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

Name of Debtor (if II1dlvlduaL enter Last, First Middle) 

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

(include married, malden, and trade names): 

Last four dlgJls of SOC Scc 

(if mare than one, state all) 

Street Address of Debtor (No and Street, City, and Stat

County of Residence or of the PrinCipal PlacL' of Busme

tvhullng Address of Debtor (if ditferent Irom street addr

Type of Debtor 

(Form of Organization) 

(Check one box) 

0 IndiVidual (Illcludcs .I0lllt Debtors) 

See Fxhiblf D on page 2 of rllfsfoJ'III, 

[J Corporation (Illcludes I.I.C and LLp) 

[J Partnership 

0 Other (I f dehtor IS not one of the ahove entilies, 

check this box and state type of entity below) 

Filing Fee (Ch~ck one bo

0 Full Filing Fcc attached 

0 Filing Fee to be paid in installments (applicable to 

unable to pay fee e,xcept in Installments. 

0 Filing Fee \\alver requested (applicable to chapter 

attach signed applicalion for the court's considera

StatisticallAdministrative Information 

0 Debtor ~still1ates

0 

distribution to unsecured creditors, 

[slimated Number of Creditors 

0 0 0 0 

1-49 51!-99 100-199 21!O-999 

Estimated Assets 

0 0 0 0 

$0 to $50,00 I to $100,001 to $500001 

$50,000 $\00000 $500,000 to $1 

million 

Estimated Liahil ities 

0 0 0 0 

$0 to $50,001 to $100,001 to $500,001 

$50000 $100,000 $500,000 to $1 

millIOn 

tion 

e) 

ss 

ess) 

x) 

indiViduals only), 

7 II1dividuals only), 

llnited States Bankruptcy Court 

or Indvldual-Taxpayer I.D (ITIN) No/Complete EIN 

Illp CODE I 

!ZIP CODE I 

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

Nature of Business 

(Check one box) 

0 Health Care Business 

0 Single Asset Real Estate as defined 111 

11 lJ SC 101(5113) 

0 Railroad 

0 Stockbroker 

0 Commodity Broker 

0 Clearing Bank 

0 Other 

Tax-F:xempt Entity 

(Check box, Ifapplieable,) 

0	 Debtor IS a tax-exempt orgal1lzatlon 

under Title 26 ofthe United States 

Code (the Internal Revcnu~ Code) 

Must attach 

signed application for the court's consid~ration certifying that the debtor is 

Rule I006(b) See Ol1lcial Form JA. 

Must
 

See Official Form JB
 

Voluntary Petition 

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

All Other Names used by the .Iomt Debtor 111 Ihe last 8 vears
 

(indude married, malden, and trade names)
 

Last four digils of Soc, Sec, or Indvldual-Taxpayer I D, (lTlN) No IComplete EIN 

(if more than one, state all) 

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

Illp CODE I 

Countv of ReSidence or of the Principal Place of Business 

Mailing Address of Joint Debtor (Ifditferent Irom street address) 

VIP CODE I 

ILIP CODE I 

Chapter of Bankruptcy Code Iinder Which 

the Petition is Filed (Check one box) 

0 Chapter 7 0 Chapter 15 Petition for 

0 Chapter'i Recognition of a Foreign 

0 Chapter I I Mam Proeeedmg 

0 Chapter 12 0 Chapter 15 Petition for 

0 Chapter IJ Recogl1ltlon of a Foreign 

Nonmaln Proceeding 

:'oiature of Debts 

(Check one box) 

0	 Debts are pnmarily consumer 0 Debts arc pnmaril) 

debts, defined In 11 lJ SC busllless debts 

101(8) as "lIlcurred by an 

individual pnmarily for a 

persona!, family, or household purpose," 

Chapter II Dehtors
 

Check one box:
 

0 Debtor is a small business dehtor as defined in 11 U SJ' II! I(51 D)
 

0	 Debtor is not a small bUSiness debtor as defIned 111 II USC 101(510) 

Check if: 

0 Debtor's aggregate noncollllngent liquidated dehts (excluding dehts ow~d to 

Insiders or affiliates) are less than $2, 190/JOO 

-----------------------------._---­

Check all applicable boxes: 

0 ;\ plan IS bell1g fi led With thiS petition 

0 Acceptances ofthe plan \\ere sollclt~d preJl~tJll()n l'roll1 on~ l)r more classes 

or creditors, 111 accordance With I IUS C I 120(b) 

THIS SPACE IS FOR 

COI!RT liSE OI'iLV 

that funds will be available t(lI distribution to unsecured creditors, 

D~btor estJlllatcs that, after any exempt property IS excluded and administrative expenses paid, there will be no funds available for 

0 0 0 

10,001- 25,001- 50,001- Over 

SO,OI!O 100,000 100,000 

0 0 0 

$50,000,00 I	 $100,000,001 $500,000,00 I More than 

to $500 to $1 billion $1 billion 

million 

0 [J 0 

$50,000,001	 $100,OOO,C)O! $500000,00 I MlHe than 

to $500 to $1 billion $1 billion 

million 

0	 0 0 

1,000- 5,001­

5.000	 10,000 25,000 

0	 0 0 

$1,000,001 $10,000,00 I 

to $10 to $50 to $100 

million millIOn million 

0 0 [J 

$1,000,001 $10,000,00 I 

to $10 to $50 to $100 

million 11111110n 111 III Illil 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 1 of 38
B I (Official Form 1) (1/08\ 

Date Filed
 

Datc Filed
 

Voluntary Petition 

(This paR~ must be completed andfiled 111 ever}' case.) 

Name of DeblOr(s) 

All Prior Bankruptcv Cases Filed Within Last 8 Years (If more than t

Location Case Number' 

Where Filed 

Location Case Number: 

Where Filed 

Name ot' Debtor Case Number 

DIstrICt. R~lationship

Exhibit A 

(To be completed if debtor IS r~quired to file periodic reports (e.g., forms 10K and 

11IQ) 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.) L the altorn~v

12, or 13 of titl

D ExhIbit A IS attached and made a part of this petition. X 

Exhibit C 

D Yes, and Exhibit Cis attaclled and made a part of this petition 

D No 

Exhibit D 

D Exhibit D completed and signed by the debtor is attached and made a part of t

[f th is is a joint petition: 

D Exhibit D also completed and signed by the joint debtor is attached and made 

Information Regarding the Debtor - Venue 

(Check any applrcable box) 

D 

preced1l1g thc date of this petition or for a longer part of such 180 days than in any other 

D There is a bankruptcv case concerning debtor's affiliate, general partner, or partnership p

D D~btor

thiS District. or the Interests of the parties will be scrved In regard to the rei let sougbt In 

Certification by a Dehtor Who Resides as a Tenant of Resid

(Chec~ all applicable boxes) 

[J I,andlord bas ajudgment against the debtor for possession otdebtor's residence. 

(Address of landlo

D 

entire monctary default that gave rise to the Judgment for possession" alter the Judgme

D 

filing of the petition 

D Debtor certifies til at helshe has scrved the Landlord witb this ccrtification (11 lJ S C 

his petition. 

a part of this petition, 

tillS DistrICt. 

wo, attach additional sh~et)

e 

District 

ending in thiS District 

ential Property 

rd) 

nt for posseSSlllil was cntered, and 

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

Date Filed 

Judgc 

Exhibit B 

(To be complekd if debtor is an 1I1divldual 

whose d~bts are primarily consumcr debts) 

for th~ petitioner named in the foreglling petition, declare that I 

have informed the petitioner that [he or she I may procced under ehaptcr 7 I I 

II. United States Code, and have explained the relief 

available under each such chapter: I further ceItlfy that I have dell\ered 10 the 

debtor the noUce reqUIred bv II USC 342(b) 

Signature of Attorney for Debtor(s) (Date) 

Does the debtor own or have possession of any property that poses or IS alleged to pose a threat of Immincnt and identifiable harm to publiC health or safetv" 

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

Debtor has been domiciled or has had a reSIdence, principal place of business, or principal assets in this DIstrict for 180 day s immediately 

IS a debtor In a foreign proceedIng and has its prInCipal place of business or pnnclpal assets in the United Statcs In this DistriCt. or 

has no prIncipal plac~ of busll1ess or assets in the Unitcd States but IS a defendant III an action or proceeding 1m a federal or state court[ m 

(If box chee~ed, complete thc followlllg.) 

(Name of landlord that obtained Judgment) 

Debtor dallns that under applicablc nonban~ruptcy law, there arc Clrcumstanecs under which the debtor would be permitted to cure tile 

Debtor bas included with this petition the depOSit with the court of any rent that would become due during the 30-day pmod alter tbc 

362(1)) 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 2 of 38
---------------

---

B I rOlllClol Form\ I (I /1I81 Pagt .~

\'oluntar~ Petition 

Jennifer R. Farrales (JllIs !H..I~t' ///11."1 ht' (Oll/p/ell'" and filed /11 t'l't',.,,, cust!) 

