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

Medziak, James Anthony 

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

(if more than one, state all) * 

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

(if more than one, state all) * ***-**-6402

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

24 South Addison Stret Apt # 104

Bensenville IL 

County of Residence or of the Principal Place of Business: County of Residence or of the Principal Place of Business:

60106

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

 

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

DUPAGE

United States Bankruptcy Court

Northern District of Illinois Eastern Division Voluntary Petition

 B1 (Official Form 1) (1/08) 

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 affliates) are less than $2,190,000.

A plan is being filed with this petition.

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

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

 Estimated Liabilities

 Estimated Assets

 Estimated Number of Creditors

Type of Debtor (Form of Organization)

(Check one box)

Nature of Business

(Check one box.)

Individual (includes Joint Debtors)

Corporation (includes LLC & LLP)

Partnership

Other (If debtor is not one of the

above entities, check this box 

and state type of entity below.)

Heath Care Business

Single Asset Real Estate as 

defined in 11 U.S.C §101 (51B)

Railroad

Stockbroker

Commodity Broker

Clearing Bank

Other

Chapter of Bankruptcy Code Under Which the Petition is Filed (Check one box)

Nature of Debts (Check one Box)

Chapter 7

Chapter 9

Chapter 11

Chapter 12

Chapter 13

Chapter 15 Petition for Recognition

of a Foreign Main Proceeding

Chapter 15 Petition for Recognition

of a Foreign Nonmain Proceeding

Debts are primarily consumer 

debts, defined in 11 U.S.C.

§ 101(8) as "incurred by an 

individual primarily for a 

personal, family, or household 

purpose."

Debts are primarily business 

debts. 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).

Filing Fee (Check one box)

Filing Fee attached

Filing Fee to be paid in installments (applicable in 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 wavier requested (applicable to chapter 7 individuals only). Must

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

 Statistical/Administrative Information

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

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

funds available for distribution to unsecured creditors.

$0 to 

$50,000

$50,001to

$100,000

See Exhibit D on page 2 of this form

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

$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 $1billion

More than

$1 billion

$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 $1billion

More than

$1 billion

Check all applicable boxes:

This space is for court use only

PFG Record # 471053 *471053FFF01volpe6z* B1 (Official Form 1) (1/08) Page 1 of 3

Case 09-49486 Doc 1 Filed 12/31/09 Entered 12/31/09 09:40:34 Desc Main

 Document Page 1 of 39
 Voluntary Petition

This page must be completed and filed in every case)

Name of Debtor(s)

Medziak, James Anthony 

All Prior Bankruptcy Case Filed Within Last 8 Years (if more than two, attach additional sheet)

 Location Where Filed: Case Number: Date Filed:

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

Name of Debtor: Case Number: Date Filed:

District: Relationship: Judge:

None

None

None

 B1 (Official Form 1) (1/08) 

Exhibit A Exhibit B

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 USC § 342(b).

/s/ Wylie W Mok

Wylie W Mok

Exhibit C

Information Regarding the Debtor - Venue

(Check the Applicable Box.)

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

(Check all applicable boxes.)

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.

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 in 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.

(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.

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.

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

Dated: 12/30/2009

If this is a joint petition:

(To be completed if debtor is an individual whose debts are primarily consumer debts.)

Debtor certifies that he/she has served the Landlord with this certification. (11 U.S.C. § 362(1))

PFG Record # 471053 *471053FFF01volpe6z* B1 (Official Form 1) (1/08) Page 2 of 3

Case 09-49486 Doc 1 Filed 12/31/09 Entered 12/31/09 09:40:34 Desc Main

 Document Page 2 of 39
 Voluntary Petition

 This page must be completed and filed in every case)

Name of Joint Debtor(s)

Medziak, James Anthony 

Signatures

Signature(s) of Debtor(s) (Individual/Joint) Signature of a Foreign Representative

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.

