B 1 (Official Form 1) (1/08) 

United States Bankruptcy Court 

Voluntary Petition

Name of Debtor (if individual, enter Last, First, Middle): 

 

Name of Joint Debtor (Spouse) (Last, First, Middle): 

 

All Other Names used by the Debtor in the last 8 years 

(include married, maiden, and trade names): 

 

All Other Names used by the Joint Debtor in the last 8 years 

(include married, maiden, and trade names): 

 

Last four digits of Soc. Sec. or Indvidual-Taxpayer I.D. (ITIN) No./Complete EIN

(if more than one, state all): 

 

Last four digits of Soc. Sec. or Indvidual-Taxpayer I.D. (ITIN) No./Complete EIN

(if more than one, state all): 

Street Address of Debtor (No. and Street, City, and State): 

 

 

 

 ZIP CODE 

Street Address of Joint Debtor (No. and Street, City, and State): 

 

 

 

 ZIP CODE 

County of Residence or of the Principal Place of Business: 

 

County of Residence or of the Principal Place of Business: 

 

Mailing Address of Debtor (if different from street address): 

 

 

 

 ZIP CODE 

Mailing Address of Joint Debtor (if different from street address): 

 

 

 

 ZIP CODE 

Location of Principal Assets of Business Debtor (if different from street address above): 

 ZIP CODE 

Type of Debtor 

(Form of Organization) 

(Check one box.) 

 Individual (includes Joint Debtors) 

 See Exhibit D on page 2 of this form. 

 Corporation (includes LLC and LLP) 

 Partnership 

 Other (If debtor is not one of the above entities, 

check this box and state type of entity below.) 

__________________________________________ 

Nature of Business 

(Check one box.) 

 Health Care Business 

 Single Asset Real Estate as defined in 

11 U.S.C. § 101(51B) 

 Railroad 

 Stockbroker 

 Commodity Broker 

 Clearing Bank 

 Other 

___________________________________ 

Tax-Exempt Entity

(Check box, if applicable.) 

 Debtor is a tax-exempt organization 

 under Title 26 of the United States 

 Code (the Internal Revenue Code). 

Chapter of Bankruptcy Code Under Which 

the Petition is Filed (Check one box.) 

Chapter 7 Chapter 15 Petition for 

 Chapter 9 Recognition of a Foreign 

 Chapter 11 Main Proceeding 

 Chapter 12 Chapter 15 Petition for 

 Chapter 13 Recognition of a Foreign 

 Nonmain Proceeding 

Nature of Debts 

(Check one box.) 

 Debts are primarily consumer Debts are primarily 

 debts, defined in 11 U.S.C. business debts. 

 § 101(8) as “incurred by an 

 individual primarily for a 

 personal, family, or house- 

 hold purpose.” 

Filing Fee (Check one box.) 

 Full Filing Fee attached. 

 Filing Fee to be paid in installments (applicable to individuals only). Must attach 

signed application for the court’s consideration certifying that the debtor is 

unable to pay fee except in installments. Rule 1006(b). See Official Form 3A. 

 Filing Fee waiver requested (applicable to chapter 7 individuals only). Must 

attach signed application for the court’s consideration. See Official Form 3B. 

Chapter 11 Debtors 

Check one box: 

 Debtor is a small business debtor as defined in 11 U.S.C. § 101(51D). 

 Debtor is not a small business debtor as defined in 11 U.S.C. § 101(51D). 

Check if: 

 Debtor’s aggregate noncontingent liquidated debts (excluding debts owed to 

insiders or affiliates) are less than $2,190,000. 

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

Check all applicable boxes: 

 A plan is being filed with this petition. 

 Acceptances of the plan were solicited prepetition from one or more classes 

of creditors, in accordance with 11 U.S.C. § 1126(b).

Statistical/Administrative Information 

 Debtor estimates that funds will be available for distribution to unsecured creditors. 

 Debtor estimates that, after any exempt property is excluded and administrative expenses paid, there will be no funds available for 

distribution to unsecured creditors. 

THIS SPACE IS FOR 

COURT USE ONLY

Estimated Number of Creditors 

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 

Over

100,000 

Estimated Assets 

$0 to 

$50,000 

$50,001 to 

$100,000 

$100,001 to 

$500,000 

$500,001 

to $1 

million 

$1,000,001 

to $10 

million 

$10,000,001 

to $50 

million 

$50,000,001 

to $100 

million 

$100,000,001 

to $500 

million 

$500,000,001 

to $1 billion 

More than 

$1 billion 

Estimated Liabilities 

$0 to 

$50,000 

$50,001 to 

$100,000 

$100,001 to 

$500,000 

$500,001 

to $1 

million 

$1,000,001 

to $10 

million 

$10,000,001 

to $50 

million 

$50,000,001 

to $100 

million 

$100,000,001 

to $500 

million 

$500,000,001 

to $1 billion 

More than 

$1 billion 

Ramos, Felipe

-0346

1270 Highland Drive

Des Plaines, Illinois

60018

Cook

Ramos, Maria

-3480

1270 Highland Drive

Des Plaines, Illinois

60018

Cook

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 Document Page 1 of 39
B 1 (Official Form 1) (1/08) Page 2 

Voluntary Petition 

(This page must be completed and filed in every case.) 

Name of Debtor(s): 

 

 All Prior Bankruptcy Cases Filed Within Last 8 Years (If more than two, attach additional sheet.) 

Location 

Where Filed: 

Case Number: 

 

Date Filed: 

 

Location 

Where Filed: 

Case Number: 

 

Date Filed: 

 

Pending Bankruptcy Case Filed by any Spouse, Partner, or Affiliate of this Debtor (If more than one, attach additional sheet.) 

Name of Debtor: 

 

Case Number: 

 

Date Filed: 

 

District:

 

Relationship:

 

Judge:

 

Exhibit A 

(To be completed if debtor is required to file periodic reports (e.g., forms 10K and 

10Q) with the Securities and Exchange Commission pursuant to Section 13 or 15(d) 

of the Securities Exchange Act of 1934 and is requesting relief under chapter 11.) 

 Exhibit A is attached and made a part of this petition. 

Exhibit B 

(To be completed if debtor is an individual 

whose debts are primarily consumer debts.) 

I, the attorney for the petitioner named in the foregoing petition, declare that I 

have informed the petitioner that [he or she] may proceed under chapter 7, 11, 

12, or 13 of title 11, United States Code, and have explained the relief 

available under each such chapter. I further certify that I have delivered to the 

debtor the notice required by 11 U.S.C. § 342(b). 

X 

Signature of Attorney for Debtor(s) (Date) 

Exhibit C 

Does the debtor own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety? 

 Yes, and Exhibit C is attached and made a part of this petition. 

 No. 

Exhibit D

(To be completed by every individual debtor. If a joint petition is filed, each spouse must complete and attach a separate Exhibit D.) 

 Exhibit D completed and signed by the debtor is attached and made a part of this petition. 

If this is a joint petition: 

 Exhibit D also completed and signed by the joint debtor is attached and made a part of this petition. 

Information Regarding the Debtor - Venue 

(Check any applicable box.) 

 Debtor has been domiciled or has had a residence, principal place of business, or principal assets in this District for 180 days immediately 

preceding the date of this petition or for a longer part of such 180 days than in any other District. 

 There is a bankruptcy case concerning debtor’s affiliate, general partner, or partnership pending in this District. 

 Debtor is a debtor in a foreign proceeding and has its principal place of business or principal assets in the United States in this District, or 

has no principal place of business or assets in the United States but is a defendant in an action or proceeding [in a federal or state court] in 

this District, or the interests of the parties will be served in regard to the relief sought in this District. 

Certification by a Debtor Who Resides as a Tenant of Residential Property 

(Check all applicable boxes.) 

 Landlord has a judgment against the debtor for possession of debtor’s residence. (If box checked, complete the following.) 

 

 (Name of landlord that obtained judgment) 

 

 (Address of landlord) 

 Debtor claims that under applicable nonbankruptcy law, there are circumstances under which the debtor would be permitted to cure the 

entire monetary default that gave rise to the judgment for possession, after the judgment for possession was entered, and 

 Debtor has included with this petition the deposit with the court of any rent that would become due during the 30-day period after the 

filing of the petition. 

 Debtor certifies that he/she has served the Landlord with this certification. (11 U.S.C. § 362(l)). 

Ramos, Felipe and Ramos, Maria

Chicago, IL 01-B37943 10/31/2001

Chicago, IL 01-B37943

/s/ Jory Chelin 1/06/10

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B 1 (Official Form) 1 (1/08) Page 3

Voluntary Petition 

(This page must be completed and filed in every case.) 

Name of Debtor(s): 

Signatures 

Signature(s) of Debtor(s) (Individual/Joint) 

I declare under penalty of perjury that the information provided in this petition is true 

and correct. 

[If petitioner is an individual whose debts are primarily consumer debts and has 

chosen to file under chapter 7] I am aware that I may proceed under chapter 7, 11, 12 

or 13 of title 11, United States Code, understand the relief available under each such 

chapter, and choose to proceed under chapter 7. 

[If no attorney represents me and no bankruptcy petition preparer signs the petition] 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. 

X 

 Signature of Debtor 

X 

 Signature of Joint Debtor 

 

 Telephone Number (if not represented by attorney) 

 Date 

Signature of a Foreign Representative 

I declare under penalty of perjury that the information provided in this petition is true 

and correct, that I am the foreign representative of a debtor in a foreign proceeding, 

and that I am authorized to file this petition. 

(Check only one box.) 

 I request relief in accordance with chapter 15 of title 11, United States Code. 

 Certified copies of the documents required by 11 U.S.C. § 1515 are attached. 

 Pursuant to 11 U.S.C. § 1511, I request relief in accordance with the 

 chapter of title 11 specified in this petition. A certified copy of the 

 order granting recognition of the foreign main proceeding is attached. 