Sign.ltllH'S 

Signaturc(s) iJf Ill-htor(s) (Individual/Joint) 

I J~(I~Irl' ullJl<r r...'11JIL\ uf f"-.'rfur\ that tflL' InformJ[IOn rro\ I(k·J III this Pl'liliun I.~ li'tll 

,11lJ (lHrl'([ 

[If P\.'llll(Hll'l' h ;ill lt1dl\ IduJI \\ Ill))l' J\,.'ht." ~Ir,-' rml1l:Jrlh lon.WIlWf dd~h ,Jnd Ild,)
 

L'lhbt.'11 (() tile under d1~1rlc'r 71 I alll J\\<.lrl: tll"lll ma\ procC'\,.'d unJc-f chZlplcr 7, I] 1::­


or 1301 [ilk II ("lIIed SW[c; (·()de. llnderswnd the rellel·~I\'LlI.lble under tJeh >1,,1)
 

chi.1r(t:[ ,1110 ,~jll)O:-'\.· 10 procc'c'd 1IIlJ'('r ck1r1r..'r 7
 

[Ifnn ~ltIl.lrllc'~ rl';1I-CsCtll~ 1l1L' dlld IlO h:-I:l~rl.lrl\.'~ [1.2ll[IOI1 rrCrnrL'f Slf:.llS till' rt:t11IllI11
 

h:l\t: (lbi,llllI.:J dlld [\..'<.-:\..1 till' 1l1Jllu: [eLjtJlll'J \1\ l S C )-1~(L')
 

I reqUe~l rl-~llct In ,11-\:()rOUlh':e \\Itll :hc (]Upll.'l \"ll' UtI--' II, Illt('d Slatl'~ ('(ldl', 

')PC(It'ICO III thiS pl'lltlOn 

\ 

\ 

I ('L.Thlil~( 1I1ll[l:.:'r {I' 1~\ll r\..·pr(,~('llk\..J ll\ dllul"Ill'\)
 

1;.'/J1,:1J9
 

D,Hc'
 

Sigllaturc of .... ttorne~·
 

Steven E. Barleben /s/ 

~1<~ll~llllrt" OJ:\tllHI1L'\ (PI ])ehlllrbi
 

"'Steven E, Barleben
 ----_._~

Prlnled ~~11lle' or ,\tll\fIlL'\ 1m Dt"~t()fl")
 

LClW Offtce of Steven E BarlebeTi
 ~'-------------

FIrm !\, ~1I11L'
 

3830 N Ashland Ave
 

AclJll':,:-' 

Chicago, IL 60613 

(773)665-7523 

Tekp[w)~t' i\ lIrnhcr 

12/31/09 

Oa;(' 

·'11 i.1 (,lS...' 111 \\hl(h 7{)/(h)(..;.)\LJ) Clppllc" tlll~ "Ign,tlure abn l.'OIl~lllLllc''' ~\

l'l'fll:I .. '-lllll.ll1,l(l1. l:ll' .11[(1["11<...'\ hel) 11U h,llll\\kcl~(,~lT'll'fan II'qUII:' lhilt lhl' Illtllflll,ltl()11 

111 I ill' ~(llcJlIk>\, 1-"; Ilkorrl'(l 

.'-,il:!nalun' of [)(.'htor (f'l)rfloration/P:lrlll('r,~hir)

I l1c'('ltHl' L,llckr f"t'J1dll\ nr pl'r 1L1f\ tlut tilL' lllll)fIlla[IOII f~ro\ IJed III 1I1i:-' petition 1;-, IruL' 

:1110 (d{leCI ,1!ld [h,ll I 11:1\l" hc'c'lI ,1ulhorl/cd tl) fik till:' pt:tlllOll Oil h-.:I:Jlf ClI" tilt' 

Jcb~or

rht' (kl)llH requl";!"" (1)(' rc'llc'l 111 ,1CI.·()rJ~\lKl' \\11\\ the l.'hnp[e'r oftltk 11 linl:('J SIJtc::' 

COtic "r'(XII ic'd II' rctltJOll 

PrllliL'J Nallll' u! AlIlhnllI.L'd Illdl\lduJ.] 

Da'.e 

Signatun' of a Fonign H.l'IJrl","il"lllali\ L' 

l '.\(,:I.1f<.:' u:1J,-'r r\:'n;jll~ l)l Ilcl'llIf\ [fl,\[ 111'-' 111!1)fITI;JII()I" [11'0\ IJI-'d Ii) 'hi,') pCllll,)I1I" Lf,I,-' 

,JIlL! '~IlIIl-·(\. til,lll <!Ill tl1,-' r(lrel~J1 iCf'rC'l,-'llldll\l' pI ,I dl-'!I:(1[ II' ,I IllII-'I~1l r'lt11-',-'('J:;1; 

,1I1d 1,ll,lt I ,1m ,1lIllwrlh..\.1 ttl rlk lh: ... rCl:IIUll 

D I le'qUl':.,t fl'!Jet' 1;-1 ;l(mJ:lll(c \\ 1:11 I-ll.1pkl I ut wk' I I I 11Il1'J ~llih':-' ('udl' 

('l'l tll-J,~>d "':l)['ll.-''> ill lh( JUUIIYh.'lll" r'I-'tllI ;I',~'J h: ] I l S (' \: I -) I ..;: (J,,-, dll,j()J,,'o 

'~ PUI,'>L1Jrilln II \ ~~. " 1)11 1[·-·\..llII-'-";[ rl-'I'l'I'\11 ,i,-\.(lrJ'-llll..,\: \\Ill: llh' 

~hllr'\ll.:'r ol111k ] SrcCI!'k'J III 1111, pl-'lllll1ll ,\ L'cr'tlj"lcJ \..e1['\ l)l'lh,-' 

L)f,lL'r gr,lllllw~ ITl'I):;lilllon llillh' IMl",:::;n 111.1111 P:llll.'(Jlll~! ','> ,1\\;lC:lL'l.] 

.. _~~~---~--~----------

(Sign,-ltllfe orForelgn f{cprL'Selll,ltl\cl 

~i~llalun' of ;\'011- \ttorrl(.'~ Bankrllrtc~ Pl'tililHI Pn:,p.,n'l' 

J dc',j~Hc under !1c'n,llly or p,'rjul\ \h~ll (i I I ,1111 ,I Il,lllh,r(,r~IL \ f!l'tllll)[l PI'l'!';:IL'r ,h 

JdlllL:J In 11 l C \ lin. 12) J rrl.:'p,Jr\:'d tillS J\lI..Unh.'I~1 1\11 l(lmf~l')hdtlllil ;111d hel\,-' 

prO'IJeJ the' uebtor \',Itll d ,-OP\ ur till:' J\!l'lIllll'llt .\llL! 111<: 1'(l[IL(:, ;111J 1111orl1l;\l.I(I:l 

requlrc-d Linder 1\ USC 0~ 111J(hl. I :(J(l1l. ..111J 3-1~(b), ,jill; I~) I~ lUlL':, O! 

gUlJt' IIll':'; h:l\l' heell prnll";ulgJll'O pU''''U'illlIO 11 L' l' '1;II!lJ '-t'tl::lg :1 I1ld\ IIllll 111 

k,-' 1'(11" "\..'[\1(',-'" l'h:Hgl-'llhlc 1'\ h~llllrurk\ ["L'[ltll1:l!'rl'p,II,-'r:, r Il.\\l:' ;;'\l'll \'IL' J('blP! 

Il()[I~'l' ll!'llh' 111:1\ IIIIIII: 1 ,111hHlnl bl'(lll'l' ;1r<\lrlJl~: ,111\ ,jno"l"\'llllI11 1IIIn:' j!H:1 Jl'hllH 

()I -!\..(L'll l111!::'- ,111\ t'l'': j'ltllll the J\..'hlll1 ~I" Il"lulrl-,]llllJL.l ,C'~\hJ:l (l:J ll,11 I (lilil II) .., 

illtcKIl:d 

~()CI'll-Sl'l.'llrll: Ilumbt:r (lr the' hallhllptl" fk'llll,)11 prq),Hl'[ ,..., IHH ~'111 IIIJI\ Idll,il 

;-.(<1((' th(' ~Lll~lJ!-S~CUflt\ nllmhlT lIl' till' llltll'cr, pnlll-'lli:J] Ti.'''plll:.... l,rlc' r'h.'r',>n!l ()I 

r';lrlne'r ul'lile' 11,lllf.-rurk'\ pL'lll:(l[l prl.'Q,If ...·r ) (R'-'ljllF-..:'d by I] I ..; C -;: I .' 

:\ 

SI~llcllll["..., nrb~IJ1l-.rllpl~~ Pl'1111011 pr'.'(lJrr.'i (If olllLl'r Pllll(lr'; I )\..'-'P(llhlbk l'cr'>l'Ill, pi 

)).11-1'1'-.'1 \, ilU~l' ~Lf,'I,]I-~l'nHlt\ I'umhcl I.~ 11lll\IJlJ ~Il)\)\. ,~'

Ndllll-'~ ~jllJ ~(l', lcll·~t'l'llflt\ I'Limbl'l~ ('It ,)'] (,lhl'! l'lJr, IJudh \\]IU rrqiiJf\..'J (II .:<':'IISll'd 

111 Ilrq\HIIl~' ll1',> dnCUllh:111 un Ie"" th...' \iJnl!llpli..'\ ik'llLilll' Ilr,.'pJIl·1 I" 11(ll all 

Illdl\, IdU:11 

If mnrL' than 0111-' r,-'r<;O:l prqxlfcd til'::" dOL:UJlh:Jil ,lltdl h .\,JJI' O:LII ....11\..'l'l) ~'(lllltJrlllrn:.'

to tile ClI,ptllpllJlC ol'Cl(la[lorrJllur l'Jcl~ rt'r"llil 

I hunAril/Jh:\ /JelilW!I /ire/JUrel' 'l'iO/IIIII' /(J (oil/ph 'oIlfll the I)/'U\'"I')J/I' (If II/if i I (lilt! 

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/'Il,!);'./ " .' I / (! /,~ ( ,'). (" ) i " (; 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 3 of 38
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.

’ 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. 

’ 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.

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 4 of 38
B 1J) (Official Form I. b;l1, D) (1~/O9) - Cant. 

03. I cCl1ify that I requested credit counseling services from an approved agency but 

was unable to obtain the services during the sevcn days from the time I made my rcquest and the 

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

so I can file my bankruptcy case now. (')ummarize exigent circUlI/stances here.) 

Ifyour 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. 

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

applicahle statement.] [Must he accompanied hy a motion/or determinotion bv the court.) 

['] Incapacity. (Defined in II 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.); 

o Disability. (Defined in 11 U.s.c. § 109(h)(4) as physically impaired to the 

extent ofbcing unable. after reasonable effol1. to participate in a credit counseling 

briefing in person. by telephonc. or through the Internet.); 

o Activc military duty in ,) military combat zone. 

05. The United States trustee or bankruptcy administrator has detcrmined that thc credit 

counseling requirement of 11 U.s.c. §) 09(h) docs not apply in this district. 

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

correct. 

Signature 0 f Debtor: __(-+1-/1-,,-(',---"I_._~_L_li_P_,_.r'_' _ fjf, 

Date: 12/31/2009 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 5 of 38
B6 Summar) (OffiCial Form 6 - Summary) (12/07) 

United States Bankruptcy Court 

Northern District Of Illinois 

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 li'om Schedules A. H. D. L. F. I. 

and J in the boxes provided. Add the amounts from Schedules A and 13 to detcrmine the total amount of the debtor's assets. Add the amounts of all 

claims from Schedules D. F.. 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. II. or 13. 

