0 Money market 

0 Brokerage 

Oother ___ _ 

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

securities, cash, or other valuables? 

0 No 

0 Yes. Fill in the details. 

Who else had access to it? Describe the contents 

Name of Financial Institution Name 

Number Street Number Street 

City State 

City , State ZIP Code 

• r,-Official Form 107~-- -«- Statement of Financial Affairs for]ndividuals Filing for Bankruptcy 

Do you still 

have it? 

0 No 

0 Yes 

paije 9 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 9 of 12
Debtor 1 lf/~;/4 Case number (if known) 2J-J,_()J,,.O 6 -PJJI!.. First Name Middle Name Last Name 

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

• No 

0 Yes. Fill in the details. 

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

Name of Storage Facility Name 

Number Street Number Street 

City State ZIP Code 

City State ZIP Code 

Identify Property You Hold or Control for Someone Else 

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

or )old in trust for someone. 

liif No 

0 Yes. Fill in the details. 

Owner's Name 

Number Street 

City State ZIP Code 

Where is the property? Describe the property r -------- --- -

--1 Number Street 

City State ZIP Code 

Give Details About Environmental Information 

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

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

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

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

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

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

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

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

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

Do you still 

have it? 

• No 

• Yes 

Value 

$ ___ _ 

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

~o 

0 Yes. Fill in the details. 

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

Name of site ""G-ov_e_m_m_e_n,..ta.,..I u-n-,-lt-------l - - -. . ~ ----

Number Street Number Street 

City State ZIP Code 

City State ZIP Code 

, .. , Official°Form·107 Statement of Financial-Affairs for Individuals Filing for Bankruptcy ·"· 1,•page· 1 O 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 10 of 12
Debtor 1 Case number(ifknown) J.,/-t-PW b- P!J/2. Last Name 

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

~ 

0 Yes. Fill in the details. 

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

Name of site Governmental unit 

Number Street Number Street 

City State ZIP Code 

City State ZIP Code 

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

'Ei No 

0 Yes. Fill in the details. 

Court or agency Nature of the case 

Case title ____________ _ 

Court Name 

Number Street 

Case number City State ZIP Code 

Give Details About Your Business or Connections to Any Business 

Status of the 

case 

0 Pending 

0 Onappeal 

0 Concluded 

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

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

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

0 A partner in a partnership 

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

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

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

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

Describe the nature of the business Employer Identification number 

Business Name 

Number Street 

······ _- -- - .. · ........ 1 Do not include Social Security number or ITIN. 

EIN: 

Name of accountant or bookkeeper Dates business existed 

I - -~ -- --- J From To 

Describe the nature of the business Employer Identification number 

Business Name 

Number Street 

[- -· .. ------- -

EIN: 

Do not include Social Security number or ITIN. 

Name of accountant or bookkeeper Dates business existed 

-C-lty ______ ,.---~--t-_·_ .._:, __ ~-.. ~-t-~t-.?-,.,-.• --~,,,--.,,.~--,~,-,?d-,e _____ -r- ·----------------~- • -Cr~ To 

Official Form 107 •·ir: ,-statement of Financial· Affairs for Individuals Filing for Bankruptcy;· · ·n,;: · . ., .. · 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 11 of 12
Debtor 1 Case number (ilknown),~'J}~· _~_a,_tJ_UJ __ b_·_-_f_'JJ._1(. __ _ First Name Middle Name Last Name 

ff Describe the nature of the business Employer Identification number 

Business Name 

I ] 

Do not include Social Security number or ITIN. 

EIN: 

Number Street Name of accountant or bookkeeper Dates business existed 

City State ZIP Code I _ - -- -- --- --~ 

From To 

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

institutions, creditors, or other parties. 

0 No 

0 Yes. Fill in the details below. 

Date Issued 

Name MM/DD/YYYY 

Number Street 

City State ZIP Code 

d -""'•••-~ 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. 

jC ~ :s ::> 

Signature of Debtor 1 Signature of Debtor 2 

Date!t:'1-Lf Date J/-J-"Z{ 

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

0 No 

D Yes 

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

0 No 

0 Yes. Name of person, ________________________ . Attach the Bankruptcy Petition Preparer's Notice, 

Declaration, and Signature (Official Form 119). 

-···- ·St,:11,:··--ZJPCodc 

Official:!Forrn 107 ·' fk:- · ~• ·, · · ··Statement of Financial Affairs for lndividlia1s Filing for Bankruptcy , page 12 

Case 21-20206-PDR Doc 17 Filed 11/10/21 Page 12 of 12