X 

 (Signature of Foreign Representative) 

 (Printed Name of Foreign Representative) 

 

 Date 

Signature of Attorney* 

X 

 Signature of Attorney for Debtor(s) 

 

 Printed Name of Attorney for Debtor(s) 

 

 Firm Name 

 

 Address 

 

 

 

 Telephone Number 

 Date 

*In a case in which § 707(b)(4)(D) applies, this signature also constitutes a 

certification that the attorney has no knowledge after an inquiry that the information 

in the schedules is incorrect. 

Signature of Debtor (Corporation/Partnership) 

I declare under penalty of perjury that the information provided in this petition is true 

and correct, and that I have been authorized to file this petition on behalf of the 

debtor. 

The debtor requests the relief in accordance with the chapter of title 11, United States 

Code, specified in this petition. 

X

 Signature of Authorized Individual 

 Printed Name of Authorized Individual 

 Title of Authorized Individual 

 Date 

Signature of Non-Attorney Bankruptcy Petition Preparer 

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as 

defined in 11 U.S.C. § 110; (2) I prepared this document for compensation and have 

provided the debtor with a copy of this document and the notices and information 

required under 11 U.S.C. §§ 110(b), 110(h), and 342(b); and, (3) if rules or 

guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum 

fee for services chargeable by bankruptcy petition preparers, I have given the debtor 

notice of the maximum amount before preparing any document for filing for a debtor 

or accepting any fee from the debtor, as required in that section. Official Form 19 is 

attached.

 Printed Name and title, if any, of Bankruptcy Petition Preparer 

 Social-Security number (If the bankruptcy petition preparer is not an individual, 

state the Social-Security number of the officer, principal, responsible person or 

partner of the bankruptcy petition preparer.) (Required by 11 U.S.C. § 110.) 

 Address 

X

 Date 

Signature of bankruptcy petition preparer or officer, principal, responsible person, or 

partner whose Social-Security number is provided above. 

Names and Social-Security numbers of all other individuals who prepared or assisted 

in preparing this document unless the bankruptcy petition preparer is not an 

individual. 

If more than one person prepared this document, attach additional sheets conforming 

to the appropriate official form for each person. 

A bankruptcy petition preparer’s failure to comply with the provisions of title 11 and 

the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or 

both. 11 U.S.C. § 110; 18 U.S.C. § 156.

Ramos, Felipe and Ramos, Maria

/s/ Jory Chelin

Jory Chelin

Law Office of Jory Ives Chelin

1454 Miner, Des Plaines, IL 60016

847-827-2700

11/30/2009

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B 1D (Official Form 1, Exhibit D) (12/09)

UNITED STATES BANKRUPTCY COURT

__________ District of __________

In re__________________________ Case No._____________

Debtor (if known)

EXHIBIT D - INDIVIDUAL DEBTOR’S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT

Warning: You must be able to check truthfully one of the five statements regarding

credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy

case, and the court can dismiss any case you do file. If that happens, you will lose whatever

filing fee you paid, and your creditors will be able to resume collection activities against

you. If your case is dismissed and you file another bankruptcy case later, you may be

required to pay a second filing fee and you may have to take extra steps to stop creditors’

collection activities.

Every individual debtor must file this Exhibit D. If a joint petition is filed, each spouse

must complete and file a separate Exhibit D. Check one of the five statements below and attach

any documents as directed.

u 1. Within the 180 days before the filing of my bankruptcy case, I received a briefing

from a credit counseling agency approved by the United States trustee or bankruptcy

administrator that outlined the opportunities for available credit counseling and assisted me in

performing a related budget analysis, and I have a certificate from the agency describing the

services provided to me. Attach a copy of the certificate and a copy of any debt repayment plan

developed through the agency.

u 2. Within the 180 days before the filing of my bankruptcy case, I received a briefing

from a credit counseling agency approved by the United States trustee or bankruptcy

administrator that outlined the opportunities for available credit counseling and assisted me in

performing a related budget analysis, but I do not have a certificate from the agency describing

the services provided to me. You must file a copy of a certificate from the agency describing the

services provided to you and a copy of any debt repayment plan developed through the agency

no later than 14 days after your bankruptcy case is filed.

Northern Illinois

Bankruptcy of Felipe Ramos

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B 1D (Official Form 1, Exh. D) (12/09) – Cont. Page 2

u 3. I certify that I requested credit counseling services from an approved agency but

was unable to obtain the services during the seven days from the time I made my request, and the

following exigent circumstances merit a temporary waiver of the credit counseling requirement

so I can file my bankruptcy case now. [Summarize exigent circumstances here.]

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If your certification is satisfactory to the court, you must still obtain the credit

counseling briefing within the first 30 days after you file your bankruptcy petition and

promptly file a certificate from the agency that provided the counseling, together with a

copy of any debt management plan developed through the agency. Failure to fulfill these

requirements may result in dismissal of your case. Any extension of the 30-day deadline

can be granted only for cause and is limited to a maximum of 15 days. Your case may also

be dismissed if the court is not satisfied with your reasons for filing your bankruptcy case

without first receiving a credit counseling briefing. 

u 4. I am not required to receive a credit counseling briefing because of: [Check the

applicable statement.] [Must be accompanied by a motion for determination by the court.]

u Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental

illness or mental deficiency so as to be incapable of realizing and making rational

decisions with respect to financial responsibilities.);

u Disability. (Defined in 11 U.S.C. § 109(h)(4) as physically impaired to the

extent of being unable, after reasonable effort, to participate in a credit counseling

briefing in person, by telephone, or through the Internet.); 

u Active military duty in a military combat zone.

u 5. The United States trustee or bankruptcy administrator has determined that the credit

counseling requirement of 11 U.S.C. ' 109(h) does not apply in this district.

I certify under penalty of perjury that the information provided above is true and

correct.

Signature of Debtor: ________________________

Date: _________________

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B 1D (Official Form 1, Exhibit D) (12/09)

UNITED STATES BANKRUPTCY COURT

__________ District of __________

In re__________________________ Case No._____________

Debtor (if known)

EXHIBIT D - INDIVIDUAL DEBTOR’S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT

Warning: You must be able to check truthfully one of the five statements regarding

credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy

case, and the court can dismiss any case you do file. If that happens, you will lose whatever

filing fee you paid, and your creditors will be able to resume collection activities against

you. If your case is dismissed and you file another bankruptcy case later, you may be

required to pay a second filing fee and you may have to take extra steps to stop creditors’

collection activities.

Every individual debtor must file this Exhibit D. If a joint petition is filed, each spouse

must complete and file a separate Exhibit D. Check one of the five statements below and attach

any documents as directed.

u 1. Within the 180 days before the filing of my bankruptcy case, I received a briefing

from a credit counseling agency approved by the United States trustee or bankruptcy

administrator that outlined the opportunities for available credit counseling and assisted me in

performing a related budget analysis, and I have a certificate from the agency describing the

services provided to me. Attach a copy of the certificate and a copy of any debt repayment plan

developed through the agency.

u 2. Within the 180 days before the filing of my bankruptcy case, I received a briefing

from a credit counseling agency approved by the United States trustee or bankruptcy

administrator that outlined the opportunities for available credit counseling and assisted me in

performing a related budget analysis, but I do not have a certificate from the agency describing

the services provided to me. You must file a copy of a certificate from the agency describing the

services provided to you and a copy of any debt repayment plan developed through the agency

no later than 14 days after your bankruptcy case is filed.

Northern Illinois

Bankruptcy of Maria Ramos

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B 1D (Official Form 1, Exh. D) (12/09) – Cont. Page 2

u 3. I certify that I requested credit counseling services from an approved agency but

was unable to obtain the services during the seven days from the time I made my request, and the

following exigent circumstances merit a temporary waiver of the credit counseling requirement

so I can file my bankruptcy case now. [Summarize exigent circumstances here.]

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If your certification is satisfactory to the court, you must still obtain the credit

counseling briefing within the first 30 days after you file your bankruptcy petition and

promptly file a certificate from the agency that provided the counseling, together with a

copy of any debt management plan developed through the agency. Failure to fulfill these

requirements may result in dismissal of your case. Any extension of the 30-day deadline

can be granted only for cause and is limited to a maximum of 15 days. Your case may also

be dismissed if the court is not satisfied with your reasons for filing your bankruptcy case

without first receiving a credit counseling briefing. 

u 4. I am not required to receive a credit counseling briefing because of: [Check the

applicable statement.] [Must be accompanied by a motion for determination by the court.]

u Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental

illness or mental deficiency so as to be incapable of realizing and making rational

decisions with respect to financial responsibilities.);

u Disability. (Defined in 11 U.S.C. § 109(h)(4) as physically impaired to the

extent of being unable, after reasonable effort, to participate in a credit counseling

briefing in person, by telephone, or through the Internet.); 

u Active military duty in a military combat zone.

u 5. The United States trustee or bankruptcy administrator has determined that the credit

counseling requirement of 11 U.S.C. ' 109(h) does not apply in this district.

I certify under penalty of perjury that the information provided above is true and

correct.

Signature of Debtor: ________________________

Date: _________________

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B6 Summary (Official Form 6 - Summary) (12/07)

United States Bankruptcy Court

_______________ District Of ______________

In re ___________________________________, Case No. ___________________

Debtor

Chapter ____________

SUMMARY OF SCHEDULES

Indicate as to each schedule whether that schedule is attached and state the number of pages in each. Report the totals from Schedules A, B, D, E, F, I,

and J in the boxes provided. Add the amounts from Schedules A and B to determine the total amount of the debtor’s assets. Add the amounts of all

claims from Schedules D, E, and F to determine the total amount of the debtor’s liabilities. Individual debtors also must complete the “Statistical

Summary of Certain Liabilities and Related Data” if they file a case under chapter 7, 11, or 13.