Signature of Attorney Signature of Non-Attorney Bankruptcy Petition Preparer

Signature of Debtor (Corporation/Partnerhsip)

/s/ James Anthony Medziak 

/s/ Wylie W Mok

Signature of Attorney for Debtor(s)

Wylie W Mok

Printed Name of Attorney for Debtor(s)

LAW OFFICES OF PETER FRANCIS GERACI

55 E. Monroe Street #3400

Chicago IL 60603

312.332.1800 (PH) 

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 relief in accordance with the chapter of title 11, 

United States Code, specified in this petition.

Signature of Authorized Individual

Printed Name of Authorized Individual

Title of Authorized Individual

Date

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 fi ling for a debtor or 

accepting any fee from the debtor, as required in that section.

Official Form 19B is attached.

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

Social Security number (If the bankrutpcy 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.)

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.

Date

Address

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. 

 << Sign & Date on Those Lines 

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.

(Signature of Foreign Representative)

(Printed Name of Foreign Representative)

Dated: 12/21/2009

James Anthony Medziak

Date: 12/30/2009

* 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.

 B1 (Official Form 1) (1/08) 

PFG Record # 471053 *471053FFF01volpe6z* B1 (Official Form 1) (1/08) Page 3 of 3

Case 09-49486 Doc 1 Filed 12/31/09 Entered 12/31/09 09:40:34 Desc Main

 Document Page 3 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT

James Anthony Medziak Debtor Bankruptcy Docket #:

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 opportunties 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 opportunties 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.

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

 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.]

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.);

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.);

Active military duty in a military combat zone.

 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.

James Anthony Medziak 

Sign & Date 

Here

Dated: 12/21/2009 /s/ James Anthony Medziak 

PFG Record # 471053 B 1D (Official Form 1, Exh.D)(12/08) Page 1 of 1

Case 09-49486 Doc 1 Filed 12/31/09 Entered 12/31/09 09:40:34 Desc Main

 Document Page 4 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT

James Anthony Medziak Debtor Bankruptcy Docket #:

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 opportunties 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 opportunties 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.

 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. [Must be accompanied by a motion for determination by the court.] [Summarize exigent circumstances 

here.]

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

 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.]

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.);

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.);

Active military duty in a military combat zone.

 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.

Dated: 12/21/2009 Sign & Date 

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.

PFG Record # 471053 B 1D (Official Form 1, Exh.D)(12/08) Page 1 of 1

Case 09-49486 Doc 1 Filed 12/31/09 Entered 12/31/09 09:40:34 Desc Main

 Document Page 5 of 39
UNITED STATES BANKRUPTCY COURT

In re NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak , Debtor

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, C, 

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 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.

Pages

 Attached 

Name of Schedule YES | NO Assets Liabilities Other

AMOUNTS SCHEDULED

SCHEDULE A - Real Property

Yes 1 $- $- $-

SCHEDULE B - Personal Property

Yes 3 $5,450 $- $-

SCHEDULE C - Property Claimed as 

Exempt Yes 1+ $- $- $-

SCHEDULE D - Creditors Holding Secured 

Claims Yes 1+ $- $- $-

SCHEDULE E - Creditors Holding 

Unsecured Priority Claims Yes 2 $- $- $-

SCHEDULE F - Creditors Holding 

Unsecured Nonpriority Claims Yes 1+ $- $17,338 $-

SCHEDULE G - Executory Contracts and 

Unexpired Leases Yes 1 $- $- $-

SCHEDULE H - CoDebtors

Yes 1 $- $- $-

SCHEDULE I - Current Income of 

Individual Debtor(s) Yes 1 $- $- $1,540

SCHEDULE J - Current Expenditures of 

Individual Debtor(s) Yes 1 $- $- $1,787

TOTALS $ 5,450 $ 17,338

TOTAL ASSETS TOTAL LIABILITIES

Record # 471053 B6 Summary (Official Form 6 - Summary) (12/07) Page 1 of 1

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 Document Page 6 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak / Debtor Bankruptcy Docket #:

STATISTICAL SUMMARY OF CERTAIN LIABILITIES - 28 U.S.C. § 159

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

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

Check this box if you are an individual debtor whose debts are NOT primarily consumer debts and, therefore, are 

not required to report any information here.

