United States Bankruptcy Court

Southern District of Florida

In re Teresa Decaria Case No. 21-11494-SMG

Debtor(s) Chapter 13

DECLARATION REGARDING PAYMENT ADVICES

Debtor:

 Copies of all payment advices, pay stubs or other evidence of payment received by the debtor from any employer within 60

days prior to the filing of the bankruptcy petition are attached. (Note: If you worked some, but not all of the 60 days prior,

attach copies of any and all received and provide explanation that you didn't work the full 60 days.

)

 Copies of all payment advices are not attached because the debtor had no income from any employer during the 60 days

prior to filing the bankruptcy petition.

 Copies of all payment advices are not attached because the debtor:

 receives disability payments

 is unemployed and does not receive unemployment compensation

 receives Social Security payments

 receives a pension

 does not work outside the home

 is self employed and does not receive payment advices

 None of the statements above apply, however, the debtor is unable to timely provide some or all copies of payment advices or

other evidence of payment received

Explain: 

Joint Debtor (if applicable):

 Copies of payment advices, pay stubs or other evidence of payment received by the joint debtor from any employer within 60

days prior to the filing of the bankruptcy petition are attached. (Note: If you worked some, but not all of the 60 days prior,

attach copies of any and all received and provide explanation that you didn't work the full 60 days.

)

 Copies of payment advices are not attached because the joint debtor had no income from any employer during the 60 days

prior to filing the bankruptcy petition.

 Copies of payment advices are not attached because the joint debtor:

 receives disability payments

 is unemployed and does not receive unemployment compensation

 receives Social Security payments

 receives a pension

 does not work outside the home

 is self employed and does not receive payment advices

 None of the statements above apply, however, the joint debtor is unable to timely provide some or all copies of payment

advices or other evidence of payment received

Explain: 

LF-10 (rev. 12/01/09) Page 1 of 2

Software Copyright (c) 1996-2021 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 1 of 9
NOTE: When submitting copies of evidence of payment such as pay stubs or payment advices, it is your responsibility to redact

(blackout) any social security numbers, names of minor children, dates of birth or financial account numbers before attaching for

filing with the court. See Local Rule 5005-1(A)(2).

/s/ Teresa Decaria Date: February 22, 2021

Teresa Decaria

Signature of Attorney or Debtor

LF-10 (rev. 12/01/09) Page 2 of 2

Software Copyright (c) 1996-2021 Best Case, LLC - www.bestcase.com Best Case Bankruptcy

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 2 of 9
Palm Coff9<t R<>alll&R U.C 

2238 Kayes S1 

l-,olywood "L 33020 

r .... es.a o..cana 

1910· sw571hot 

o.oulhN<l'S: rano;:twn FL 33332 

EMPLOYER 

Palm CoffN RCIIIMl'I u.c 

2238�oS1 

Hol,wood FL .J.J020 

EMPLOYEE 

T..-n&o.c&ia 

\9101 ow571ho1 

sou1-1,_ FL 33332 

PAY PERIOO 

-s.,; .... "li 

P9'IOCI D>oif19• 

.... -. 

NET PAY. 

Pdy Swll o.n..i 

PAV DATE 02119,2021 

NET PAY· $434 54 

02/lJ/2021 

0211WZQ2l 

02/19/2021 

"' c ... ,.m 

3.!i00.00 

DEDUCTIONS 

TAXES cu"ont = 

F_odn_ ll lro>mt T8< 21.2, IW.H SUMMARY Current 'rm 

, "00 211.00 ,_..., ssccoo S3 SOO 00 -�- ,� �� ,�_ ... � $454 22 - �00 �00 

Net Pay S434.S4 

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 3 of 9
Palm Cott.,,. R.,..,1.,,,, ttC 

2238 Hayes St 

Hdlywood F� 33020 

T�·e"" o..can,,. 

191011w57thC1 

SQUth"""5t ranchos FL :i.3332 

EMPLOYER 

Polm CoffN Roo,1.,.. UC 

22MI Hoyfl S1 

HOlywoo<I FL jJ!m 

!MPLOYU 

T .. tuO.C.11 

111101 ow57tl>CI 

IO<Jt-t ,....,,,.. FL ),3)32 

··�

Houro Roll Cunlnl 

PAYPERIOO - Pa1 Da

.... E

:« 

l><li"IJ - 

NET PAY; 

OEDOCTIONS 

Pay sue OAtall 

PAY DATE 02112,'2021 

NET PAY $4�.&4 

"""""' 02/IZ/20,11 

02/1Zl2021 

TAXES Cu"ont = f-ral lncomo To, rr zt 1t3.2ti UMr.tAIO' Cumint = --· "00 •MOO T<)b,t p""I ssce co $1000 00 M""""'"' ,� ··� ,- ... � $.Wl 76 

=- �00 �00 

Net Pay $434.54 

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 4 of 9
P;,lm Coffltto ROWS!ers LLC 

2238 Haves SI 

Hollywood FL 33020 

T ..-esa O..C..na 

1910· sw57thct 

soothNeSt ranches FL 33332 

EMPLOYER 

Palm CorlM i'.OOS!Ofll UC 

2238HayO< St 

_,......_ Fl 33020 

EMPLOYEE 

Teresa�na 

1g101 sw sr .. d 

sw1-.1 """""" FL 3:J.3�

MEMO 

Sala')' 

CurlWll 

2:,00.W 

Pi\YPERIOO 

- ll<oG .... "'9 

- Endi,,;;: Ptt,-�l •. 