NAME OF SCHEDULE

ATTACHED

(YES/NO) NO. OF SHEETS ASSETS LIABILITIES OTHER

A - Real Property $

B - Personal Property $

C - Property Claimed

 as Exempt

D - Creditors Holding

 Secured Claims

$

E - Creditors Holding Unsecured 

 Priority Claims

 (Total of Claims on Schedule E)

$

F - Creditors Holding Unsecured

 Nonpriority Claims

$

G - Executory Contracts and

 Unexpired Leases

H - Codebtors

I - Current Income of

 Individual Debtor(s)

$

J - Current Expenditures of Individual

 Debtors(s)

$

TOTAL $ $

Northern Illinois

William Cusimano

Yes 1 300,000

Yes 3 46,648

Yes 3

Yes 2 409,431.90

Yes 1 6,113.00

yes 3 25,381.84

Yes 1

Yes 1

Yes 1 3,167.00

Yes 1 6,364.00

17 346,648.00 440,896.74

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Form 6 - Statistical Summary (12/07)

United States Bankruptcy Court

_______________ District Of ______________

In re ___________________________________, Case No. ___________________

Debtor

Chapter ____________

STATISTICAL SUMMARY OF CERTAIN LIABILITIES AND RELATED DATA (28 U.S.C. § 159)

If you are an individual debtor whose debts are primarily consumer debts, as defined in § 101(8) of the Bankruptcy Code (11 U.S.C.

§ 101(8)), filing a case under chapter 7, 11 or 13, you must report all information requested below. 

Q Check this box if you are an individual debtor whose debts are NOT primarily consumer debts. You are not required to report any

information here.

This information is for statistical purposes only under 28 U.S.C. § 159.

Summarize the following types of liabilities, as reported in the Schedules, and total them.

Type of Liability Amount

Domestic Support Obligations (from Schedule E) $

Taxes and Certain Other Debts Owed to Governmental Units

(from Schedule E)

$

Claims for Death or Personal Injury While Debtor Was

Intoxicated (from Schedule E) (whether disputed or undisputed)

$

Student Loan Obligations (from Schedule F) $

Domestic Support, Separation Agreement, and Divorce Decree

Obligations Not Reported on Schedule E

$

Obligations to Pension or Profit-Sharing, and Other Similar

Obligations (from Schedule F)

$

TOTAL $

State the following:

Average Income (from Schedule I, Line 16) $

Average Expenses (from Schedule J, Line 18) $

Current Monthly Income (from Form 22A Line 12; OR, Form

22B Line 11; OR, Form 22C Line 20 )

$

State the following:

1. Total from Schedule D, “UNSECURED PORTION, IF

ANY” column

$

2. Total from Schedule E, “AMOUNT ENTITLED TO

PRIORITY” column.

$

3. Total from Schedule E, “AMOUNT NOT ENTITLED TO

PRIORITY, IF ANY” column

$

4. Total from Schedule F $

5. Total of non-priority unsecured debt (sum of 1, 3, and 4) $

Northern Illinois

Ramos, Felipe and Ramos, Maria

0.00

6,113.00

0.00

0.00

0.00

0.00

6,113.00

3,167.00

6,364.00

7,829.00

86,838.01

6,113.00

0.00

25,381.84

112,219.85

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B6A (Official Form 6A) (12/07)

In re _____________________________________________, Case No. ______________________________

Debtor (If known)

SCHEDULE A - REAL PROPERTY

Except as directed below, list all real property in which the debtor has any legal, equitable, or future interest, including all property owned as a cotenant, community property, or in which the debtor has a life estate. Include any property in which the debtor holds rights and powers exercisable for

the debtor’s own benefit. If the debtor is married, state whether the husband, wife, both, or the marital community own the property by placing an “H,”

“W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the debtor holds no interest in real property, write “None” under

“Description and Location of Property.”

Do not include interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and

Unexpired Leases.

If an entity claims to have a lien or hold a secured interest in any property, state the amount of the secured claim. See Schedule D. If no entity claims

to hold a secured interest in the property, write “None” in the column labeled “Amount of Secured Claim.”

If the debtor is an individual or if a joint petition is filed, state the amount of any exemption claimed in the property only in Schedule C - Property

Claimed as Exempt.

DESCRIPTION AND

LOCATION OF

PROPERTY

NATURE OF DEBTOR’S

INTEREST IN PROPERTY

CURRENT VALUE

OF DEBTOR’S

INTEREST IN

PROPERTY, WITHOUT

DEDUCTING ANY

SECURED CLAIM

OR EXEMPTION

AMOUNT OF

SECURED

CLAIM

Total


(Report also on Summary of Schedules.)

Ramos, Felipe and Ramos, Maria

1270 Highland Drive,

Des Plaines, Ill.100% ownership in

joint tenancy

J $300,000 $386,111.63

$300,000.00

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B6B (Official Form 6B) (12/07)

In re _______________________________________________, Case No. _________________________

Debtor (If known)

SCHEDULE B - PERSONAL PROPERTY

Except as directed below, list all personal property of the debtor of whatever kind. If the debtor has no property in one or more of the categories,

place an “x” in the appropriate position in the column labeled “None.” If additional space is needed in any category, attach a separate sheet properly

identified with the case name, case number, and the number of the category. If the debtor is married, state whether the husband, wife, both, or the marital

community own the property by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the debtor is an

individual or a joint petition is filed, state the amount of any exemptions claimed only in Schedule C - Property Claimed as Exempt.

Do not list interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and

Unexpired Leases.

If the property is being held for the debtor by someone else, state that person’s name and address under “Description and Location of Property.” 

If the property is being held for a minor child, simply state the child's initials and the name and address of the child's parent or guardian, such as

"A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

TYPE OF PROPERTY

N

O

N

E

DESCRIPTION AND LOCATION

OF PROPERTY

CURRENT VALUE OF

DEBTOR’S INTEREST 

IN PROPERTY, WITHOUT DEDUCTING ANY

SECURED CLAIM

OR EXEMPTION

1. Cash on hand.

2. Checking, savings or other financial accounts, certificates of deposit

or shares in banks, savings and loan,

thrift, building and loan, and homestead associations, or credit unions,

brokerage houses, or cooperatives.

3. Security deposits with public utilities, telephone companies, landlords, and others.

4. Household goods and furnishings,

including audio, video, and computer

equipment.

5. Books; pictures and other art

objects; antiques; stamp, coin,

record, tape, compact disc, and other

collections or collectibles.

6. Wearing apparel.

7. Furs and jewelry.

8. Firearms and sports, photographic, and other hobby equipment.

9. Interests in insurance policies.

Name insurance company of each 

policy and itemize surrender or

refund value of each.

10. Annuities. Itemize and name

each issuer.

11. Interests in an education IRA as

defined in 26 U.S.C. § 530(b)(1) or under

a qualified State tuition plan as defined in

26 U.S.C. § 529(b)(1). Give particulars. 

(File separately the record(s) of any such

interest(s). 11 U.S.C. § 521(c).)

Ramos, Felipe and Ramos, Maria

On our person J $75

Chase (J), TCF Bank (W), Bank of America (W) $426 , $1,164, $714

X

couch, chair, dining room set, 2 beds, lamps,

refrigerator, stove

J $2,550

25 CD's and 40 DVD's $325

Miscellaneous Clothes $1,000

X

X

State Farm Ins. Co. W $2,094.00

X

X

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 11 of 39
B6B (Official Form 6B) (12/07) -- Cont.

In re ______________________________________________, Case No. _________________________

Debtor (If known)

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

TYPE OF PROPERTY

N

O

N

E

DESCRIPTION AND LOCATION

OF PROPERTY

CURRENT VALUE OF

DEBTOR’S INTEREST 

IN PROPERTY, WITHOUT DEDUCTING ANY

SECURED CLAIM

OR EXEMPTION

12. Interests in IRA, ERISA, Keogh, or

other pension or profit sharing plans. 

Give particulars.

13. Stock and interests in incorporated

and unincorporated businesses.

Itemize. 

14. Interests in partnerships or joint

ventures. Itemize. 

15. Government and corporate bonds

and other negotiable and nonnegotiable instruments.

16. Accounts receivable.

17. Alimony, maintenance, support,

and property settlements to which the

debtor is or may be entitled. Give

particulars.

18. Other liquidated debts owed to 

debtor including tax refunds. Give

particulars.

19. Equitable or future interests, life

estates, and rights or powers exercisable

for the benefit of the debtor other than

those listed in Schedule A – Real

Property.

20. Contingent and noncontingent

interests in estate of a decedent, death

benefit plan, life insurance policy, or trust.

21. Other contingent and unliquidated

claims of every nature, including tax

refunds, counterclaims of the debtor, and

rights to setoff claims. Give estimated

value of each.

Ramos, Felipe and Ramos, Maria

401K Plan (H), 401K plan (W) H $7,000, $5,000

X

X

U.S. Savings bonds W $1,800.00

X

X

X

X

X

X

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 12 of 39
B6B (Official Form 6B) (12/07) -- Cont.

In re _________________________________________________, Case No. _________________________

Debtor (If known)

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

TYPE OF PROPERTY

N

O

N

E

DESCRIPTION AND LOCATION

OF PROPERTY

CURRENT VALUE OF

DEBTOR’S INTEREST 

IN PROPERTY, WITHOUT DEDUCTING ANY

SECURED CLAIM

OR EXEMPTION

22. Patents, copyrights, and other

intellectual property. Give particulars.

23. Licenses, franchises, and other general

intangibles. Give particulars.

24. Customer lists or other compilations

containing personally identifiable

information (as defined in 11 U.S.C.

 § 101(41A)) provided to the debtor by

individuals in connection with obtaining a

product or service from the debtor

primarily for personal, family, or

household purposes. 

 25. Automobiles, trucks, trailers,

and other vehicles and accessories.

26. Boats, motors, and accessories.

27. Aircraft and accessories.

28. Office equipment, furnishings,

and supplies.

29. Machinery, fixtures, equipment,

and supplies used in business.

30. Inventory.

31. Animals.

32. Crops - growing or harvested.

Give particulars.

33. Farming equipment and implements.

34. Farm supplies, chemicals, and feed.

35. Other personal property of any kind

not already listed. Itemize.

__________continuation sheets attached Total
 $

(Include amounts from any continuation

sheets attached. Report total also on

Summary of Schedules.)