:\AME OF SCHEDlLF: 

ATTACHED 

(YES/NO) 1\0. OF SHEETS ASSETS LIABILITIES OTHER 

i\ - Real Proper!\ $ 

B - Personal Pro pert) $ 

C - Property Claimed 

as Exempt 

0- Creditors Hold111g 

Secured Claims 

$ 

E - Creditors Holdmg Unsecured 

I'rJor;t\ Claulls 

(Total ot'C.'lamls on Schedule F) 

$ 

F - Creditors Hold111g Unsccurcd 

~onpnorlt: Clall11s 

$ 

G - Executory Contracts and 

Unexpired Leases 

H - Codebtors 

J - Current Incomc of 

Ind"'ldual Dehlor(s) 

$ 

.I - Current Expenditures of Individual 

Dehtors(s) 

$ 

TOTAL $ $ 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 6 of 38
Form 6 - Statistical Summary (12/07j 

United States Bankruptcy Court 

Northern District Of Jlljnois 

In rt: _ Cast: No. _ 

Dt:btor 

Chapter _ 

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

II' you are an individual debtor whose debts are primarily consumer debts. as defined in § ]() I(8) of the Bankruptcy Code (I I U.s.c. 

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

o Check this box if you are an individual debtor whose debts are NOT primarily consumer dcbts. You are not required to rcport an) 

infomlation 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 Govemmental Units 

(from Scheduk L) 

$ 

Claims for Death or Personal Injury While Debtor Was 

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

$ 

Student Loan Obligations (from Schedulc F) $ 

Domestic Support. Separation Agreement. and Divorce Decree 

Obligations Not Reported on Schedule ,. 

$ 

Obligations to Pension or Profit-Sharing, and Other Similar 

Obligations (trom Schedule F) 

$ 

TOTAL $ 

State t he 0 IIowmg: 

Average Income (trom Schedule L Line 16) $ 

Average Expenses (trom Schedule J. Line 18) $ 

Current Monthly Income (ti'om Form 22A Line 12: OR Fom] 

228 Line II: OR Form 22C Line 20 ) 

$ 

Sta e t the f0 11OWIO!!:: 

I. Total from Schedule D, "UNSECURED PORTION, IF 

AN'\''' column 

$ 

2. Total from Schedule E. "AMOUNT ENTITLED TO 

PR10RlTY" column. 

$ 

3. Total from Schedule I. "AMOUNT NOT ENTITLED TO 

PRIORITY, IF ANY" column 

$ 

4, Total from Schedule F $ 

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

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 7 of 38
B6A (Official Form 6A) (12/07)
 

In re _ Case '\0. _
 

Debtor (If known) 

SCHEDULEA-REALPROPERTY 

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 whieh the debtor holds rights and powers exercisahle for 

the debtor's own henelit. If the dehtor is married. state whether the husband. wife. hoth. or the marital community own the property hy placing an "'H." 

"'W:' "'.I." or "C" in the column laheled ··Hushand. Wit\:. Joint. or Community,'" If the dehtor holds no interest in real property. write "None'" under 

"Description and Location 0 r Property:' 

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

llncxpired Leases. 

Ifan entity claims to have a lien or hold a secured interest in any property. state the amount of the seeured claim. See Schedule D. Ifno entity claims 

to hold a secured interest in the property. write '"None'" in the columnlaheled '"Amount of Secured Claim:' 

If the dehtor is an individual or ifajoint petition is tiled. state the amount ofany exemption claimed in the property only in Schedule C - Property 

Claimed as Exempt. 

DESCRIPTIOi' Ai'D 

LOCATION OF 

PROPERTY 

:"ATlIRE OF DEBTOR'S 

INTEREST I!\ PROPERTY 

....:­

:z 

Qj;; 

~~

- :E: ~:E: -0

<::> <....> 

..,., 

~~=> 

= 

CURRENT VALl:E 

OF DEBTOR'S 

INTEREST I:" 

PROPERTY, WITHOll'f 

DEDt:CTI:"G ANY 

SECl:RED CLAI"I 

OR EXEI\IPTlO\l 

AMOlI\TOF 

SECIIRED 

CLAI,"I 

Total~

(Report also on Summary of Schedules.) 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 8 of 38
868 (Official Form 68) (12/07) 

In re _ Case :'\in. _ 

Debtor (If known) 

SCHEDULE B - PERSONAL PROPERTY 

Fxcept as directed below. list all personal property ofthe debtor ofwhatever kind. Ifthc debtor has no propel1y in one or more ofthe 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 

identificd \\ith the case name. case number. and the number of the category. II' the debtor is married. state whether the husband. wi fe. hoth. or the marital 

community own the property by placing an '"[I." '"W:' ".1:' or "C" in the column labeled '"I1usband. Wife. Joint. or Community."' If the debtor is an 

individual or ajoint petition is liled. state the amount of any exemptions claimed only in Schedule C - Property Claimed as Exempt. 

Do not list interests in executory contracts and unexpir'ed leases on this schedule. List them in Schedule G - Executor), Contracts and 

li nexpir'ed Leases. 

If the property is being held lor the debtor by someone else. state that person's name and address under "Description and Location of Propcrty:' 

If the property is being held for a minor child. simply state the child's initials and tile 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 namc. Sec. II U.S.c. ~112 and Fed. R. 13ankr. P. J007(m). 

TYPE OF PROPERTY 

I Cash on hand 

2 Check mg. savings or other finan-


Cial accounts. certificates of deposit
 

or shares in hanks. savings and loan.
 

thrift. huild1l1g and loan. and homestead assoclanons. or credit unions.
 

brokerage houses. or cooperatives.
 

3. Security deposits with publiC utilities. telephone companies. landlords. and others.
 

4. Household goods and fUrJlIShmgs.
 

including audio. video. and computer
 

equipment.
 

5. Books: pictures and other an
 

oblects: antiques: stamp. com.
 

record. tape. compact diSC. and other
 

collections or collecnbles
 

6 Wearing appard 

7 Furs and Jcwelr\ 

8 Firearms and sports. photographic. and other hobb\' equipment.
 

9 Interests m insurance poliCies 

Name lIlsurancc company' of each 

pollcv and itemize surrender or 

refund value of each 

10. Annuities. Itemize and name
 

each Issuer.
 

II. Interests in an education IRA as 

defined in 26 USC 530(b)( I) or under 

a qualilled State tuition plan as defined in 

26 U SC 529(b)(I) Give particulars 

(File separately the record(s) of an\ ,"ch 

Interest( s) 11 USC ~521(c))

N 

0 

:'i 

E 

DESCRIPTION AND LOCATION 

OF PROPERTY 

~~3=% ::> 

g~«0'"' ..... 

~~

CTRRE:\T VALUE OF 

DEBTOR'S INTEREST 

IN PROPERTY, WITHOF" DEIKCTlNG ANY 

SEClIREIJ CLAL'" 

OR EXE:'ttl'T10:\ 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 9 of 38
B6B (Official Form 6B) (12/07) -- Cont. 

In re ,---- ' Case '\0. _ 

Debtor (If known) 

SCHEDULE B-PERSONAL PROPERTY 

(Continuation Sheet) 

TYPE OF PROPERTY 

12. Interests in IRA. ERISA, Keogh. or 

other pension or profit shaflng plans. 

Give particulars 

13 S[()ck and interests in Incorporated 

and unincorporated businesses 

IlL'mlLe 

14. Inlerests In partnerships Oflolnt 

ventures. ltemiLe 

15. Government and corporate bonds 

and other negotiable and nonnegotiable instruments 

16. Accounts receivable 

17 Alimony. maintenance. support, 

and property settlements to \Vh ich the 

debtor is or may be entitled Give 

particulars 

IR. Other liqUidated debts owed to 

debtor 111cluding ta" refunds. Give 

particulars 

19. Equitable or future interests. lite 

estates, and fights or powers e"erclsable 

for the benefit of the debtor other than 

those listed 111 Schedule i\- Real 

Property. 

211. Contingent and noncontl11gent 

I11terests In estale of a decedent. death 

benefit plan. Ilti: Insurance policy. or trust 

21. Other contl11gent and unliquidated 

claims of every nature. I11cl uding ta" 

refunds, counterclaims of the debtor, and 

fights to setotT claims Give estimated 

value of each. 

'\ 

0 

'\ 

E 

DESCRIPTION AND LOCATION 

OF PROPERTY 

!i 

~i:;

~~

fil 

40""u 

~~

Cl 'RRE'JT VALlE OF 

DEBTOR'S I:'iTEREST 

IN PROPERTY, WITU011'1 DEIWCTING ANY 

SECliRED CUI't 

OR EXEMPTIO,\ 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 10 of 38
B6B (Official Form 6B) (12/07) -- Cont. 

In re _ Case No, _ 

Debtor (Ifknown) 

SCHEDULE B-PERSONAL PROPERTY 

(COllfinualiol1 Sheet) 

TYPE OF PROPERTY 

N 

o 

N 

E 

DESCRIPTIO" A"D LOCATION 

OF PROPERTY 

ClRREIH \'\LUE OF 

DEBTOR'S '''TEREST 

I" PROPERTY, WITHOIIT DEDl'CTI'\G A:\'Y 

SEClRED CL.\I\I 

OR EXEMPTIO" 

22 Patents. copynghts, and other 

intellectual property Give particulars 

23 Licenses, franchises, and other general 

IIltanglbles GIVC particulars 

24 Customer lists or other compilations 

contalll ing personally Identifiable 

mformaunn (as defined III II USC 

101 (41 A») provided to the debtor by 

IndiViduals in connection with obtainmg a 

product or semce from the debtor 

prllnarily for persnnal, family. nr 

househnld purposes 

25. Autmnoblks. trucks, trailers, 

and other vehicles and accessones 

2h Boat~, motors. and JCLLSSorics. 