NET P,\Y: 

OEDUCTIOHS 

Pay Stub Detail 

PAY DATE Ov:l!i.2021 

NET PAY. $434 S4 

01/30/2021 

02..:)512021 

02!")5{.1021 

TAXES , __ = F

So,.

ede

,ol 

ral 

s.,c,..

Income 

,1y 

Tax v" ·�� SUMMARY CurRnt = "00 ,�oo TCIIII Pay ssoe oc $2 500.00 -- ,� = ·- 5"5.46 S327.JO 

-- �.00 �.00 

Ne1 Pay $43-4.54 

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 5 of 9
Palm Cofloo Roasters LLC 

2238 H-lyes SI 

Hcflywood FL 3J020 

T e<o:s.l Ooc;>r,o 

\9101 SN 57!h cl 

s:>.Jlhwesl raoc:hes FL 33332 

EMPLOYER 

Palm Col'leo Roo,t9'$ LLC 

2�:)8 Hoyeo St 

Hollywood Fl :J.3020 

EMPLOYEE 

r.,...,o.e. .. 

19101, .. 57thet 

sculhest r3nd>es FL :!J332 

··�

PAT PERIOO 

- 118\;Nrr>r,g 

--· ...,_. 

MET PAT· 

Cl><>cls Ho. 238 

P"Y Stuo Detail 

rAYOATS 01129'2021 

NET PAY $434 54 

Ched No 238 

Olfl'.112021 

0112'9llW\ 

Olfl9/2021 

,., 

S.rl"'i' 

Houn Rot. OEOUCl�

TAXES c .... ren1 = Federal Income fax 

"" ·�· SUMh'.ARY Cu,,-nt vm 

--· "00 12'.00 local Pay 

""'00 �-00 l.lc<llcmc 1.2� N.00 

·- 

-� $lt>I 64 

- ,000 so 00 

Net Pay $434.54 

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 6 of 9
?aim Goff"" Roasters LLC 

2238 Hayes Sl 

1->cllywood FL 33020 

Tttr�sa Dec,w,a 

19101 SW 5711\ d 

swlh-t tanches FL :.3332 

EMPLOYER 

Palm Col!M R<>Ut�ct LLC 

22:)6 Hr;u SI 

Holtywoo<I Fl 3J020 

EMPLOYEE 

,19-

101 - ... 57", ct 

oou1-.1 r...-.ct>es FL >33'.l.2 

MEMO: 

Ho"" Rote 

1,500 00 

PAYPERIOD 

Period s.,;;.,rw,g 

Ponod En<11n�r ..,_ 

NET PAY 

llEllUCTIOHS 

Pay Stub O<,!ai1 

PAY DATE 01122i2021 

NET PAY $434 5-4 

01116!2021 

01/llllQ2! 

OlfllJ2021 

Current 

TAXES �-- = 

Fe<loral lncorr� Tu 

"" 81.63 --· Current = Social SfJ<:ur>t1 "00 noo � Tola! P11Y ,SOOOO $1,50000 - ,� 21.75 ,,_ 

='" $196 aa 

-- ,000 ,000 

Net Pay $434.54 

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 7 of 9
�;;,Im Cc:ff"" Roastet• l..LC 

2238 Hares SI 

Hollywood FL 33020 

Te<�sa Decooa 

19101 sw571hd 

soutnwes1 rand!es FL 33332 

EMPLOYER 

Pilm Coffee Ro;ut .... LLC 

2233 HayH St 

Hdt;wo<>d FL J.3020 

EMPLOYEE 

T

1�

..-

,

o 

o

.. 

, o

�

w57thct 

soulhwHtr�ocho>&FLSJ3.32 

MEMO: 

P4Y PERIOD - - ... Endi1111 - . 

Pay Clalot: 

NET P4Y: 

Pay Stub De!,.I 

PAY DATE 01/1512021 

NET PAY $-434.54 

Ch•d.No 2J:l 

S"ila' r)' 

ttouro Raio cur ..... 1 

TAXES Cutro..i = Federal lnoone Tax V2' �� SUMMMY Cum,nt = - """' "00 sacn Tda1Pa1 ssoe co $1 000.00 ··� ,� "� ,_ $6ii.4f; SlJ0.92 =- �00 sc.oc 

Net Pay $434.54 

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 8 of 9
Palm Coffee Roasters LLC 

2238 H�Y<J$ S! 

Hollywood FL 33020 

Teresa O&ear1a 

19101 SW 57th ci 

southwest ranches FL 33332 

EMPLOYER 

P31ri Cott .. Raat191"• LLC 

22:)8 HayH St 

HcljWOOO FL 3J020 

EMPI.OYEE 

T..,osa Deca"o 

W1D1 •w 57lh d 

soo-t ronches FL 33332 

MEMO 

Hoors Rot• Curront 

�00 

PAY PERIOD 

Per 00 B<>gonnlf1] 

PorOOE�

Pay Dato: 

NET PAY: 

DEDUCTIONS 

Pay St,b Detail 

PAY DATE 01'C8,'2021 

NET PAY $434.54 

01,02,2021 

01�20ll 

01,0&2021 

Curr.nl 

TAXES Curr.nt vru 

r_odor!I _ Income 

., 

fa, 2? 21 27 21 SUMMARY Curr•"t = �1 00 3, oc TOOIIP•) sscooo $�00 Modicaro 

'" '" ,._ $65 '6 ses ee 

--· �00 �00 

Net Pay $434.54 

Case 21-11494-SMG Doc 11 Filed 02/22/21 Page 9 of 9