Ramos, Felipe and Ramos, Maria

X

X

X

X

2005 Nissan (26,000 Miles) (J)

2007 Toyota (40,000 Miles)(J) $13,000.00, $11,500.00

X

X

X

X

X

X

X

X

X

X

46,648

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 13 of 39
B6C (Official Form 6C) (12/07)

In re ____________________________________________, Case No. _________________________

Debtor (If known)

SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

Debtor claims the exemptions to which debtor is entitled under:

(Check one box)

G 11 U.S.C. § 522(b)(2)

G 11 U.S.C. § 522(b)(3)

G Check if debtor claims a homestead exemption that exceeds

 $136,875.

DESCRIPTION OF PROPERTY

SPECIFY LAW

PROVIDING EACH

EXEMPTION

VALUE OF

CLAIMED

EXEMPTION

CURRENT

VALUE OF PROPERTY

WITHOUT DEDUCTING 

 EXEMPTION

Ramos, Felipe and Ramos, Maria

✔

Chase Checking Account 735 ILCS 5/12-1001 $426 $426

TCF Account 735 ILCS 5/12-1001 $1,164 $1,164

Bank of America Account 735 ILCS 5/12-1001 $714 $714

Household furniture and

furnishings 735 ILCS 5/12-1001 $1,802 $2,550

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 14 of 39
B6C (Official Form 6C) (12/07)

In re ____________________________________________, Case No. _________________________

Debtor (If known)

SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

Debtor claims the exemptions to which debtor is entitled under:

(Check one box)

G 11 U.S.C. § 522(b)(2)

G 11 U.S.C. § 522(b)(3)

G Check if debtor claims a homestead exemption that exceeds

 $136,875.

DESCRIPTION OF PROPERTY

SPECIFY LAW

PROVIDING EACH

EXEMPTION

VALUE OF

CLAIMED

EXEMPTION

CURRENT

VALUE OF PROPERTY

WITHOUT DEDUCTING 

 EXEMPTION

Ramos, Felipe and Ramos, Maria

✔

2005 Nissan car 735 ILCS 5/12-1001 $2,400.00 $13,000.00

House at 1270 Highland Drive,

Des Plaines, IL 60018 735 ILCS 5/12-901 $30,000 $300,000

2007 Toyota car 735 ILCS 5/12-1001 $2,400 $11,500

State Farm Ins. Co. cash value 735 ILCS 5/12-1001 $2,094 $2,094

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 15 of 39
B6D (Official Form 6D) (12/07) 

In re ____________________________________, Case No. __________________________________ 

 Debtor (If known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

State the name, mailing address, including zip code, and last four digits of any account number of all entities holding claims secured by 

property of the debtor as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful 

to the trustee and the creditor and may be provided if the debtor chooses to do so. List creditors holding all types of secured interests such as 

judgment liens, garnishments, statutory liens, mortgages, deeds of trust, and other security interests. 

 List creditors in alphabetical order to the extent practicable. If a minor child is the creditor, state the child's initials and the name and 

address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 

and Fed. R. Bankr. P. 1007(m). If all secured creditors will not fit on this page, use the continuation sheet provided. 

 If any entity other than a spouse in a joint case may be jointly liable on a claim, place an “X” in the column labeled “Codebtor,” include the 

entity on the appropriate schedule of creditors, and complete Schedule H – Codebtors. If a joint petition is filed, state whether the husband, wife, 

both of them, or the marital community may be liable on each claim by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, 

Joint, or Community.” 

 If the claim is contingent, place an “X” in the column labeled “Contingent.” If the claim is unliquidated, place an “X” in the column 

labeled “Unliquidated.” If the claim is disputed, place an “X” in the column labeled “Disputed.” (You may need to place an “X” in more than one of 

these three columns.) 

 Total the columns labeled “Amount of Claim Without Deducting Value of Collateral” and “Unsecured Portion, if Any” in the boxes

labeled “Total(s)” on the last sheet of the completed schedule. Report the total from the column labeled “Amount of Claim Without Deducting Value 

of Collateral” also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report the total from the column 

labeled “Unsecured Portion, if Any” on the Statistical Summary of Certain Liabilities and Related Data. 

Ƒ Check this box if debtor has no creditors holding secured claims to report on this Schedule D. 

CREDITOR’S NAME AND 

MAILING ADDRESS 

INCLUDING ZIP CODE AND 

AN ACCOUNT NUMBER 

(See Instructions Above.)

CODEBTOR

HUSBAND, WIFE, 

JOINT, OR 

COMMUNITY 

DATE CLAIM WAS 

INCURRED, 

NATURE OF LIEN , 

AND

DESCRIPTION 

AND VALUE OF 

PROPERTY

SUBJECT TO LIEN 

CONTINGENT 

UNLIQUIDATED 

DISPUTED

AMOUNT OF CLAIM 

WITHOUT

DEDUCTING VALUE 

OF COLLATERAL 

UNSECURED 

PORTION, IF 

ANY

ACCOUNT NO. 

VALUE $ 

 

ACCOUNT NO. 

VALUE $ 

 

ACCOUNT NO. 

VALUE $ 

 

____continuation sheets

 attached 

Subtotal Ź

(Total of this page) 

 $ $

 Total Ź

(Use only on last page) 

 $ $ 

(Report also on Summary of 

Schedules.) 

(If applicable, report 

also on Statistical 

Summary of Certain 

Liabilities and Related 

Data.)

Ramos, Felipe and Ramos, Maria

✔

ACCOUNT NO.1908

Toyota Financial

P.O. Box 8026

Cedar Rapids, IA 52409

J

We borrowed $21,000 to

purchase Toyota car in

2007

VALUE $11,500

$12,226.38 $726.38

ACCOUNT NO.8000-1

Nissan Motor Acceptance Corp.

P.O. Box 660360

Dallas, TX 75266

J

In 2005, we borrowed

$30,000 to purchase 2005

Nissan car

VALUE $13,000

$10,930.52

ACCOUNT NO.8943

American General Financial Services

P.O. Box 3893

Evansville, IN 47737

J

In 2008, we borrowed

$10,000 and placed a 2nd

mortgage on our house

VALUE $300,000

$10,275.00 $10,111.63

1 33,431.90 11,001.38

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 16 of 39
B6D (Official Form 6D) (12/07) – Cont. 2

In re ____________________________________, Case No. __________________________________ 

 Debtor (if known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS 

(Continuation Sheet) 

CREDITOR’S NAME AND 

MAILING ADDRESS 

INCLUDING ZIP CODE 

AND AN ACCOUNT 

NUMBER

(See Instructions Above.)

CODEBTOR 

HUSBAND, WIFE, 

JOINT, OR 

COMMUNITY

DATE CLAIM WAS 

INCURRED, NATURE 

OF LIEN , AND 

DESCRIPTION AND 

VALUE OF PROPERTY 

SUBJECT TO LIEN 

CONTINGENT 

UNLIQUIDATED 

DISPUTED

AMOUNT OF CLAIM 

WITHOUT 

DEDUCTING VALUE 

OF COLLATERAL 

UNSECURED

PORTION, IF 

ANY

ACCOUNT NO. 

VALUE $ 

 

ACCOUNT NO. 

VALUE $ 

 

ACCOUNT NO. 

VALUE $

 

ACCOUNT NO. 

VALUE $

 

ACCOUNT NO. 

VALUE $

 

Sheet no.___of___continuation 

sheets attached to Schedule of 

Creditors Holding Secured 

Claims 

Subtotal (s)Ź

(Total(s) of this page) 

 $ $

 Total(s) Ź

(Use only on last page) 

 $ $ 

 (Report also on 

Summary of Schedules.) 

(If applicable, 

report also on 

Statistical Summary 

of Certain 

Liabilities and 

Related Data.) 

ACCOUNT NO.

OCWEN Loan Servicing

P.O. Box 24737

West Palm Beach, FL 33416

J

In 2006, we borrowed

$356,000 to buy our house at

1270 Highland Drive, Des

Plaines

VALUE $300,000

$376,000 $76,000

ACCOUNT NO.

VALUE $

ACCOUNT NO.

VALUE $

ACCOUNT NO.

VALUE $

ACCOUNT NO.

VALUE $

$376,000 $76,000

409,431.90 87,001.38

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 17 of 39
B6E (Official Form 6E) (12/07)

In re , Case No.

Debtor (if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS

A complete list of claims entitled to priority, listed separately by type of priority, is to be set forth on the sheets provided. Only holders of

unsecured claims entitled to priority should be listed in this schedule. In the boxes provided on the attached sheets, state the name, mailing address,

including zip code, and last four digits of the account number, if any, of all entities holding priority claims against the debtor or the property of the

debtor, as of the date of the filing of the petition. Use a separate continuation sheet for each type of priority and label each with the type of priority.

The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the

debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as

"A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the

entity on the appropriate schedule of creditors, and complete Schedule H-Codebtors. If a joint petition is filed, state whether the husband, wife,

both of them, or the marital community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife,

Joint, or Community." If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in

the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more

than one of these three columns.)

Report the total of claims listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all claims listed on this Schedule

E in the box labeled “Total” on the last sheet of the completed schedule. Report this total also on the Summary of Schedules.

Report the total of amounts entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all amounts

entitled to priority listed on this Schedule E in the box labeled “Totals” on the last sheet of the completed schedule. Individual debtors with

primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data.

Report the total of amounts not entitled to priority listed on each sheet in the box labeled “Subtotals” on each sheet. Report the total of all

amounts not entitled to priority listed on this Schedule E in the box labeled “Totals” on the last sheet of the completed schedule. Individual debtors

with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data.

 Check this box if debtor has no creditors holding unsecured priority claims to report on this Schedule E.

TYPES OF PRIORITY CLAIMS (Check the appropriate box(es) below if claims in that category are listed on the attached sheets.)