'27 AlfCruft and acceS~Oflc:S

28 OffIce eqUipment. furlltshlllgs, 

and supp! ies 

29. Machll1ery. ft'\tures. equipment. 

and supplies used III busllless 

30 Ill\clltm, 

31 Annnals 

32 Crops - growing or harvested. 

Give particulars 

33 Fannll1g equipment and Implements 

34 Fann supplics, chemlc'lls, and fecd 

35 Other persnnal property of all\ killd 

not alreadv listed Itemlzc 

_____contillualion shcets attached Total" $ 

(Include amounts from an~' cont1l1Uatlon 

sheets attached Report total also all 

Summary of Schedules) 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 11 of 38
B6C (Official Form 6C) (12/07) 

In rc _ Case '110. _ 

Debtor (Ifknown) 

SCHEDULE C - PROPERTY CLAIMED AS EXEMPT 

Debtor claims the exemptions Lo which debtor is entitled under: o Chcck if debtor claims a homcstead cxcmption that cxcecds 

(Check one box) $136.875. 

o II USc. 9522(b)(2) 

o II us.c. 522(b)(3) 

DESCRIPTIO:\ OF PROPF:RTY 

SPECIFY LAW 

PROVIDING F:ACII 

EXEMPTION 

VALliE OF 

CLAIMED 

F:XHIPTION 

ClJRRF:Nl 

VALliI' OF PROPERTY 

WITH()lIT DF:DlICTlNG 

EXF:MPTlO:\ 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 12 of 38
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 dale of tiling 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 hokling 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 chi Id. by John Doe. guardian." Do not disclose the child's name. See. II U.s.c. §112 

and Fed. R. Bankr. P. 1007(m). Ifall secured creditors will not tit 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. lfajoint 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 "I lusband. WifC. 

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 trom 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, iI' Any" on the Statistical Summary or Certain Liabilities and Related Data. 

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

CREDITOR'S NAME AND ..l DATE CLAI!\1 WAS E- ... ;.. 

O AMOUNT OF CLAIM

MAILJ"IG '"" ADDRESS IX ~IXE- INClIRRED, Z E- O WITHOl'T 

I"ICLUDING ZIP CODE AND 0 0- "I ATCRE OF L1E"I , '"" E- DEDUCTING VALUE o"'E-""~ (J 0 EAN ACCOl!NT NUMBER AI\D Z -;., ;., OF COLLATER\L

'"" ~~a f- Q.,

(See instructions Above.) 0 DESCRIPTIOI\ 0- ~'

0 ~O~ z :J 

I '-' !J)~"- AI\D VALliE OF 0 0 

PROPERTY I.i 7-

::c ;., 

Sl"B.JECT TO L1E"I 

ACCOUNT NO. 

VALUE S 

ACCOUNT NO. 

V:\LlIE $ 

ACCOUNT NO. 

r VALL:ES 

continuation sheets Subtotal $ 

I'NSECliRED
 

PORTlOI\, IF
 

A"IY
 

I 

$ 

(Total of Ihis page) --auachcd I 

Total $ $ 

(lise only at) last page) 

(Report also on Summary at (It applicable. report 

Schedules) also on Stallstlcal 

Summary of Certain 

LiabilIties and Related 

Data I 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 13 of 38
B6E (Official Form 6E) (12/07) 

In re -' Case No. _ 

Debtor (if known) 

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS 

;\ 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. slate the name. mailing address. 

including zip code. and last tllur 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 tiling of the petition. Use a separate continuation sheet tllr each ty pc of priority and label each \\ith 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 tile cllild's parent or guardian. such as 

"1\.8 .. a minor child. by .101m Doe. guardian." Do not disclose the child's name. See. J I U.S.c. 9112 and Fed. R. 8ankr. P. 1007(m). 

Ifany entity other than a spousc in ajoint case may be jointly liable on a claim. place an "X" in the column labelcd "Codebtor." include the 

entity on the appropriate schedule of creditors, and complete Schedule H-Codebtors. [f ajoint petition is tiled. statc whether the husband. wife. 

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

.Ioint. or Community." If the claim is contingent. place an "X" in the column labeled "Contingent." If the claim is unliquidated. place an "X" 111 

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 thc 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 slleet. Report the total of all 

amounts not entitled to priority listed on this Schedule [ in tile box labeled "Totals" on the last sheet of the completed schedule. Individual debtors 

with primarily consumer debts report tllis total also on the Statistical Summary ol'Certain L.iabilities and Related Data. 

D Check this box ifdebtor has no creditors holding unsecured priority claims to repOli on this Schedule E. 

TYPES OF PRIORITY CLAIMS (Check the appropriate box(es) below If claims 111 that categol) arc listed on the attached sheets) 

D Domestic Support Obligations 

Claims for domestic support that arc owed to or recoverable by a spouse. fomler 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 

II U.S.c. 9 507(a)(I). 

D Extensions of credit in an involuntary case 

Claims arising in the ordinary course of the debtor's business or financial atfairs alter the commencement of the case but betore the earlier of the 

appointment of a tmstee or the order for relief. II U.S.c. 9 507(a)(3). 

D Wages, salaries, and commissions 

Wages. salaries. and commissions. including vacation. severance. and sick leave pay owing to employees and commissions owing to qualitying 

independent sales representatives up to $10.950* per person eamed within 180 days immediately preceding the tiling of the original petition. or the 

cessation of business. whichever occurred tirst. to the extent provided in II U,SC, 507(a)(4). 

D Contributions to employee benefit plans 

Money owed to employee benefit plans for services rendered within 180 days immediately preceding the liling ol'the original petition. or the 

cessation of business. whichever occurred first. to the extent provided in II U.s.c. 507(a)(5). 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 14 of 38
B6E (Official Form 6E) (12/07) - Cont, 

In re _ Case No, _
 

Debtor (if known)
 

D Cel'tain fal"mCI"S and fishcl'men 

Claims of certain timllers and tishermen, up to $5,4UO* per farmer or tisherman, against the debtor, as provided in II USc. 5U7(a)(6). 

D Deposits by individuals 

Claims of individuals up to $2,425* t'lr deposits for the purchase, lease. or rental of property or services for personaL family. or household usc, 

that were not delivered or provided. II U.S.c. 507(a)(7). 

D Taxes and Certain Othcr Dcbts Owed to Governmcntall1nits 

Taxes. customs duties. and penalties owing to lCderaL state. and local governmental units as set fOl1h in II USc. 507(aH8). 

D Commitments to Maintain the Capital of an 1nsuI'cd Depository Institution 

Claims based on commitments to the FDIC. RTC, Director of the Otlice of Thritl 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. II USc. 

507 (a)(9). 

D Claims for Death or Personal Injury Whilc Debtor Was Intoxicated 

Claims for death or personal injury resulting from the operation of a motor vehide or vessel while the debtor was intoxicated from using alcohoL a 

drug. or another substance. 11 USc. 507(a)(IO). 

* Amounts are subject to adjustment on April I. 2U IO. and every three years thereatler with respect to cases commenced on or atkr the date of 

adjustment. 

continuation sheets attached 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 15 of 38
--

B6F (Official Form 6F) (12/07) 

In re -------------rDo-e-;"b"""7- - -------- Case No. ----------;O(i"f'k-n-o-w-n')----­ tor 

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS 

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

the debtor or the property of the debtor. as of the date of tiling of the petition. The complete account number of any account the debtor has with thc 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 thc name and 

address ofthc child's parent or guardian. such as "A.B., a minor child, by John Doe, guardian." Do not d.isclose the child's namc. Sec, II use. 112 and red. 

R. Bankr. P. I007(m). Do not include claims listed in Schedules D and E. If all creditors will not tit on this page, use the continuation sheet provided. 

If any entity other than a spouse in ajoint 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 completc Schedule I1- Codebtors. II' ajoint pctition 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:' ".I:' or "C' in the column labeled "Husband, Wife, Joint. or Community." 

If the claim is contingent. place an "X" in the column labeled "Contingent." Iflhe 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.. 

D Ch ec k. tliS I' box 1 'fd e I Jtor laS no crc d' Itors lId' 10 ll1g unsecured I c aUlls to report on t h' IS Sid , C le u e I r

CREDITOR'S NAME, 

MAILING ADDRESS 

INCLUDING ZIP CODE. 

AND ACCOUNT NUMBER 

ISee inslrllCllons a/701"e I 

ACCOUNT NO 

ACCOUNT NO 

ACCOUNT NO 

ACCOUNT NO. 

e<::

,..., 

'-' '-Co 

'-W 

t"' 

0 

w 

continuation shects attached 

'-W 

w... >­ ~~ t: 

,..; '-' :z ~~

:z Z~

co8 «-~

[/)-,8 

W 

DATE CLAIM WAS 

f­

:z 

w 

0

:z 

f:

:z 

t"' 

u 

'-'; 

a 

f­

<r: 

0 

:J 

0' 

-:z 

-' 

0 

;;J 

'­

:J 

r:J.... 

[/) 

15 

Subtotal~

Total~

AMOUNT OF 

INCURRED AND CLAIM 

CONSIDERAnON FOR
 

CLAIM.
 

Ir CLAIM IS SUBJECT TO
 

SETOFF, SO STATE.
 

