Fill in this information to identify your case: 

United States Bankruptc;y Court for the: 

Southern District of Florida 

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

Official Form 101 

D Chapter? 

D Chapter 11 

D 9fiapter 12 

W/'Chapter 13 

----·------·-·-------------~ 

c:::~:--· . :~-. ~::·,. ,"t·! 

D Check if this is an 

amended filing 

·, 1-, r1 -. 

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 fonn asks, "Do you own a car," 

the answer would be yes if either debtor owns a car. When infonnation 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 infonnation as Debtor 1 and the other as Debtor 2. The 

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

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

infonnation. 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. 

•,,, Identify Yourself 

1. Your full name 

2. 

Write the name that is on your 

government-issued picture 

identification (for example, 

your driver's license c,r 

passport). 

Bring your picture 

identification to your meeting 

with the trustee. 

All other names y,ou 

have used in the last 8 

years 

Include your married or 

maiden names. 

3. Only the last 4 di!~its of 

your Social Secu1·ity 

number or federal 

Individual Taxpayer 

Identification number 

(ITIN) 

Official Form 101 

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

First name 

~,f\"OJ\ 

First name 

Middle name Middle name 

C,v\S.~ eQ{\· 

Last name Last name 

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

First name First name 

Middle name Middle name 

Last name Last name 

First name First name 

Middle name Middle name 

Last name Last name 

XXX - xx - !i _3_ 3 :ti XXX xx - -------- OR OR 

9 xx - xx 9 xx - xx -------- --------

Voluntary Petition for Individuals Filing for Bankruptcy page 1 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 1 of 9
Debtor 1 First Name Middle Name 

4. Any business names 

and Employer 

Identification Numbers 

(EIN) you have used in 

the last 8 years 

Include trade names a.nd 

doing business as names 

s. Where you live 

s. Why you are choosing 

this district to file for 

bankruptcy 

Official Form 101 

Last Name 

About Debtor 1 : 

0 I have not used any business names or EINs. 

Business name 

Business name 

EIN 

EIN 

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 

Chef one: 

r:!f'over the last 180 days before filing this petition, 

I have lived in this district longer than in any 

other district. 

0 I have another reason. Explain. 

(See 28 U.S.C. § 1408.) 

Case number (if known) _____________ _ 

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

0 I have not used any business names or EINs. 

Business name 

Business name 

EIN 

EIN 

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 

Check one: 

0 Over the last 180 days before filing this petition, 

I have lived in this district longer than in any 

other district. 

0 I have another reason. Explain. 

(See 28 U.S.C. § 1408.) 

Voluntary Petition for Individuals Filing for Bankruptcy page 2 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 2 of 9
Debtor 1 Case number (if known) _____________ _ 

First Name Middle Name Last Name 

•,,, Tell the Court About Your Bankruptcy Case 

1. The chapter of the 

Bankruptcy Code you 

are choosing to file 

under 

s. How you will pay the fee 

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. 

D Chapter 7 

D Chapter 11 

D 9apter 12 

IJYChapter 13 

~ill 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. 

D 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). 

D 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 1038) and file it with your petition. 

-:_---~av: ~~u-fi-le_d_f_o_r ·--;zbankruptcy within the 

last 8 years? 

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? 

11. Do you rent your 

residence? 

Official Form 101 

• Yes. District __________ When 

District __________ When ______ Case number _________ _ 

MM/ DD/YYYY 

District __________ When ______ Case number _________ _ 

MM/ DD/YYYY 

igNo 

D Yes. Debtor 

District 

__________________ Relationship to you 

__________ When ______ Case number, if known ______ _ 

MM/DD /YYYY 

Debtor __________________ Relationship to you 

District __________ When ______ Case number, if known. ______ _ 

MM/DD/YYYY 

J No. Go to line 12. 

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

D No. Go to line 12. 

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

part of this bankruptcy petition. 

Voluntary Petition for Individuals Filing for Bankruptcy page 3 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 3 of 9
Debtor 1 Case number (if known) _____________ _ 

First Name Middle Name Last Name 

Report About Any Businesses You Own 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 E.uch as 

a corporation, partnership, or 

LLC. 

If you have more thar one 

sole proprietorship, use a 

separate sheet and attach it 

to this petition. 

~- Go to Part 4. 

D Yes. Name and location of business 

Name of business, if any 

Number Street 

City State 

Check the appropriate box to describe your business: 

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

D Single Asset Real Estate (as defined in 11 U.S.C. § 101 (518)) 

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

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

D None of the above 

ZIP Code 

--------------- -----------·--··· 

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 (510). 

Official Form 101 

If you are filing under Chapter 11, the court must know whether you are a sma// 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 anJ-6f these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1 )(8). 

~o. I am not filing under Chapter 11. 

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

the Bankruptcy Code. 

D Yes. I am filing under Chapter 11, 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. 

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

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

Voluntary Petition for Individuals Filing for Bankruptcy page 4 

• 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 4 of 9
Debtor 1 Case number (it known) _____________ _ 

First Name Middle Name Last Name 

Report if You Own or Have Any Hazardous Property or Any Property That Needs Immediate Attention 

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? 

Official Form 101 

D Yes. What is the hazard? 