 Domestic Support Obligations 

Claims for domestic support that are owed to or recoverable by a spouse, former spouse, or child of the debtor, or the parent, legal guardian, or

responsible relative of such a child, or a governmental unit to whom such a domestic support claim has been assigned to the extent provided in

11 U.S.C. § 507(a)(1).

Extensions of credit in an involuntary case

Claims arising in the ordinary course of the debtor's business or financial affairs after the commencement of the case but before the earlier of the

appointment of a trustee or the order for relief. 11 U.S.C. § 507(a)(3).

Wages, salaries, and commissions

Wages, salaries, and commissions, including vacation, severance, and sick leave pay owing to employees and commissions owing to qualifying

independent sales representatives up to $10,950* per person earned within 180 days immediately preceding the filing of the original petition, or the

cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(4).

Contributions to employee benefit plans

Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or the

cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(5).

Ramos, Felipe and Ramos, Maria

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 18 of 39
B6E (Official Form 6E) (12/07) – Cont.

In re , Case No. 

Debtor (if known)

Certain farmers and fishermen

Claims of certain farmers and fishermen, up to $5,400* per farmer or fisherman, against the debtor, as provided in 11 U.S.C. § 507(a)(6).

Deposits by individuals

Claims of individuals up to $2,425* for deposits for the purchase, lease, or rental of property or services for personal, family, or household use,

that were not delivered or provided. 11 U.S.C. § 507(a)(7).

Taxes and Certain Other Debts Owed to Governmental Units

Taxes, customs duties, and penalties owing to federal, state, and local governmental units as set forth in 11 U.S.C. § 507(a)(8).

Commitments to Maintain the Capital of an Insured Depository Institution

Claims based on commitments to the FDIC, RTC, Director of the Office of Thrift Supervision, Comptroller of the Currency, or Board of

Governors of the Federal Reserve System, or their predecessors or successors, to maintain the capital of an insured depository institution. 11 U.S.C.

§ 507 (a)(9).

Claims for Death or Personal Injury While Debtor Was Intoxicated

Claims for death or personal injury resulting from the operation of a motor vehicle or vessel while the debtor was intoxicated from using alcohol, a

drug, or another substance. 11 U.S.C. § 507(a)(10).

* Amounts are subject to adjustment on April 1, 2010, and every three years thereafter with respect to cases commenced on or after the date of

adjustment.

____ continuation sheets attached

✔

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 19 of 39
B6E (Official Form 6E) (12/07) – Cont.

In re __________________________________________, Case No. _________________________________

Debtor (if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS

(Continuation Sheet)

Type of Priority for Claims Listed on This Sheet

CREDITOR’S NAME, 

MAILING ADDRESS

INCLUDING ZIP CODE,

AND ACCOUNT NUMBER

(See instructions above.)

DATE CLAIM WAS

INCURRED AND

CONSIDERATION

FOR CLAIM

AMOUNT

OF

CLAIM

AMOUNT

ENTITLED

TO

PRIORITY

AMOUNT

NOT

ENTITLED

TO

PRIORITY, IF

ANY

Account No.

Account No.

Account No.

Account No.

Sheet no. ___ of ___ continuation sheets attached to Schedule of

Creditors Holding Priority Claims

Subtotals


(Totals of this page)

$ $

Total


(Use only on last page of the completed

Schedule E. Report also on the Summary

of Schedules.)

$

Totals


(Use only on last page of the completed

Schedule E. If applicable, report also on 

the Statistical Summary of Certain

Liabilities and Related Data.)

$ $

CODEBTOR

HUSBAND, WIFE,

JOINT, OR

COMMUNITY

CONTINGENT

UNLIQUIDATED

DISPUTED

09-29-406-010

Cook County Collector

P.O. Box 4488

Carol Stream, IL 60197

July, 2008-Dec. 2008

real estate taxes

$6,113 $6,113

$6,113 $6,113

$6,113

$6,113

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 20 of 39
B6F (Official Form 6F) (12/07)

In re __________________________________________, Case No. _________________________________

Debtor (if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

State the name, mailing address, including zip code, and last four digits of any account number, of all entities holding unsecured claims without priority against

the debtor or the property of the debtor, as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is

useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and

address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed.

R. Bankr. P. 1007(m). Do not include claims listed in Schedules D and E. If all creditors will not fit on this page, use the continuation sheet provided.

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an “X” in the column labeled “Codebtor,” include the entity on the

appropriate schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital

community may be liable on each claim by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.”

If the claim is contingent, place an “X” in the column labeled “Contingent.” If the claim is unliquidated, place an “X” in the column labeled “Unliquidated.”

If the claim is disputed, place an “X” in the column labeled “Disputed.” (You may need to place an “X” in more than one of these three columns.)

Report the total of all claims listed on this schedule in the box labeled “Total” on the last sheet of the completed schedule. Report this total also on the

Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report this total also on the Statistical Summary of Certain Liabilities

and Related Data..

G Check this box if debtor has no creditors holding unsecured claims to report on this Schedule F.

CREDITOR’S NAME,

 MAILING ADDRESS

 INCLUDING ZIP CODE,

 AND ACCOUNT NUMBER

(See instructions above.)

CODEBTOR

HUSBAND, WIFE,

JOINT, OR

COMMUNITY

DATE CLAIM WAS

INCURRED AND

CONSIDERATION FOR

CLAIM.

 IF CLAIM IS SUBJECT TO

SETOFF, SO STATE.

CONTINGENT

UNLIQUIDATED

DISPUTED

AMOUNT OF

CLAIM

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

Subtotal
 $

_____continuation sheets attached Total


 (Use only on last page of the completed Schedule F.)

 (Report also on Summary of Schedules and, if applicable, on the Statistical

Summary of Certain Liabilities and Related Data.)

$

Ramos, Felipe and Ramos, Maria

2701

Sam's Club

P.O. Box 530942

Atlanta, GA 30353

H

miscellaneous purchases

2006-2009

$2,024.00

4676

AT&T Mobility

c/o: AFNI, Inc.

P.O. Box 3427

Bloomington, IL. 61702

W

Television service 2001

$318.76

6686

MCM

Dept. 12421

P.O. Box 603

Oaks, PA 19456

H

miscellaneous purchases

2006-2008

$2,666.01

9675

First Source Advantage, LLC

P.O. Box 628

Buffalo, NY 14240-0628

H

miscellaneous purchases

2005-2009

$3,720.10

2

$8,728.87

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 21 of 39
B6F (Official Form 6F) (12/07) - Cont. 

In re __________________________________________, Case No. _________________________________

Debtor (if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

(Continuation Sheet)

CREDITOR’S NAME,

 MAILING ADDRESS

 INCLUDING ZIP CODE,

 AND ACCOUNT NUMBER

(See instructions above.)

CODEBTOR

HUSBAND, WIFE,

JOINT, OR

COMMUNITY

DATE CLAIM WAS

INCURRED AND

CONSIDERATION FOR

CLAIM.

 IF CLAIM IS SUBJECT TO

SETOFF, SO STATE.

CONTINGENT

UNLIQUIDATED

DISPUTED

AMOUNT OF

CLAIM

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

Sheet no.___of___ continuation sheets attached

to Schedule of Creditors Holding Unsecured

Nonpriority Claims

Subtotal
 $

Total


 (Use only on last page of the completed Schedule F.)

 (Report also on Summary of Schedules and, if applicable on the Statistical

Summary of Certain Liabilities and Related Data.)

$

Ramos, Felipe and Ramos, Maria

8802

Main Street Acquisition Corp.

c/o: Mercantile Adjustment Bureau

P.O. Box 9016

Williamsville, NY 14231

H

miscellaneous purchases

2005-2009

$5,594.11

2643

Barclay's Bank Delaware

c/o: Northstar Location Services

Attn: Financial Services Dept.

4285 Genesee, Cheektowaga, NY 14225

H

miscellaneous purchases

2006-2009

$3,850.49

2701

Sam's Club

P.O. Box 530942

Atlanta, GA 30353

W

miscellaneous purchases

2006-2009

$404.95

8525

Chase

Cardmember Services

P.O. Box 15153

Wilmington, DE 19886

H

miscellaneous purchases

2006-2009

$735.19

9013

HSBC Card Services

Payment Center

PO Box 17313

Baltimore, MD 21297

W

miscellaneous purchases 2006-2008

2,918.60

1 2 16,421.94

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 22 of 39
B6F (Official Form 6F) (12/07) - Cont. 

In re __________________________________________, Case No. _________________________________

Debtor (if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

(Continuation Sheet)

CREDITOR’S NAME,

 MAILING ADDRESS

 INCLUDING ZIP CODE,

 AND ACCOUNT NUMBER

(See instructions above.)

CODEBTOR

HUSBAND, WIFE,

JOINT, OR

COMMUNITY

DATE CLAIM WAS

INCURRED AND

CONSIDERATION FOR

CLAIM.

 IF CLAIM IS SUBJECT TO

SETOFF, SO STATE.

CONTINGENT

UNLIQUIDATED

DISPUTED

AMOUNT OF

CLAIM

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

Sheet no.___of___ continuation sheets attached

to Schedule of Creditors Holding Unsecured

Nonpriority Claims

Subtotal
 $

Total


 (Use only on last page of the completed Schedule F.)

 (Report also on Summary of Schedules and, if applicable on the Statistical

Summary of Certain Liabilities and Related Data.)

$

Ramos, Felipe and Ramos, Maria

9742

Northwest Metro Valley

1875 Dempster - Suite 5

Park Ridge, IL 60068

Medical Care

2009

$492.39

1675

Capital One Bank

P.O. Box 6492

Carol Stream, IL 60199

Miscellaneous purchases

2004-2009

$2,657.24

2 2 3,149.63

25,381.84

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 23 of 39
B6G (Official Form 6G) (12/07)

In re , Case No. 

Debtor (if known)

SCHEDULE G - EXECUTORY CONTRACTS AND UNEXPIRED LEASES 

Describe all executory contracts of any nature and all unexpired leases of real or personal property. Include any timeshare

interests. State nature of debtor’s interest in contract, i.e., “Purchaser,” “Agent,” etc. State whether debtor is the lessor or

lessee of a lease. Provide the names and complete mailing addresses of all other parties to each lease or contract described. If

a minor child is a party to one of the leases or contracts, state the child's initials and the name and address of the child's parent

or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and

Fed. R. Bankr. P. 1007(m).