$ 

$ 

(USC 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.)
 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 16 of 38
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) 

0::: 

0 

f0:: 

'-L: 

0 

o 

u 

ACCOUNT NO 

ACCOUNTNO 

ACCOUNT NO 

ACCOUNT NO 

ACCOUNT NO 

u.i 

'"-' >­ ~O:::f .0 Z ,..., . ...... '- ...... Z Z~ «-~

~~ou 

::c 

Sheet no _o!~ continuatIOn sheets attached 

to Schedule of Creditors Iioiding Unsecured 

Nonpnont\ Claims 

DATE CLAIM WAS ,...,

Z tl; a INCURRED AND '-Ll f­ '-L: 

CONSIDERAnON FOR v « fz C: ...... CLAIM. ::e- f: C/l

IF CLAIM IS SUBJECT TO Z 5 C: 0 SI:TOFF. SO STATI~. u 

-

Subtotal~

Total~

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

(Report also on Summary of Schedules and. ifapplicable on the Statistical
 

Summary of Certain Liabilities and Related Data)
 

AMOUNT OF
 

CLAIM
 

$ 

$ 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 17 of 38
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) 

0::: 

0 

f0:: 

'-L: 

0 

o 

u 

ACCOUNT NO 

ACCOUNTNO 

ACCOUNT NO 

ACCOUNT NO 

ACCOUNT NO 

u.i 

'"-' >­ ~O:::f .0 Z ,..., . ...... '- ...... Z Z~ «-~

~~ou 

::c 

Sheet no _o!~ continuatIOn sheets attached 

to Schedule of Creditors Iioiding Unsecured 

Nonpnont\ Claims 

DATE CLAIM WAS ,...,

Z tl; a INCURRED AND '-Ll f­ '-L: 

CONSIDERAnON FOR v « fz C: ...... CLAIM. ::e- f: C/l

IF CLAIM IS SUBJECT TO Z 5 C: 0 SI:TOFF. SO STATI~. u 

-

Subtotal~

Total~

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

(Report also on Summary of Schedules and. ifapplicable on the Statistical
 

Summary of Certain Liabilities and Related Data)
 

AMOUNT OF
 

CLAIM
 

$ 

$ 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 18 of 38
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) 

0::: 

0 

f0:: 

'-L: 

0 

o 

u 

ACCOUNT NO 

ACCOUNTNO 

ACCOUNT NO 

ACCOUNT NO 

ACCOUNT NO 

u.i 

'"-' >­ ~O:::f .0 Z ,..., . ...... '- ...... Z Z~ «-~

~~ou 

::c 

Sheet no _o!~ continuatIOn sheets attached 

to Schedule of Creditors Iioiding Unsecured 

Nonpnont\ Claims 

DATE CLAIM WAS ,...,

Z tl; a INCURRED AND '-Ll f­ '-L: 

CONSIDERAnON FOR v « fz C: ...... CLAIM. ::e- f: C/l

IF CLAIM IS SUBJECT TO Z 5 C: 0 SI:TOFF. SO STATI~. u 

-

Subtotal~

Total~

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

(Report also on Summary of Schedules and. ifapplicable on the Statistical
 

Summary of Certain Liabilities and Related Data)
 

AMOUNT OF
 

CLAIM
 

$ 

$ 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 19 of 38
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) 

0::: 

0 

f0:: 

'-L: 

0 

o 

u 

ACCOUNT NO 

ACCOUNTNO 

ACCOUNT NO 

ACCOUNT NO 

ACCOUNT NO 

u.i 

'"-' >­ ~O:::f .0 Z ,..., . ...... '- ...... Z Z~ «-~

~~ou 

::c 

Sheet no _o!~ continuatIOn sheets attached 

to Schedule of Creditors Iioiding Unsecured 

Nonpnont\ Claims 

DATE CLAIM WAS ,...,

Z tl; a INCURRED AND '-Ll f­ '-L: 

CONSIDERAnON FOR v « fz C: ...... CLAIM. ::e- f: C/l

IF CLAIM IS SUBJECT TO Z 5 C: 0 SI:TOFF. SO STATI~. u 

-

Subtotal~

Total~

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

(Report also on Summary of Schedules and. ifapplicable on the Statistical
 

Summary of Certain Liabilities and Related Data)
 

AMOUNT OF
 

CLAIM
 

$ 

$ 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 20 of 38
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 Icases of real or personal property. Include any timcsharc 

interests. State nature of debtor's interest in contract. i.e" "Purchascr," "Agenl.·' etc.· Statc \\hethcr dcbtor is the lessor nr 

lessce ora lease. Provide the namcs and complete mailing addresses of all othcr partics to each lease or contract dcscribed. If 

a minor child is a party to onc orthe leases or contracts. state the child's initials and the name and address orthc child's parent 

or guardian. such as ";\.fL a minor child, by John One, guardian." Do not disclose the chIld's name. Sec, II l:.S.C. 112 and 

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

D Chcck this box if dcbtor has no executory contracts or unexpired Icases, 

NAME AND MAILING ADDRESS, DESCRIPTION OF CO:'liTRACT OR LEASE A"lD 

I"ICLl'DING ZIP CODE, NATl'RE OF DEBTOR'S I"lTEREST. STATE 

OF OTHER PARTIES TO LEASE OR CO"lTRACT. WHETHER LEASE IS FOR NONRESIDENTIAL 

REAL PROPERTY. STATE CONTRACT 

"I1:MBER OF A'iY GOVER"IMENT CONTRACT. 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 21 of 38
B6H (Official Form 6H) (12/07) 

In re _ Case No. _ 

Debtor (if known) 

SCHEDULEH-CODEBTORS 

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

debtor in the schcdules of creditors. Include all guarantors and co-signers. lfthc dcbtor resides or resided in a community propcrty state. 

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

Wisconsin) within thc eight-year period immediately preceding the commencement of the case. identil~v the name of the debtor's spouse and of any 

fonner spouse who resides or resided with the debtor in the community prnperty state. commonwealth. or ten·itory. Include all names used by the 

nondebtor spouse during the eight ycars immediately preceding the commencement or this case. II' a minor child is a codebtor or a creditor. state the 

child's initials and the name and address or the child's parent or guardian. such as ";\.I~ .. a minor child. by John Doc. guardian." Do not disclose the 

child's name. Sec. II liSe ill12 and Fed. R. Bankr. 1'. 1007(m). 

D Check this box ir debtor has no eodebtors. 

I\'AME AND ADDRESS OF CODEBTOR ]\AME A:'IID ADDRESS OF CREDITOR

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 Document Page 22 of 38
B61 (Official Form 61) (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 ajoint petition is 

fileu. unless the spouses are separateu and ajoint petition is not filed. Do not state the name of any minor child. The average monthly income 

calculateu on this form may differ from the current monthly income calculated on From 22A, 2213, or 22C. 

Debtor's Marital DEPENDENTS OF [WHTOR AND SPOUSE 

Status: 

RELATIONSHIP(S) AGE(S) 

Employment: DEBTOR SPOUSE 

Occupation 

Name or L~mplOyer

l \ IlIII", 

Address of Employer 

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

case filed) 

I.	 Monthly gross wages. salary. and commissions 

(Prorate ifnot paiu monthly) 

2. Fstimate monthly overtime 

3. SU13TOTAL 

4. LESS PA YROLL DEDUCTIONS 

a. Payroll ta:\cs anu social security 

b. Insurance 

c. Union uues
 

u Other (Specif~ ): _
 

5. SUBTOTAL OF PA YROLL DEDUCTIONS 

6. TOTAL NET MONTHL Y 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 uividends 

10.	 Alimony. maintenance or support payments payable to the debtor f(1r 

the debtor's use or that of dependents listed above 

II.	 Social security or government assistance 

(Specil~ )_-,---- _ 

12.	 Pension or retirement income 

13.	 Other monthly income 

(Specify): _ 

14.	 SUBTOTAL OF LINES 7 THROUGII 13 

15.	 AVERAGE MONTHLY INCOME (Aud amounts on lines 6 anu 14) 

16. COMBINED AVERAGE MONTHLY INCOME: (Combinc column 

totals /i'om line 15) 

DEBTOR SPOUSE 

$ $ 

$ $ 

$ I $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ 

I : $ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

I:	 $ 

$ 

(Report also on Summary of Scheuules anu. ir 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 1l1110wing thc filing of this document: 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 23 of 38
---- ---

-------

-----

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

In re _ Case No. _ 

Debtor (if known) 

SCHEDULE J - CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S) 

Complete tillS schedule by estllnatll1g the average or projected monthly expenses of the debtor and the debtor's family at time case filed I'rorak any payments made b,­

weeki" 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 Fonn22A or 22C. 

Check this box ,falolnl pelition is filed and debtor's spouse maintallls a separate household Complete a separate schedule ofexpenditurL's labeled "Spousc" 

Rent or home mortgage payment (include lot rellted lor mobile home) 

a. Arc real estate taxes II1cluded" Yes No
 

b Is property insurance IIlcludcd" Yes No
 

2. Utilities a Electricity and heating fuel $ 

b. Watcr and sewer $ ------_._­

c. Telephone $ 

d.Other _ $ 

3 Home maintenance (repairs and upkeep) $ 

4 Food $ 

Clothlllg $ 

6. Laundry and dry cleaning $ 

7 Medical and dental expenses $ 

R Transportation (not Including car payments) $ 

9 Recreation, clubs and entertainment. newspapers, magazines, ctc, $ 

10 Chalilable contributions $ 

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

,J Homeowner's or renter's $ --_._._.---­

b Lire $
 

c Health $
 

d Auto $
 

e Other _ $ _....__.__._-­

12 Taxes (not deducted trom wagcs or included in home mortgage paymcnts) 

(Specify) _ $ 

13 Installment payments. (In chaptcr 11.12, and 13 cases, do not list payments to be included 111 the plan) 

a Auto $ 

b Other _ $ 

c.Other _ $ 

14. Aillnony, mall1tenance. and support paid to others $ 

15 Payments for support of addilional dependents not living at your home $ 

16 Regular expenses from operation ofbusll1ess, profession. or farm (attach detaIled statement) $ 

17. Other _ $ 

IR. AVERAGE MONTHL Y EXPENSES (Total lines 1-17 Report also on Summary of Schedules and, I $ If applicable, on the StatistICal Summary of Certain Ltabilities and Related Data) 

19. Describe any IIlcrease or decrease III expenditures reasonablY' anlicipated to occur within the vear following the tilin.g of this document 

20 STATEMENT OF MONTHL Y NET INCOME 

a. AYerage monthly Income trom Line 15 of Schedule I $
 

b Average monthlY expenses from 1,Ine IHabove $----­


c. MonthlY net II1come (a mlllus b i
 $-----­

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 24 of 38
Jennifer R. Farrales In rl' Casl':\o _ 

Debtor (if klw'r\nj 

DECLARATION CONCERNI~GDEBTOR'S SCHEDULES 

DLC!;\RATI01\ Ll"IlFR 1'1''\,\\ 1'1 \ll I'LiZlldZ'1 III 1i\Il]V[bL,\[ 1)[11 [\lIZ 

I dl'clarc under pcn<lll\ rd pl'rlllr\ lhdt 1h:J\\..' n';;ld llH: (oregolllg SlIlllllUr: ;lIlJ ,,(lk'Juk~ 1.,:OllS1SllJlg ot 