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

Where is the property? ___________________________ _ 

Number Street 

City State ZIP Code 

Voluntary Petition for Individuals Filing for Bankruptcy page 5 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 5 of 9
Debtor 1 Case number (if known) _____________ _ 

First Name Middle Name Last Name 

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 mus1 

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. 

Official Form 101 

About Debtor 1: 

You must check one: 

D 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. 

D 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 

~n, if any. 

ilfi 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. 

D I am not required to receive a briefing about 

credit counseling because of: 

D Incapacity. I have a mental illness or a mental 

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

D 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. 

D 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. 

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

You must check one: 

D 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. 

D 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. 

D 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. 

D I am not required to receive a briefing about 

credit counseling because of: 

D Incapacity. I have a mental illness or a mental 

deficiency that makes me 

incapable of realizing or making 

rational decisions about finances. 

D 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. 

D 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. 

Voluntary Petition for Individuals Filing for Bankruptcy page 6 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 6 of 9
Debtor 1 Case number (if known) _____________ _ 

First Name Middle Name last Name 

Answer These Questions for Reporting Purposes 

16. What kind of debts do 

you have? 

11. Are you filing under 

Chapter7? 

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? 

18. How many creditors do 

you estimate that you 

owe? 

19. How much do you 

estimate your assets to 

be worth? 

20. How much do you 

estimate your liabilities 

to be? 

•§A Sign Below 

Foryou 

Official Form 101 

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." 

D )fo. 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. 

D No. Go to line 16c. 

D Yes. Go to line 17. 

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

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

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

adm~ative expenses are paid that funds will be available to distribute to unsecured creditors? 

il-49 

!:!"No 

D Yes 

0 50-99 

0 100-199 

0 ~-999 

h$50. ooo 

0 $50,001-$100,000 

0 $100,001-$500,000 

D $500,001-$1 million 

0 $0-$50,000 

s$50.001-$100.000 

ba $100,001-$500,000 

D $500,001-$1 million 

0 1,000-5,000 

0 5,001-10,000 

0 10,001-25,000 

D $1,000,001-$10 million 

D $10,000,001-$50 million 

D $50,000,001-$100 million 

D $100,000,001-$500 million 

D $1,000,001-$10 million 

D $10,000,001-$50 million 

D $50,000,001-$100 million 

D $100,000,001-$500 million 

0 25,001-50,000 

0 50,001-100,000 

D More than 100,000 

D $500,000,001-$1 billion 

D $1,000,000,001-$10 billion 

D $10,000,000,001-$50 billion 

D More than $50 billion 

D $500,000,001-$1 billion 

D $1,000,000,001-$10 billion 

D $10,000,000,001-$50 billion 

D More than $50 billion 

I have examined this petition, and I declare under penalty of pe~ury 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 

w_ith. a bankruptcy case can result.lll-~,000, or imprisonment for up to 20 years, or both. 

,:8~:· ~"·•~-3~71. ~~ 'X- - ~-"'-- ,___,-,-- X 

Signature of Debtor 1 1 /_ 

Executed on O 3 / 0/ / ,;(7 J--'J__ 

MM I rDD /yyyy 

-----------------

Signature of Debtor 2 

Executed on ______ _ 

MM/ DD /YYYY 

Voluntary Petition for Individuals Filing for Bankruptcy page 7 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 7 of 9
Debtor 1 First Name Middle Name 

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. 

Official Form 101 

Case number (it known) _____________ _ 

Last Name 

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 

Voluntary Petition for Individuals Filing for Bankruptcy page 8 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 8 of 9
Debtor 1 First Name Middle Name 

For you if you are filing this 

bankruptcy without an 

attorney 

If you are represented by 

an attorney, you do not 

need to file this page. 

Official Form 101 

Case number (if known) _____________ _ 

Last Name 

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

should understand that many people find it extremely difficult to represent 

themselves successfully. Because bankruptcy has long-term financial and legal 

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

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

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

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

hearing, or cooperate with the court, case trustee, U.S. trustee, bankruptcy administrator, or audit 

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

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

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

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

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

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

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

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

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

Bankruptcy fraud is a serious crime; you could be fined and imprisoned. 

If you decide to file without an attorney, the court expects you to follow the rules as if you had 

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

successful, you must be familiar with the United States Bankruptcy Code, the Federal Rules of 

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

be familiar with any state exemption laws that apply. 

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

consequences? 

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

inaccurate or incomplete, you could be fined or imprisoned? 

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

D Yes. Name of Person _________________________ _ 

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

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

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

-~--~c.ause me t9Jose my · hts or roperty if I do not properly handle the case. 

X 

Signature of Debtor 1

1 , 

Date tJ ~l (J!a~ )_ )_ - MM/ D / Y 

Signature of Debtor 2 

Date 

MM/ DD /YYYY 

Contact phone ( 1= o L:z ) 1 r:r 1 -- 7 

t_ C-!-. 'Jo_ i Contact phone 

Cell phone Cell phone 

Email address VY\~ 0..'0~Q. Gct~+a11 ed ~ < 

1 __ ~yvt aA.'.- t - CD 'YL -

Email address 

Voluntary Petition for Individuals Filing for Bankruptcy page 9 

Case 22-11705-AJC Doc 1 Filed 03/01/22 Page 9 of 9