Check this box if debtor has no executory contracts or unexpired leases.

 NAME AND MAILING ADDRESS, 

INCLUDING ZIP CODE,

OF OTHER PARTIES TO LEASE OR CONTRACT.

DESCRIPTION OF CONTRACT OR LEASE AND

NATURE OF DEBTOR’S INTEREST. STATE

WHETHER LEASE IS FOR NONRESIDENTIAL

REAL PROPERTY. STATE CONTRACT

NUMBER OF ANY GOVERNMENT CONTRACT.

Ramos, Felipe and Ramos, Maria

✔

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 24 of 39
B6H (Official Form 6H) (12/07)

In re , Case No. 

Debtor (if known)

SCHEDULE H - CODEBTORS

Provide the information requested concerning any person or entity, other than a spouse in a joint case, that is also liable on any debts listed by the

debtor in the schedules of creditors. Include all guarantors and co-signers. If the debtor resides or resided in a community property state,

commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or

Wisconsin) within the eight-year period immediately preceding the commencement of the case, identify the name of the debtor’s spouse and of any

former spouse who resides or resided with the debtor in the community property state, commonwealth, or territory. Include all names used by the

nondebtor spouse during the eight years immediately preceding the commencement of this case. If a minor child is a codebtor or a creditor, state the

child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the

child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

 Check this box if debtor has no codebtors.

NAME AND ADDRESS OF CODEBTOR NAME AND ADDRESS OF CREDITOR

Ramos, Felipe and Ramos, Maria

✔

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 25 of 39
B6I (Official Form 6I) (12/07)

In re , Case No. 

Debtor (if known)

SCHEDULE I - CURRENT INCOME OF INDIVIDUAL DEBTOR(S)

The column labeled “Spouse” must be completed in all cases filed by joint debtors and by every married debtor, whether or not a joint petition is

filed, unless the spouses are separated and a joint petition is not filed. Do not state the name of any minor child. The average monthly income

calculated on this form may differ from the current monthly income calculated on From 22A, 22B, or 22C.

Debtor’s Marital

Status:

DEPENDENTS OF DEBTOR AND SPOUSE

 RELATIONSHIP(S): AGE(S):

Employment: DEBTOR

Occupation

Name of Employer

How long employed

Address of Employer

 SPOUSE

INCOME: (Estimate of average or projected monthly income at time

case filed)

1. Monthly gross wages, salary, and commissions

 (Prorate if not paid monthly)

2. Estimate monthly overtime

3. SUBTOTAL

4. LESS PAYROLL DEDUCTIONS

 a. Payroll taxes and social security

 b. Insurance

 c. Union dues

 d. Other (Specify): 

5. SUBTOTAL OF PAYROLL DEDUCTIONS

6. TOTAL NET MONTHLY TAKE HOME PAY

7. Regular income from operation of business or profession or farm

 (Attach detailed statement)

8. Income from real property

9. Interest and dividends

10. Alimony, maintenance or support payments payable to the debtor for 

 the debtor’s use or that of dependents listed above

11. Social security or government assistance

 (Specify): 

12. Pension or retirement income

13. Other monthly income

 (Specify): 

14. SUBTOTAL OF LINES 7 THROUGH 13

15. AVERAGE MONTHLY INCOME (Add amounts on lines 6 and 14)

16. COMBINED AVERAGE MONTHLY INCOME: (Combine column

totals from line 15) 

DEBTOR SPOUSE

$________________ $______________

$________________ $______________

$_______________ $_____________

$ $ 

$ $

$ $

$ $

$ $

$ $

$ $ 

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

 $

(Report also on Summary of Schedules and, if applicable,

on Statistical Summary of Certain Liabilities and Related Data)

17. Describe any increase or decrease in income reasonably anticipated to occur within the year following the filing of this document:

William Cusimano

Married Son (24), Daughter (23), Sister (9), Sister-in-law (25)

Banquet Server

Starwood

12 years

6100 N. River

Rosemont, Ill.

telephone operator

Starwood

13 years

6100 N. River

Rosemont, Ill.

2,606 2,606

2,606 2,606

1,183

83

60

401K loans 1,152

782 1,259

1,824 1,343

0.00 0.00

1,824

3,167

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 26 of 39
$______________

B6J (Official Form 6J) (12/07)

In re , Case No. 

Debtor (if known)

SCHEDULE J - CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S)

Complete this schedule by estimating the average or projected monthly expenses of the debtor and the debtor’s family at time case filed. Prorate any payments made biweekly, quarterly, semi-annually, or annually to show monthly rate. The average monthly expenses calculated on this form may differ from the deductions from income

allowed on Form22A or 22C.

Check this box if a joint petition is filed and debtor’s spouse maintains a separate household. Complete a separate schedule of expenditures labeled “Spouse.”

1. Rent or home mortgage payment (include lot rented for mobile home) $ _____________

a. Are real estate taxes included? Yes ________ No ________

b. Is property insurance included? Yes ________ No ________

2. Utilities: a. Electricity and heating fuel $ ______________

b. Water and sewer $ ______________

c. Telephone $ ______________

d. Other ___________________________________________________________________ $ ______________

3. Home maintenance (repairs and upkeep) $ ______________

4. Food $ ______________

5. Clothing $ ______________

6. Laundry and dry cleaning $ ______________

7. Medical and dental expenses $ ______________

8. Transportation (not including car payments) $ ______________

9. Recreation, clubs and entertainment, newspapers, magazines, etc. $ ______________

10.Charitable contributions $ ______________

11.Insurance (not deducted from wages or included in home mortgage payments)

a. Homeowner’s or renter’s $ ______________

b. Life $ ______________

c. Health $ ______________

d. Auto $ ______________

e. Other ___________________________________________________________________ $ ______________

12. Taxes (not deducted from wages or included in home mortgage payments)

(Specify) ___________________________________________________________________________ $ ______________

13. Installment payments: (In chapter 11, 12, and 13 cases, do not list payments to be included in the plan)

a. Auto $ ______________

b. Other ______________________________________________________________ $ ______________

c. Other ____________________________________________________________ $ ______________

14. Alimony, maintenance, and support paid to others $ ______________

15. Payments for support of additional dependents not living at your home $ ______________

16. Regular expenses from operation of business, profession, or farm (attach detailed statement) $ ______________

17. Other __________________________________________________________________________ $______________

18. AVERAGE MONTHLY EXPENSES (Total lines 1-17. Report also on Summary of Schedules and,

 if applicable, on the Statistical Summary of Certain Liabilities and Related Data.)

19. Describe any increase or decrease in expenditures reasonably anticipated to occur within the year following the filing of this document: ________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

20. STATEMENT OF MONTHLY NET INCOME

a. Average monthly income from Line 15 of Schedule I $______________

b. Average monthly expenses from Line 18 above $______________

c. Monthly net income (a. minus b.) $______________

Ramos, Felipe and Ramos, Maria

3,134

✔

✔

175

100

87

960

60

30

25

220

20

70

104

100

225

1.019

garnishment of wages 765

repayments to my 401K 1,262

Miscellaneous car repairs and maintenance 35

6,364

Union Dues - $60

3,167

6,364

(3,197)

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 27 of 39
B7 (Official Form 7) (12/07)

UNITED STATES BANKRUPTCY COURT

______________________________ DISTRICT OF _____________________________

In re:_____ ___________________________________, Case No. ___________________________________

 Debtor (if known)

STATEMENT OF FINANCIAL AFFAIRS

This statement is to be completed by every debtor. Spouses filing a joint petition may file a single statement on which

the information for both spouses is combined. If the case is filed under chapter 12 or chapter 13, a married debtor must furnish

information for both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not

filed. An individual debtor engaged in business as a sole proprietor, partner, family farmer, or self-employed professional,

should provide the information requested on this statement concerning all such activities as well as the individual's personal

affairs. To indicate payments, transfers and the like to minor children, state the child's initials and the name and address of the

child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C.

§112 and Fed. R. Bankr. P. 1007(m).

Questions 1 - 18 are to be completed by all debtors. Debtors that are or have been in business, as defined below, also

must complete Questions 19 - 25. If the answer to an applicable question is "None," mark the box labeled "None." If

additional space is needed for the answer to any question, use and attach a separate sheet properly identified with the case name,

case number (if known), and the number of the question.

DEFINITIONS

"In business." A debtor is "in business" for the purpose of this form if the debtor is a corporation or partnership. An

individual debtor is "in business" for the purpose of this form if the debtor is or has been, within six years immediately preceding

the filing of this bankruptcy case, any of the following: an officer, director, managing executive, or owner of 5 percent or more

of the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership; a sole proprietor or

self-employed full-time or part-time. An individual debtor also may be “in business” for the purpose of this form if the debtor

engages in a trade, business, or other activity, other than as an employee, to supplement income from the debtor’s primary

employment.

"Insider." The term "insider" includes but is not limited to: relatives of the debtor; general partners of the debtor and

their relatives; corporations of which the debtor is an officer, director, or person in control; officers, directors, and any owner of

5 percent or more of the voting or equity securities of a corporate debtor and their relatives; affiliates of the debtor and insiders

of such affiliates; any managing agent of the debtor. 11 U.S.C. § 101. 

______________________________________________________________________________________________________

1. Income from employment or operation of business

None State the gross amount of income the debtor has received from employment, trade, or profession, or from operation of

the debtor's business, including part-time activities either as an employee or in independent trade or business, from the

beginning of this calendar year to the date this case was commenced. State also the gross amounts received during the

two years immediately preceding this calendar year. (A debtor that maintains, or has maintained, financial records on

the basis of a fiscal rather than a calendar year may report fiscal year income. Identify the beginning and ending dates

of the debtor's fiscal year.) If a joint petition is filed, state income for each spouse separately. (Married debtors filing

under chapter 12 or chapter 13 must state income of both spouses whether or not a joint petition is filed, unless the

spouses are separated and a joint petition is not filed.)