In: ~t1O\\kdg(', II1l"Orln,IIIOll. dlld [ll'lle-l 

Dale' 12/31/09 

Dale 

IH.cJ. \IUT!O" \r>.D SIG\ \11 RI: or \0'1-\1 IORi,U II·\\(-;RI PI<'\ PFTITIOr>. PREI' \R~:R I~l'l' II I .~.( . 1[(\1 

j Jl'llale lInd':l ]'>:11:.1:\) (,1(i'l'lllll\" t1:at (II I dill it biltl~nJptl\ p::utll111!"1::p.lrL'1 ,h lkflJl.'d li1 Ii'" l II). I ~i prq";l'L'd \11:" d',I,-UJ,ll'I,1 )',11 l\1:1IP:':lhd[",'11 ,:11J '':' pili" Id::J 

til:: d('hlor \\ Itll a llJ!1\ l'f III I~ JiJ,-'lImc'llt :-lIIJ Ill''': null ::es ,lnd III fl'l! 1)1:11'011 rL:lj 1I1f ~:J UI1J'.."1 I) l i l ::: I I(II h). I j ~Ii h I dnd _;f~! rI dlld : l' :J uit:, ,11 '--' ,1[\),-,1 II ,-'" 11'1\ l' k::il 

i!rolllull!<JleJ purSLI,m: tll 11 (: S l' I ]()Il',) Sl't11!1g J i1U\lllllll1l t"l'l' (or :-,t:r'\J(t''-, dl;lrt.'~allk l'\ h:l:lk\UUll.y p::tltlOIl fJn.:p,Hl'r". [ hd\~' ~1\c'llliH: l!\:hIOI 11\)11(( I,j :11... ill,j\I["llli!"1 

am0lJI11 h,'t~He pi l'pi..lI\Il;.! LiIW dCl(l11l1~'I]\ :lll (dill\! 1\11 :1 d~bkl1 Ll\ acCepUl1\.l all~ 1l'L: 1:','[11 III',,' lkhl,)I, d~ ICL]UII..::d h\ [h,11 ~:'(lll]rl

1

1Ill1te,j ,II I:, Pl'J N:llll~ JJ1J Illk. lI',lIl~ SOl'l:lI S[:(\lllh ~I\l

l'r13<li1~rllptl~ r~'rltluI1 PICP:1ICI (/«I/!ilr,',! /1\ .I / ,'')( .;\ I ill I 

I.' ,i/[' ,\It;~,",'//1,'( 1 /,,'lill')II,1", /lun'l /\ !lll! Llil ul.iIl/,!l/d!, \Ii/IL' l/iL' jil/lllt' ItI!l'II/ //1\ I ",I,I!, \\ (/'101 \ 1L \, (Url/\ I {,'II,'/\'I" IJ.! rlit' 

IIi I1 \ 1.":'" \ i /1,' \ (Ii 'c 1/i JIl' 11 / 

Address 

\ 

~1~TllJlllr,-' (11' 13i-IIl~rup(cy 1\'11 lIon Prepiu::1 DalC 

..; /J,lli~I·II/i.'(,' f"II//'J!)'" !\/Jurcl \ '.i/,'I'r. I" ,m/'.'I II Iii, rr/l\ '\;'I)!/.\ of !I/ 'II' ,h, ,/1/ " 

I I' "" ( "1,'( 

DfCI.AJU1'10'\ l ~()EI{ !'E'\ALTY OF PERJrRY 0'\ BEIIALF OF .\ COI<PORC\ 110'\ OR pun '\ I· RSIIII' 

1. the- I till.' rll l'''I-.!L'11 I (il ullh.'1 011,,-,-" III ~\Il ~111111,:rlL'lJ cl~"I.'I\: \'11111.-' ...:nrrhlriltl(lll \'1,1 Ili,'IPi',n ,If ,In ':L1IIlWI/I'J (Ii Ilk' 

[Jdrtlll'rshlr] \11 till' _ _ ,__ ll"tlrpUI.1llnI1 (11- f':lrllh.:r:-;!lII'III:lllll'<J ,l"" lkhlur III \!ll) ,,'(b,- d~l"I:,r\.· 1I11l:,'r [l1.-'ll'll:\ (lJ [l~'rl\lr\ lil,l: I:l,\h" 

fe'ilJ llll' torcg()lflg "L1lllm,l\\ Jild ,,(he-dull's. consistIng 01 "heLI'. (TOfU! \//1)11/1 '_'1/ _'Iilllll/tlil jJLlgl! !)/II\ .') ;llld lll:ll tlll'\ .lrl' tfUl' dTlJ uir:c(\ II.' Lhl' hl'~! III II'," 

~1l0\\kd~(' 111I,lrm.1tIUJl.•111L,] h'21lct 

Slgl1(Hurc 

Case 10-00212 Doc 1 Filed 01/05/10 Entered 01/05/10 17:02:41 Desc Main

 Document Page 25 of 38
87 (Oftic,al Foml 7) (I HI7) 

UNITED STATES BANKRUPTCY COURT 

___-----'-N--'-o=f'--'t=h=e-"-f=o DISTRICT OF -----"-'Il"'Ii"'o"'o"'is"-- _ 

In re: Case No. ..",- _ 

DebtOi (lfkno\\Il) 

STATEMENT OF FINANCIAL AFFAIRS 

This statement is tn be completed by every debtor. Spouses tiling a joint petition may tile a single statement on which 

the information I()r both spouses is combined. If the case is tiled undcr chapter 12 or chapter 13. a married debtor musl furnish 

information lor both spouses whelher or not a joint pelilion is filed. unless the spouses are separaled and cljoint pctilion is not 

liled. An individual debtor engaged in business as a sole proprielor. partner. family farmer. or selt~employed professional. 

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

affairs. To indicale payments. transfers and the like to minor children. state the child's inilials and the name and address of the 

child's parenl or guardian. such as "A.B .. a minor child. h:- John Doe. guardian." Do nol disclosc the child',; name. See. II (I.S.C. 

112 and Fed. R. 8ankr. P. 1007(m). 

Queslions I - 18 are to he completed hy all debtors. Deblors that are or have heen in husiness. as delined below. also 

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

additional space is needed lor the answer to any question. use and attach a scparate sheet proper!:- idenlified with the case name. 

case numher (if known). and the numher of the question. 

DEF/;\/TlOlVS 

"1/7 husiness." A dehlor is "in business" tor the purpose of this I()rm if the debtor is a corporation or partnership. An 

individual debtor is "in husiness" for the purpose of this fom1 if the dehtor is or has been. within six :-ears immedialely preceding 

the filing of this bankruptcy case. any of the tollowing: an ofticer. director. managing exccutive. or owner 01'5 percenl or more 

of the v(Hing or equit:- securities of a corporalion: a partncr. other than a limited partner. of a partnership: a sole proprietor or 

self~cmployed hill-time or paI1-lime. An individual dehtor also may be "in business" I()r the purpose of this form if the debtor 

engages in a trade. busincss. or olher activity. other than as an emplo:- ee. lo supplemcnt income li'om the dehtor', primar:­

employment. 

"Insider" The lenn "insider" includes but is not limiled to: relalives oflhe debtor: general partners ol'the debtor and 

lheir relatives: corporations of which the debtor is an officer. direclor. or person in conlrol: ofticers. directors. and anv owner of 

5 percent or more of the vOling or equity securities of a corporale debtor and lheir relatives: aniliates of the debtor and insiders 

of such afliliales: any managing agenl of the debtor. II USc. 101. 

1. Income from employment or opel'ation of business 

~onc

D 

State the gross amount of income the debtor has received trom employment. trade, or profession. or Irom operalion of 

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

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

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

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

of the debtor's liscal year.) Ifajoint petilion is tiled. state income lor each spouse separately. (Married dcblors tiling 

under chapter 12 or chapter 13 must state incol11e of both spouses whether or not a joint petition is liled. unless tile 

spouses are separated and ajoint petition is not tiled.) 

AMOUNT SOl ~RCI

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 Document Page 26 of 38
2 

2. Income othel' than fl'Om employment or operation of business 

'\one'	 State the amount or income received by the debtor other than from employment. tradc. prolCssion. opcration orthe 

D	 debtor's business during the two years immediately preccding thc commcnccmcnt of this case. Gi\'e particulars, Ira 

jOll1t petition is tiled. state income for each spousc separatcl!, (Marricd debtors tiling undcr chapter 12 or chaptcr 13 

must state income for each spouse whether or not aioint petition is filed. unless, the spouses arc separated and ajoint 

petition is not filed,) 

AMOUNT	 SOURCF 

3. Paymcnts to CJ'cditors 

Complete a. or b., as appropriate, and c. 'Jone 

D	 a, Individual or joinr debtor(s} with primari(v consumer debrs: 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 aggrcgate value of all property that constitutes or is affected by such transrer 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 Jiling under chapter 12 or chapter 13 must include payments by either or both spouses 

\vhether or not aioint petition is filed. unless the spouses arc separated and ajoint pctition is not filed,) 

NAME AND ADDRESS OF CREDITOR	 DATES or AMOUNT AMOUNT 

PAYMENTS PAID STILL OWINC; 

None 

o b, Dehror I1hose debrs (Ire 170r primilrllv consumer debrs: List each payment or other transfer to any creditor made 

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

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

any pay ments that were made to a creditor on account of a domestic support obligation or as part or 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 eithcr or both spouses 

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

NAME AND ADDRESS OF CREDITOR DATES OF AMOUNT AMOUNT 

PAYMENTS/ PAID OR STILI 

TRANSFERS VALUE OF OWI'JG 

TRANSFERS 

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 Document Page 27 of 38
3 

o	 c. 04// debtors. List all payments madc within one year immcdiately preceding thc commencemcnt of this casc 

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

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

a joint petition is not tiled.) 

NAME AND ADDRESS OF CREDITOR DATE OF AMOUNT AMOUNT 

AND RLLATIONSHIP TO DLBTOR PAYMENT PAID STILL OWINU 

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

'\onL 

o a. List all suits and administrative proceedings to which the debtor is or was a party within one year immediately 

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

intlmnation concerning either or both spouses whether or not ajoint petition is liled. unless the spouses arc separated 

and a joint petition is not tiled.) 

CAPTION OF SUIT 

AND CASE NUMBER NATURE OF PROCEEDING 

COURT OR i\Cjj'NCY 

AND LOCATION 

STATUS OR 

DISPOSITION 

o 

b. Describe all property that has been attaclled. gamished or seized under any legal or equitable process within one 

year immediately preceding the commencement ol'this case. (Married debtors tiling under chapter 12 or chapter 13 

must include inl'ormation concerning property of either or both spouses whether or not a Joint petition is Ii Icd. unless 

the spouses are separated and ajoint petition is not lib!.) 

