AMENDED

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

✔

0.00

0.00

17,176.00

4,909.00

Southern District of Florida

2,170.00

1,191.67

4,909.00

0.00

Ulises F Ruiz

17,176.00

Case 21-13907-RAM Doc 9 Filed 05/25/21 Page 1 of 8
AMENDED

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

Ulises Ruiz

0.00

0.00

✔

Case 21-13907-RAM Doc 9 Filed 05/25/21 Page 2 of 8
AMENDED

12/15

3.

4.

6.

7.

8.

1.

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

Debtor 1 Ulises F Ruiz

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...

Bed $250.00, TV $150.00, TV $150.00, Sofa $200.00, Dinning Room table $100.00

(All of the above listed items belongs to Mr. Ruiz partner. He is not the owner of these items)

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...

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...

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?

$ 0.00

Examples:

Examples:

page 1 of 5

Case 21-13907-RAM Doc 9 Filed 05/25/21 Page 3 of 8
AMENDED

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

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...

Jewelry

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

gold, silver

 No

 Yes. Describe...

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: Region Bank Account #:0265711688

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...........

Examples:

Examples:

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...........................................................................................................................................➤ $ 0.00

Describe Your Financial Assets

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

$ 

Examples:

$ 4,909.00

Debtor 1 Ulises F Ruiz Case number(if known)

First Name Middle Name Last Name

page 2 of 5

Case 21-13907-RAM Doc 9 Filed 05/25/21 Page 4 of 8
AMENDED

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

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....

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....

Examples:

Money or property owed to you?

Debtor 1 Ulises F Ruiz Case number(if known)

First Name Middle Name Last Name

page 3 of 5

Case 21-13907-RAM Doc 9 Filed 05/25/21 Page 5 of 8
AMENDED

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

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.

Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

Accounts receivable or commissions you already earned

 No

 Yes. Describe...

Office equipment, furnishings, and supplies

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, electronic

devices

 No

 Yes. Describe...

Machinery, fixtures, equipment, supplies you use in business, and tools of your trade

 No

 Yes. Describe...

Inventory

 No

 Yes. Describe...

Interests in partnerships or joint ventures

 No

 Yes. Describe........

Customer lists, mailing lists, or other compilations

 No

 Yes.Do your lists include personally identifiable information (as defined in 11 U.S.C. § 101(41A))?

Any business-related property you did not already list

 No

 Yes. Give specific information ...........

Florida Profit Corporation MOTA PIZZA RUSTICA CORP Document Number: P15000076702 FEI/EIN Number: 47-5019225 (This

corporation has been inactive since 2018 when it was evicted and sued by the landlord. The corporation was kept active with the State of

Florida due to the ongoing litigation but there was no actual active business, and there are no assets owned by it.)

$ 0.00

Part 6:

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...........................................................................................................................................➤ $ 4,909.00

Add the dollar value of the portion you own for all of your entries from Part 5, including any entries for pages

you have attached for Part 5. Write that number here...........................................................................................................................................➤ $ 0.00

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

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

Debtor 1 Ulises F Ruiz Case number(if known)

First Name Middle Name Last Name

page 4 of 5

Case 21-13907-RAM Doc 9 Filed 05/25/21 Page 6 of 8
AMENDED

46.

53.

54.

Do you own or have any legal or equitable interest in any farm- or commercial fishing-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

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 $ 0.00

58. Part 4: Total financial assets, line 36 $ 4,909.00

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 ................... $ 4,909.00 Copy personal property total➤ + $

4,909.00

63. Total of all property on Schedule A/B. Add line 55 + line 62 $ 4,909.00

information...

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

$ 0.00

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

$ 0.00

+ $ 0.00

Debtor 1 Ulises F Ruiz Case number(if known)

First Name Middle Name Last Name

page 5 of 5

Case 21-13907-RAM Doc 9 Filed 05/25/21 Page 7 of 8
AMENDED

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

05/25/2021

✔

Ulises F Ruiz

■

/s/ Ulises F Ruiz

Case 21-13907-RAM Doc 9 Filed 05/25/21 Page 8 of 8