AMOUNT SOURCE 

Northern Illinois

Ramos, Felipe and Ramos, Maria

2010 - $2,779, 2009 Starwood Hotel (all 3 years)

$75,893 2008-$125,79

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 28 of 39
2

2. Income other than from employment or operation of business

None State the amount of income received by the debtor other than from employment, trade, profession, operation of the

debtor's business during the two years immediately preceding the commencement of this case. Give particulars. If a

joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13

must state income for each spouse whether or not a joint petition is filed, unless the spouses are separated and a joint

petition is not filed.)

AMOUNT SOURCE

_____________________________________________________________________________________________________

3. Payments to creditors

Complete a. or b., as appropriate, and c. None

a. Individual or joint debtor(s) with primarily consumer debts: List all payments on loans, installment purchases of

goods or services, and other debts to any creditor made within 90 days immediately preceding the commencement of

this case unless the aggregate value of all property that constitutes or is affected by such transfer is less than $600.

Indicate with an asterisk (*) any payments that were made to a creditor on account of a domestic support obligation or

as part of an alternative repayment schedule under a plan by an approved nonprofit budgeting and credit counseling

agency. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses

whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) 

NAME AND ADDRESS OF CREDITOR DATES OF AMOUNT AMOUNT

PAYMENTS PAID STILL OWING

______________________________________________________________________________________________________

None

G b. Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor made

within 90 days immediately preceding the commencement of the case unless the aggregate value of all property that

constitutes or is affected by such transfer is less than $5,475. If the debtor is an individual, indicate with an asterisk (*)

any payments that were made to a creditor on account of a domestic support obligation or as part of an alternative

repayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency. (Married

debtors filing under chapter 12 or chapter 13 must include payments and other transfers by either or both spouses

whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR DATES OF AMOUNT AMOUNT

PAYMENTS/ PAID OR STILL

TRANSFERS VALUE OF OWING

TRANSFERS

________________________________________________________________________________________________

$20,235 (Felipe) - 2009 State of Illinois Department of Unemployment

✔

Nissan - P.O. Box 66030 - Dallas, TX 75266 Aug, Sept,

Oct. 2009 $1,740 total $10,930.52

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 29 of 39
3

None

G c. All debtors: List all payments made within one year immediately preceding the commencement of this case

 to or for the benefit of creditors who are or were insiders. (Married debtors filing under chapter 12 or chapter 13 must

include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and

a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR DATE OF AMOUNT AMOUNT

AND RELATIONSHIP TO DEBTOR PAYMENT PAID STILL OWING

______________________________________________________________________________________________________

4. Suits and administrative proceedings, executions, garnishments and attachments

None a. List all suits and administrative proceedings to which the debtor is or was a party within one year immediately

preceding the filing of this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include

information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated

and a joint petition is not filed.)

CAPTION OF SUIT COURT OR AGENCY STATUS OR

AND CASE NUMBER NATURE OF PROCEEDING AND LOCATION DISPOSITION

______________________________________________________________________________________________________

None b. Describe all property that has been attached, garnished or seized under any legal or equitable process within one

year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13

must include information concerning property of either or both spouses whether or not a joint petition is filed, unless

the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS DESCRIPTION 

OF PERSON FOR WHOSE DATE OF AND VALUE

BENEFIT PROPERTY WAS SEIZED SEIZURE OF PROPERTY

_____________________________________________________________________________________________________

5. Repossessions, foreclosures and returns

None List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu 

of foreclosure or returned to the seller, within one year immediately preceding the commencement of this case. 

(Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both

spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

DATE OF REPOSSESSION, DESCRIPTION

NAME AND ADDRESS FORECLOSURE SALE, AND VALUE

 OF CREDITOR OR SELLER TRANSFER OR RETURN OF PROPERTY

_

______________________________________________________________________________________________________

Ocwen Loan Servicing, LLC v. Felipe

Ramos & Maria Ramos

Case 09CH-25357, foreclosure Daley Center, Chicago Pending

✔

H&R Block

PO Box 3052, Milwaukee, WI 53201 October, 2009

$338.00 is being garnished from my

paycheck every 2 weeks

✔

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4

6. Assignments and receiverships

None a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the

commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by

either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not

filed.)

TERMS OF

NAME AND ADDRESS DATE OF ASSIGNMENT

OF ASSIGNEE ASSIGNMENT OR SETTLEMENT

________________________________________________________________________________________________

None b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year

immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must

include information concerning property of either or both spouses whether or not a joint petition is filed, unless the

spouses are separated and a joint petition is not filed.)

 NAME AND LOCATION DESCRIPTION

NAME AND ADDRESS OF COURT DATE OF AND VALUE

OF CUSTODIAN CASE TITLE & NUMBER ORDER Of PROPERTY

______________________________________________________________________________________________________

7. Gifts 

None List all gifts or charitable contributions made within one year immediately preceding the commencement of this case

except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member

and charitable contributions aggregating less than $100 per recipient. (Married debtors filing under chapter 12 or

chapter 13 must include gifts or contributions by either or both spouses whether or not a joint petition is filed, unless

the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS RELATIONSHIP DESCRIPTION

OF PERSON TO DEBTOR, DATE AND VALUE

OR ORGANIZATION IF ANY OF GIFT OF GIFT

_____________________________________________________________________________________________________

8. Losses

None List all losses from fire, theft, other casualty or gambling within one year immediately preceding the commencement

of this case or since the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must

include losses by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a

joint petition is not filed.)

DESCRIPTION DESCRIPTION OF CIRCUMSTANCES AND, IF

AND VALUE OF LOSS WAS COVERED IN WHOLE OR IN PART DATE

PROPERTY BY INSURANCE, GIVE PARTICULARS OF LOSS

______________________________________________________________________________________________________

✔

✔

✔

St. Emily Church, 1400 Central, Mt.

Prospect, IL 60016 Our church 11/2008-10/2009

$240 cash

✔

Four Winds Casino - $400 cash gambling

July, '08-Aug '08

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

 Document Page 31 of 39
5

9. Payments related to debt counseling or bankruptcy

None List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for 

consultation concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in bankruptcy

within one year immediately preceding the commencement of this case.

DATE OF PAYMENT, AMOUNT OF MONEY OR

NAME AND ADDRESS NAME OF PAYER IF DESCRIPTION AND

OF PAYEE OTHER THAN DEBTOR VALUE OF PROPERTY

______________________________________________________________________________________________________

10. Other transfers None

 a. List all other property, other than property transferred in the ordinary course of the business or financial affairs of

the debtor, transferred either absolutely or as security within two years immediately preceding the commencement of

this case. (Married debtors filing under chapter 12 or chapter 13 must include transfers by either or both spouses

whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF TRANSFEREE, DESCRIBE PROPERTY

RELATIONSHIP TO DEBTOR TRANSFERRED AND 

DATE VALUE RECEIVED

______________________________________________________________________________________________________

None

G b. List all property transferred by the debtor within ten years immediately preceding the commencement of this case

to a self-settled trust or similar device of which the debtor is a beneficiary.

NAME OF TRUST OR OTHER DATE(S) OF AMOUNT OF MONEY OR DESCRIPTION

DEVICE TRANSFER(S) AND VALUE OF PROPERTY OR DEBTOR’S

INTEREST IN PROPERTY

______________________________________________________________________________________________________

11. Closed financial accounts 

None List all financial accounts and instruments held in the name of the debtor or for the benefit of the debtor which were

closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. Include

checking, savings, or other financial accounts, certificates of deposit, or other instruments; shares and share accounts

held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and other financial

institutions. (Married debtors filing under chapter 12 or chapter 13 must include information concerning accounts or

instruments held by or for either or both spouses whether or not a joint petition is filed, unless the spouses are

separated and a joint petition is not filed.)

TYPE OF ACCOUNT, LAST FOUR AMOUNT AND

NAME AND ADDRESS DIGITS OF ACCOUNT NUMBER, DATE OF SALE 

OF INSTITUTION AND AMOUNT OF FINAL BALANCE OR CLOSING 

______________________________________________________________________________________________________

✔

✔

✔

✔

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6

12. Safe deposit boxes

None List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables

within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or

chapter 13 must include boxes or depositories of either or both spouses whether or not a joint petition is filed, unless

the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS NAMES AND ADDRESSES DESCRIPTION DATE OF TRANSFER

OF BANK OR OF THOSE WITH ACCESS OF OR SURRENDER,

OTHER DEPOSITORY TO BOX OR DEPOSITORY CONTENTS IF ANY

_

______________________________________________________________________________________________________

13. Setoffs

None List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days preceding

the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information

concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint

petition is not filed.)

DATE OF AMOUNT

NAME AND ADDRESS OF CREDITOR SETOFF OF SETOFF

_____________________________________________________________________________________________________

14. Property held for another person

None List all property owned by another person that the debtor holds or controls.

NAME AND ADDRESS DESCRIPTION AND

OF OWNER VALUE OF PROPERTY LOCATION OF PROPERTY

_____________________________________________________________________________________________________

15. Prior address of debtor

None

G If debtor has moved within three years immediately preceding the commencement of this case, list all premises 

which the debtor occupied during that period and vacated prior to the commencement of this case. If a joint petition is

filed, report also any separate address of either spouse.

ADDRESS NAME USED DATES OF OCCUPANCY

_____________________________________________________________________________

✔

✔

✔

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7

16. Spouses and Former Spouses

None If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska, Arizona,

 California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within eight

years immediately preceding the commencement of the case, identify the name of the debtor’s spouse and of 

any former spouse who resides or resided with the debtor in the community property state. 

NAME

______________________________________________________________________________________________________

17. Environmental Information.

For the purpose of this question, the following definitions apply:

 "Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination,

releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or

other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes,

or material.

"Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or

formerly owned or operated by the debtor, including, but not limited to, disposal sites. 

"Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous

material, pollutant, or contaminant or similar term under an Environmental Law.