NAMF AND ADDRESS 

OF PERSON FOR WHOSE 

BENEFIT PROPERT'{ WAS SIIZED 

DATE OF 

SEIZURE 

D]SCRIPTION 

AND VALUE 

OF PROPERTY 

5. Reposscssions, fOl'cclosurcs and rcturns 

'\one 

o 

List all propeliy that has been repossessed by a creditor. sold at a foreclosure sale, transtCrred through a deed in lieu 

of foreclosure or returned to the seJler. within onc yca I' immediately preceding the commencement of this casco 

(Married debtors ti ling under chapter 12 or chapter 13 must include information concerning property of cithcr or both 

spouses whether or not ajoint petition is tiled, unless the spouses are separated and ajoint petition is not tiled.) 

NAME AND ADDRESS 

OF CREDITOR OR SELLER 

DATI OF REPOSSESSION. 

FORECLOSURE SAl E. 

TRANSITR OR RETURN 

DESCRIPTION 

AND VALliE 

OF PROPERTY 

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 Document Page 28 of 38
4 

6. Assignments and receiverships 

:\one	 a. Dcscribe any assignment ofpropcrty fix thc bcnclit ol'creditors made "ithin 120 days immcdiatcly preceding the 

o	 commenccmcnt of this casc. (Man'ied debtors IIling under chaptcr 12 or chaptcr 13 must include any assignmcnt by 

cithcr or both spouses whether or not a joint pctition is filed. unlcss thc spouses arc scparatcd and a joint pctition is not 

filcd.) 

TERMS OF 

NAME AND ADDRESS DATE OI ASSIGNMENT 

OF ASSIGNEE ASSIGNMENT OR SETTLEME~T

:\one 

o 

b. List all propcrty which has bcen in the hands of a custodian. receiver. or court-appointcd oflicial within one yen 

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

include information conceming property of either or both spouscs whethcr or not ajoint petition is tiled. unless thc 

spouses are separated and ajoint petition is notllled.) 

NAME AND ADDRESS 

OF CUSTODIAN 

NAME AND LOCATION 

OF COURT 

CASE TITLE & NUMBER 

DATE OF 

ORDER 

DESCRIPTION 

AND VALUE 

Of PROPERTY 

7. Gifts 

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

o	 except ordinary and usual gifts to family members aggregating less than $200 in valuc pcr individual family member 

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

chapter 13 must includc gills or contributions by cithcr or both spouscs whcthcr or not a joint pctition is tiled. unlcss 

the spouses arc scparated and ajoint pctition is not filed.) 

NAME AND ADDRESS RELATIONSHIP	 DESCRIPTION 

or PERSON TO DEBTOR. DATE	 AND VAI.L:E 

OR ORGANIZATION IF ANY OF GIFT	 or GIrT 

8. Losses 

None	 List all losses from fire. theft. other casualty or gambling within one year immediately preccding thc commencement 

o	 of this casc or since the commencement of this case. (Married dcbtors liling under chapter 12 or chapter 13 must 

include losses by either or both spouses whether or not ajoint pctition is filed. unlcss the spouses are separated and a 

joint pctition is not tiled.) 

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 

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 Document Page 29 of 38
5 

9. Payments related to debt counselin~ or bankruptcy 

None 

D 

List all payments m~de or property tr~nsferrcd by or on behalfofthc debtor to any persons. including attorneys. for 

consultation concerning debt consolidation. reliefunder the bankruptcy law or preparation ora petition in bankruptcy 

within one year Immedi~tely preceding the commencement of this c~se.

NAME AND ADDRESS 

OF PAYEE 

DATE OF PAYMENT. 

NAME OF PA YER IF 

OTHER THAN DEBTOR 

AMOUNT OF MONEY OR 

DESCRIPTION AND 

VALUE OF PROPERTY 

~OIlC

D 

lIl. Other tmnsfel's 

a. List all other property. other th~n propel1y translerred in the ordin~ry course or the business or linancial alhlirs or 

the debtor. transtCrred either absolutely or as seclll'ity within two years immediately preceding the commcncement of 

this case. (Married debtors tiling under ch~pter J 2 or chapter 13 must include tr~nsfers by either or both spouses 

whether or not ajoint petition is filed. unless the spouses are separated and ajoint petition is not tiled.) 

NAME AND ADDRESS OF TRANSFERf£ 

RELATIONSHIP TO DEBTOR 

DATE 

DESCRIBE PROPERTY 

TRANSFERRED AND 

VALUE RECUVID 

:-':one 

D 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 bcneficiary. 

NAML 01 TRUST OR OTHER 

DEVICE 

DATE(S) OF 

TRANSFER(S) 

AMOUNT OF MONEY OR DESCRIPTION 

AND VALUE OF PROPERTY OR DERTOR'S 

INTEREST IN PROPERTY 

11. Closed financial accounts 

NOlle 

D 

List all tinancial accounts and instruments held in the name of the debtor or for the benefit or the debtor which were 

closed. sold. or otherwise transferred within one yea I' immediately preceding the commencement or 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 tunds. cooperatives, associations. brokerage houses and other financial 

institutions. (Married debtors tiling under chapter 12 or chapter 13 must include infornlation concerning accounts or 

instruments held by or ror either or both spouses whether or not ajoint petition is tiled. unless the spouses are 

separated and ajoint petition is not tiled.) 

NAME AND ADDRESS 

OF INSTITUTION 

T'y'Pr. OF ACCOUNT. LAST FOUR 

DIGITS OF ACCOUNT NUMBER. 

AND AMOUNT OF FINAL BALANCE 

AMOUNT AND 

DATE OF SALE 

OR CLOSING 

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6 

12. Safe deposit boxes 

'ione	 List each safe deposit or other box or depository in which the debtor has or had securities. cash. or other valuables 

D	 within one year immediately preceding the COnlll1enCemcnt of this case. (Married dcbtors tiling under chapter 12 or 

chapter 13 must include boxes or depositories or either or both spouses whether or not a Joint petition is liled. unless 

the spouses arc separated and ajoint petition is not tiled.) 

NAME AND ADDRESS NAMES AND ADDRESSES DESCRIPTION DATE OF TRANSFER 

OF BANK OR OF THOSE WITII ACCESS OF OR SURRLNDER. 

OTHER DEPOSITORY TO BOX OR DEPOSITORY CONTENTS IF ANY 

13. Setoffs 

'ione 

D 

List all setotl's 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 tiling under chapter 12 or chapter 13 must include information 

conccrning cither or both spouses whcther or not ajoint petition is filed, unless the spouses are separated and aioint 

petition is not tiled.) 

NAME AND ADDRESS OF CREDITOR 

DATE 01 

SETOFF 

AMOUNT 

OF SETOFF 

14. Property held for another person 

'ione	 List all property owned by anothcr person that the debtor holds or controls. 

D 

'iAME AND ADDRESS DESCRIPTION AND 

or OWNER VALUE OF PROPERTY lOCATIO'! OF PROPFRTY 

-------------------------------------------_..._--­

15. Prior address of debtor 

Nonr 

o	 Irdcbtor has movcd within three year's immcdiatcly preceding the commencement or this case. list all premises 

\\ hich thc debtor occupied during that period and vacated prior to the commencement of this casc. If ajoint petition is 

lilcd. rcport also any separalc address of either spouse. 

ADDRESS	 NAME USED DATES OF OCCUPANCY 

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7 

16. Spouses and FOI'mel' Spouses 

!'-:one 

D 

If the debtor resides or resided in a eommunity property state. eommonwealth. or territory (including Alaska. Arizona. 

Califomia. ldal1O. Louisiana. Nevada. New Mexico. Puerto Rico. Texas. Washington. or Wisconsin) witllin eight 

years immediately preceding the commencement of the ease. identify the name of tile 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 Illl10wing delinitions 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 opcrated by the debtor. including. but not limited to. disposal sites. 

"llazardous Material" means anything defined as a hazardous waste. hazardous substancc. toxic substance. hazardous 

materiaL pollutant. or contaminant or similar term under an Environmental Law. 

:,one a. List the name and address of every site for which the debtor has received notice in writing by a govemmental 

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

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

SITE NAME NAME AND ADDRESS DATE OF ENVIRONMENTAL 

AND ADDRESS Or: GOVERNMENTAL UNIT NOTICE LAW 

None 

D 

b. List the name and address of every site Illr which the debtor provided notice to a governmental unit ofa release 

ofllazardous Material. Indicate the govemmental unit to which the notice was sent and the date of the notice. 

SlTENAME NAME AND ADDRESS DATE OF El':VIRON MEN'IAL 

AND ADDRESS Or: GOVERNMENTAL UNIT NOTICE LAW 

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

D respect to which the debtor is or was a party, Indicate the name and address of the govemmental 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. :"ature, location and name of business 

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

D	 and beginning and ending dates of all businesses in which the debtor was an onicer. director. partner. or managing 

executive of a corporation. partner in a partnership. sole proprietor. or was sell~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 

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8 

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

thc commencement of this case. 

I/the debtor is (J partnership. list the names. addresses. taxpayer-identification numbers. nature of the businesses. 

and beginning and ending dates of all businesses in wllicllthe debtor \vas partner or owned 5 percent or more oC 

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

Ifthe debtor is a corporation. list the names. addrcsscs. taxpayer-identilication numbers. naturc or thc busincsscs. 

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

the voting or equity sccuritics \\ ithin 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 ENDINC; DATES 

TAXPAYER-I.D. NO. 

(ITIN)I COMPLETE EIN 

NOllc b. Identity any business listed in response to subdivision a.. above. that is "single asset real cstatc" as 

D defined in II usc. 9 101. 

NAME ADDRESS 

The following questions are to be completed by every debtor that is corporation or partnership and by any indi\ idual 

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

oftlcer. director. managing cxecuti ye. 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 sclf-employetl in a trade. prorcssion. or other activity. 

either full- or part-time. 

(An individual or/omt dehtor should complete this portion ofthe stalemen! on(v ifthe dehtor is or has heen in 

business, as defined above. within SIX years immedimely preceding the cOlllmencement oj this case A debtor who has not heen 

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

19. Books, reeOl'ds and financial statements 

~()nc

D a. List all bookkeepers and accountants WllO within two years immediately preceding tile tiling of this 

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

NAML AND ADDRESS DAIIS SERVICES REl'\DFRED 

NOllc b. List all fions or individuals who within two years immediately preceding the tiling of this bankruptcy 

D case have auditetl the books of account and records. or prcpared a financial statement or thc tlcbtor. 

NAME ADDRESS DATES SERVICES RENDERED 

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9 

None 

D C. List all fim1s 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. Ifany orthe books of account and records arc not available. c.\plain. 

NAME ADDRESS 

None 

D 

d. List all financial institutions. creditors and other parties. including mercantile and trade agencies. to \\hom a 

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

NAME AND ADDRESS DATE ISSUED 

NOlle 

D 

20. Inventories 

a. List the dates of the last two inventories taken of your property. the name of the person who supervised the 

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

DATE OF INVENTORY INVENTORY SUPERVISOR 

DOLLAR AMOUNT 

OF INVENTORY 

(Specify cost. market or other 

basis) 

None 

D 

b. List the name and address of the person having possession of the records of each of the invcntories reported 

in a.. above. 

DATE OF INVENTORY 

NAME AND ADDRESSES 

OF CUSTODIAN 

OF I!'IVIHIOR'{ RICORDS 

21. Current Partners, Offieers, Directors and Shareholders 

:\one a. If the debtor is a partnership. list the nature and percentage ofpm1ncrship interest oreach member of the 

D pm1nership. 

NAME AND ADDRESS NATURE OF INTEREST PERCENTAeil: OF INTEREST 

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

D 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 TITLI OF STOCK OWNERSIlIP 

--------------_._..._._---­

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10 

22 . Former partners, officers, directors and shareholders 

Nonc 

D a. If the debtor is a partnership. list each member who withdrew from the partnership within one year immeuiatcly 

preceuing the commencement of this case. 

NAML ADDRESS DATE OF WITHDRAWAL 

None b. lrthe uebtor is a corporation. list all officers or uirectors whose relationship with the corporation temlinated 

D within one ye3l" immediately preceuing the commencement of this case. 

NAME AND ADDRESS TITLE DATE OF TERMINATION 

23. Withdrawals from a partnership or distributions by a corporation 

None lfthe debtor is a partnership or corporation. list all withdrawals or distributions crediteu or given to an insider. 

D including compensation in any t()nn. bonuses. loans. stock redemptions. options exereiseu anu any other perquisite 

during one year immediately preceding the commencement of this case. 

NAML & ADDRESS AMOUNT OF MONEY 

OF RLClPIENT. DATE AND PURPOSE OR DESCRIPTION 

RELATIONSI Ill' TO DEBTOR OF WITIIDRAWAI. AND VAl.UE OF PROPERTY 

24. Tax Consolidation Group. 

'>onc 

D 

II' the uebtor is a corporation. list the name anu reueral taxpayer-identification number of the parent corporation or any 

consolidated group for tax purposes of which thc uebtor has been a member at any time within six yeal'S 

iml11euiately preceuing the commencement of tile case. 

NAME OF PARENT CORPORAnON TAxpAYER-IDENTIFICATION NUMBER (UN) 

25. Pension Funds. 

:\one If the uebtor is not an individuaL list the name and federal taxpayer-identification numbcr of any pension funu to 

D which the uebtor. as an cmployer. has been responsiblc for contributing at any time within six ye3l"s immcuiatcly 

preceuing the commcncement of the case. 

NAME OF PENSION FUND TAXPAYER-IDENTIFICATION NUMBER (EIN) 

****** 

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 Document Page 35 of 38
II 

/ f/c ()!lIjJ!eled h,1' tlt1 IIldit'u.!uu! or flldiriduu! und ."pOIl'H) 

I uc:clarc undcr pcnalt\ of pc 'Ill I) that I h,ne lead thc ans\\crs conLlIllcu in the fllrcgoing statemcntll! !in'l:lCl<11 

"mms lllid ,,11\ "ttachmcnts thercto and that thc) arc' trllc l\l,d c:orrc'ct 

" 

12/31/09 Dat<: 

Ilrrkbtlll 

I)i\lC	 ~ign~I',lJJ\.'

ll! .1 111111 llchtlll 

(i f all\ ) 

I (.kC!clrC lilldel 11e1LJll\ ()t'PCI1LJI": ',!UI J 1](,\( I":il,! d1\.: ;~lh\\Cr~ c\ Il1(1111l'd 1'1 tl1\: ~(llc~.'\lll1~t -;!:lll'lih.~llr 111' i'II1.III(I:11 :JI!;lil\ ,j!111 :111~ ,1!;;r,'llllll'li!-; 

[ilclc[t) and ThaI rl;(: ;1,\: IIIIC ~lnd Lllfrcll to Illl'lJC)( (l(lll} ~llll\\k(I~'L II )(1l111.l11lJll '111l! helle) 

Print Name and Title 

1)[( I..\K\I 10\ \\1) Sll;\ \ I I IU. Of \0\- \ I I Ol{",f. \ II \\"RI I'IC\ Pf [lTIO\ I'I\f:I'.\IU.R IS"I' II [ ,S,(, 11111 

) lkL];llC lIIHk:: i1Cll(lll} "(IX'lllIl.' 111;1I (I) 1,111\ il h:1I1J.-ltlP1C\ !J1'1111(J11llICjl,I[I,'f a .... lkfllll'd 111 II L .\ l' ilU 1. ) I Pi\.:p.II<.:L: 1!:1~ dl)ulllk'lll 1 'I ' 

L01~IP~lb,11I0I1 :mJ 11,\\1.: [JIO\ Ilkd [Ill' ddHu[ \\1111 J Cl)~J\' ufthis ,iOClllllCIIl,IllL! [il...: Illl!ll:CS ,\I1J 111J'OII112111011ICqllll.:d :IIIJCI I I >. l :< Iln,:l)I, I: [II 

illlJ _;.:~( tl I. dlld I_~) 11' I \Iks '.1: ~lIIJL'II[lC" h:l\ (' hecn PIOlillJl~:(lI~d jJlIl,'ll:llIl 1\) I I l .\ ( I )i)lll I "dtlll~ (\ 111;1\.111'11\11 :l"_' 1;11 '-\..'1\ 11..:(\ (iJi]: .C!(.lhl.: h\ 

baJl~rllptc\ ])('1111011 PIt:P,U~I_" \ II,I\L' fl\~11 tll~ ddJ10[ [1UJIL~ l1l'!l1...: Illd\lllHll1l <\Illl'llll: lll.:llliC Pl"':i'dllll~ (1)1\ dllllllll":I;: ((11 ill'l1;! ]'.11 ,I dl'!~ll'l ,if ,1LlL'PI'il~'

Ilfly rec (1()111 111L' dcbl(lr. J'\ rcquII..:d tl~ IluI '\C'Lllt11l 

'f 1/",' !'rillt:nl/)/' \ /h'f!'I(11i /,1",',0 .. 1)",'1'1.\ nli,! U!lI/I.I:l'ldlJu/ Illite {(J~'lIdll!,', /uli' ,':.' (/1,'\ i, ud,lI,"', ,;n./ \()I.."U/-I<..'L,'IIU: ,111I/l1/'l" !I Ii.', /'IIII,ll"/ 

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::-'J~[).i!lllt' l)! Biln~lllpl(\ Petlllun PrCf)Jr-:1	 I),lk 

~;,lllIC" ,llld S,',cl"I-SCClIil;\' 1IlIIllll(,l~ •..lJ i111 clh-:I IIlJI\ Idllal:-. \\Iw plq':l[(..\: \11 d"hL.:d 11 ]11'-'p 11111~ til'" dl"(llm-:~lt 11Il;\..'Y:; Ill<..' bill1kll1[lk'. fl...:lltlllll :)ICPdll'l I, 

1:01 1I1 :1ll11\ Idll,11 

,I /)ankrupt!..)' petition prepflf/:r's [uilure to comply Itli/h thl! pro l'i.\io/1.\ o/tirlf:' // (/nd /he rt>ueml Ruin' l~r H((n!.."I/)I, I' Procedure muy re.wl! ill 

fines or impdHJnmeni or horh. IX ('.S,t: ,~' /56. 

x 

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-----

United States Bankruptcy Court
 

Northern	 Illinois District Of 

In	 re 

Case No. 

Debtor Chapter 

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR 

1.	 Pursuant to 11 U.s.C. § 329(a) and Fed. Bankr. P. 2016(b), I certify that I am the attorney for the abovenamed debtor(s) and that compensation paid to me within one year before the filing of the petition in 

bankruptcy, or agreed to be paid to me, for services rendered or to be rendered on behalf of the debtor(s) 

in contemplation of or in connection with the bankruptcy case is as follows: 

For legal services, I have agreed to accept	 $ _ 

Prior to the filing of this statement I have received	 $ _ 

Balance Due	 $ _ 

2.	 The sou rce of the com pensati on paid to me was: 

DDebtor DOther (specify) 

3.	 The source of compensation to be paid to me is: 

DDebtor D Other (specify) 

4.	 D I have not agreed to share the above-disclosed compensation with any other person unless they are 

membersand associates of my law firm. 

D I have agreed to share the above-disclosed compensation with a other person or persons who are not 

members or associates of my law firm. A copy of the agreement, together with a list of the names of 

the people sharing in the compensation, is attached. 

5.	 In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy 

case, including: 

a.	 Analysis of the debtor's financial situation, and rendering advice to the debtor in determining whether 

to file a petition in bankruptcy; 

b.	 Preparation and filing of any petition, schedules, statements of affairs and plan which may be required; 

c.	 Representati on of the debto r at the meeti ng of cred itors and confi rm ation heari ng, and any adj ou rn ed 

heari ngs thereof; 

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 Document Page 37 of 38
DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR (Continued) 

d. Reprerentation of the debtor in adversary proceedings and other contesed bankruptcy matters; 

e. [Other provisions as needed] 

6. By agreement with the debtor(s), the above-disclosed fee does not include the following services: 

CERTIFICATION 

I certify that the foregoing is a complete statement of any agreement or arrangement for 

payment to me for representation of the debtor(s) in this bankruptcy proceedings. 

Date Sgnature of Attorney 

Name of law firm 

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 Document Page 38 of 38