________________________________________________________________________________________________

None a. List the name and address of every site for which the debtor has received notice in writing by a governmental

unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the

governmental unit, the date of the notice, and, if known, the Environmental Law:

SITE NAME NAME AND ADDRESS DATE OF ENVIRONMENTAL

AND ADDRESS OF GOVERNMENTAL UNIT NOTICE LAW

______________________________________________________________________________________________________

None b. List the name and address of every site for which the debtor provided notice to a governmental unit of a release

 of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

SITE NAME NAME AND ADDRESS DATE OF ENVIRONMENTAL

AND ADDRESS OF GOVERNMENTAL UNIT NOTICE LAW

_____________________________________________________________________________________________________

None c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with

respect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a party

to the proceeding, and the docket number.

NAME AND ADDRESS DOCKET NUMBER STATUS OR 

OF GOVERNMENTAL UNIT DISPOSITION

______________________________________________________________________________________________________

18 . Nature, location and name of business

None a. If the debtor is an individual, list the names, addresses, taxpayer-identification numbers, nature of the businesses,

and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing

executive of a corporation, partner in a partnership, sole proprietor, or was self-employed in a trade, profession, or

other activity either full- or part-time within six years immediately preceding the commencement of this case, or in

✔

✔

✔

✔

✔

Case 10-01041 Doc 1 Filed 01/13/10 Entered 01/13/10 10:41:36 Desc Main

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8

which the debtor owned 5 percent or more of the voting or equity securities within six years immediately preceding

the commencement of this case.

If the debtor is a partnership, list the names, addresses, taxpayer-identification numbers, nature of the businesses,

and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of

the voting or equity securities, within six years immediately preceding the commencement of this case.

If the debtor is a corporation, list the names, addresses, taxpayer-identification numbers, nature of the businesses,

and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of

the voting or equity securities within six years immediately preceding the commencement of this case.

LAST FOUR DIGITS

OF SOCIAL-SECURITY BEGINNING AND 

NAME OR OTHER INDIVIDUAL ADDRESS NATURE OF BUSINESS ENDING DATES

TAXPAYER-I.D. NO.

(ITIN)/ COMPLETE EIN

______________________________________________________________________________________________________

None b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as

defined in 11 U.S.C. § 101.

NAME ADDRESS

______________________________________________________________________________________________________

The following questions are to be completed by every debtor that is a corporation or partnership and by any individual

debtor who is or has been, within six years immediately preceding the commencement of this case, any of the following: an

officer, director, managing executive, or owner of more than 5 percent of the voting or equity securities of a corporation; a

partner, other than a limited partner, of a partnership, a sole proprietor, or self-employed in a trade, profession, or other activity,

either full- or part-time.

(An individual or joint debtor should complete this portion of the statement only if the debtor is or has been in

business, as defined above, within six years immediately preceding the commencement of this case. A debtor who has not been

in business within those six years should go directly to the signature page.)

_____________________________________________________________________________________________________

19. Books, records and financial statements

None a. List all bookkeepers and accountants who within two years immediately preceding the filing of this

bankruptcy case kept or supervised the keeping of books of account and records of the debtor.

NAME AND ADDRESS DATES SERVICES RENDERED

________________________________________________________________________________________________

None b. List all firms or individuals who within two years immediately preceding the filing of this bankruptcy

case have audited the books of account and records, or prepared a financial statement of the debtor.

NAME ADDRESS DATES SERVICES RENDERED

_____________________________________________________________________________________________________

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9

None c. List all firms or individuals who at the time of the commencement of this case were in possession of the 

books of account and records of the debtor. If any of the books of account and records are not available, explain.

NAME ADDRESS

________________________________________________________________________________________________

None d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a

financial statement was issued by the debtor within two years immediately preceding the commencement of this case.

NAME AND ADDRESS DATE ISSUED

________________________________________________________________________________________________

20. Inventories

None a. List the dates of the last two inventories taken of your property, the name of the person who supervised the

taking of each inventory, and the dollar amount and basis of each inventory.

 DOLLAR AMOUNT

OF INVENTORY

DATE OF INVENTORY INVENTORY SUPERVISOR (Specify cost, market or other

basis)

____________________________________________________________________________________________________

None b. List the name and address of the person having possession of the records of each of the inventories reported

in a., above. 

NAME AND ADDRESSES

OF CUSTODIAN

DATE OF INVENTORY OF INVENTORY RECORDS

____________________________________________________________________________________________________

21 . Current Partners, Officers, Directors and Shareholders

None a. If the debtor is a partnership, list the nature and percentage of partnership interest of each member of the 

partnership.

NAME AND ADDRESS NATURE OF INTEREST PERCENTAGE OF INTEREST

______________________________________________________________________________________________________

None b. If the debtor is a corporation, list all officers and directors of the corporation, and each stockholder who 

directly or indirectly owns, controls, or holds 5 percent or more of the voting or equity securities of the 

corporation.

NATURE AND PERCENTAGE 

NAME AND ADDRESS TITLE OF STOCK OWNERSHIP

__________________________________________________________________________________________________

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22 . Former partners, officers, directors and shareholders

None a. If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately

preceding the commencement of this case.

NAME ADDRESS DATE OF WITHDRAWAL

___________________________________________________________________________________________________

None b. If the debtor is a corporation, list all officers or directors whose relationship with the corporation terminated 

within one year immediately preceding the commencement of this case.

NAME AND ADDRESS TITLE DATE OF TERMINATION

___________________________________________________________________________________________________

23 . Withdrawals from a partnership or distributions by a corporation

None If the debtor is a partnership or corporation, list all withdrawals or distributions credited or given to an insider,

including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite

during one year immediately preceding the commencement of this case.

NAME & ADDRESS AMOUNT OF MONEY 

OF RECIPIENT, DATE AND PURPOSE OR DESCRIPTION

RELATIONSHIP TO DEBTOR OF WITHDRAWAL AND VALUE OF PROPERTY

___________________________________________________________________

24. Tax Consolidation Group. 

None If the debtor is a corporation, list the name and federal taxpayer-identification number of the parent corporation of any

consolidated group for tax purposes of which the debtor has been a member at any time within six years

immediately preceding the commencement of the case. 

NAME OF PARENT CORPORATION TAXPAYER-IDENTIFICATION NUMBER (EIN)

_____________________________________________________________________________________________________

25. Pension Funds. 

None If the debtor is not an individual, list the name and federal taxpayer-identification number of any pension fund to

 which the debtor, as an employer, has been responsible for contributing at any time within six years immediately

preceding the commencement of the case.

NAME OF PENSION FUND TAXPAYER-IDENTIFICATION NUMBER (EIN)

* * * * * *

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11

[If completed by an individual or individual and spouse]

I declare under penalty of perjury that I have read the answers contained in the foregoing statement of financial

affairs and any attachments thereto and that they are true and correct.

Date __________________________ Signature

_____________________________________________

of Debtor

Date __________________________ Signature_________________________________________ 

of Joint Debtor

(if any)

__________________________________________________________________________________________________________________________

[If completed on behalf of a partnership or corporation]

I declare under penalty of perjury that I have read the answers contained in the foregoing statement of financial affairs and any attachments

thereto and that they are true and correct to the best of my knowledge, information and belief.

Date __________________________ Signature

__________________________________________________

_________________________________________________

Print Name and Title

[An individual signing on behalf of a partnership or corporation must indicate position or relationship to debtor.]

____ continuation sheets attached

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571

___________________________________________________________________________________________________

DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)

 I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for

compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. §§ 110(b), 110(h),

and 342(b); and, (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services chargeable by

bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting

any fee from the debtor, as required by that section.

_____________________________________________________ _____________________________

Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer Social-Security No. (Required by 11 U.S.C. § 110.)

If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social-security number of the officer, principal,

responsible person, or partner who signs this document.

________________________________

_________________________________

Address

X _____________________________________________________ ____________________

 Signature of Bankruptcy Petition Preparer Date

Names and Social-Security numbers of all other individuals who prepared or assisted in preparing this document unless the bankruptcy petition preparer is

not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in

fines or imprisonment or both. 18 U.S.C. § 156.

Print Name and Title

Address

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2

2. Income other than from employment or operation of business

None State the amount of income received by the debtor other than from employment, trade, profession, operation of the

debtor's business during the two years immediately preceding the commencement of this case. Give particulars. If a

joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13

must state income for each spouse whether or not a joint petition is filed, unless the spouses are separated and a joint

petition is not filed.)

AMOUNT SOURCE

_____________________________________________________________________________________________________

3. Payments to creditors

Complete a. or b., as appropriate, and c. None

a. Individual or joint debtor(s) with primarily consumer debts: List all payments on loans, installment purchases of

goods or services, and other debts to any creditor made within 90 days immediately preceding the commencement of

this case unless the aggregate value of all property that constitutes or is affected by such transfer is less than $600.

Indicate with an asterisk (*) any payments that were made to a creditor on account of a domestic support obligation or

as part of an alternative repayment schedule under a plan by an approved nonprofit budgeting and credit counseling

agency. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses

whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) 

NAME AND ADDRESS OF CREDITOR DATES OF AMOUNT AMOUNT

PAYMENTS PAID STILL OWING

______________________________________________________________________________________________________

None

G b. Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor made

within 90 days immediately preceding the commencement of the case unless the aggregate value of all property that

constitutes or is affected by such transfer is less than $5,475. If the debtor is an individual, indicate with an asterisk (*)

any payments that were made to a creditor on account of a domestic support obligation or as part of an alternative

repayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency. (Married

debtors filing under chapter 12 or chapter 13 must include payments and other transfers by either or both spouses

whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR DATES OF AMOUNT AMOUNT

PAYMENTS/ PAID OR STILL

TRANSFERS VALUE OF OWING

TRANSFERS

________________________________________________________________________________________________

✔

Toyota - P.O. Box 8026 - Cedar Rapids, IA

75266

Aug, Sept,

Oct. 2009 $1,377 total $12,226.38

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