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)

$ 0 

$ 0 

$ 0 

$ 0 

$ 0 

$ 0 

Type of Liability

TOTAL $ 0 

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)

$ 1,787.00

$ 2,024.02

$ 1,539.67 

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)

$ 0.00

$ 0.00

$0 

$ 17,338.00

$ 17,338.00

Record # 471053 B 6 Summary (Official Form 6 - Summary) (12/07) Page 1 of 1

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 Document Page 7 of 39
UNITED STATES BANKRUPTCY COURT

In re NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak, Debtor

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 

co-tenant, 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 husband, wife, or both 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 amount of any exemption claimed in the 

property only in Schedule C - Property Claimed as Exempt.

Current Value of Debtors 

Interest in Property 

Without Deducting and 

Secured Claim or 

Exemption

Amount of 

Secured Claim

Nature of 

Debtor's Interest

 in Property

Description and Location of Property

 Husband

 Wife

 Joint

Or

Community

[x] None

Total Market Value of Real Property 

(Report also on Summary of Schedules) 

PFG Record # 471053 B6A (Official Form 6A) (12/07) Page 1 of 1

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 Document Page 8 of 39
UNITED STATES BANKRUPTCY COURT

In re NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak, Debtor

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 labled "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 husband, wife, or both own the 

property by placing an "H," "W," "J," or "C" in the column labeled "HWJC." 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 interest in executory and unexpired leases on this schedule. List them in Schedule G. 

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." In 

providing the information in this schedule, do not include the name or address of a minor child. Simpy state a "minor child."

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

H

W

J

C

Current Value of 

Debtor's Interest in 

Property, Without 

Deducting Any 

Secured Claim or 

01. Cash on Hand X

02. 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.

checking account with TCF Bank. H $ 700

checking account with TCF Bank. H $ 1,800

03. Security Deposits with public utilities, 

telephone companies, landlords and others. X

04. Household goods and furnishings, 

including audio, video, and computer 

equipment.

Household goods; TV, VCR, stereo, sofa, vacuum, 

table, chairs, lamps, TV Stand, bedroom sets, 

washer/dryer, stove, refrigerator, microwave, pots/pans, 

dishes/flatware

H $ 1,000

05. Books, pictures and other art objects, 

antiques, stamp, coin, record, tape, compact 

disc, and other collections or collectibles.

Books, Compact Discs, Tapes/Records, Family Pictures H $ 100

06. Wearing Apparel

Necessary wearing apparel. H $ 50

07. Furs and jewelry.

Earrings, watch, costume jewelry H $ 50

08. Firearms and sports, photographic, and 

other hobby equipment. X

09. Interests in insurance policies. Name 

insurance company of each policy and 

itemize surrender or refund value of each.

X

PFG Record # 471053 *471053FFF05schdbz* B6B (Official Form 6B) (12/07) Page 1 of 3

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 Document Page 9 of 39
UNITED STATES BANKRUPTCY COURT

In re NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak, Debtor

SCHEDULE B - PERSONAL PROPERTY

Type of Property

N

O

N

E

Description and Location of Property

H

W

J

C

Current Value of 

Debtor's Interest in 

Property, Without 

Deducting Any 

Secured Claim or 

10. Annuities. Itemize and name each issuer. X

11. Interests in an educational 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 records(s) of any such 

interest(s). 11 U.S.C. 521(c); Rule 1007(b)).

X

12. Interest in IRA,ERISA, Keogh, or other 

pension or profit sharing plans. Give 

particulars

X

13. Stocks and interests in incorporated and 

unincorporated businesses. X

14. Interest in partnerships or joint ventures. 

Itemize. Itemize. X

15. Government and corporate bonds and 

other negotiable and non-negotiable 

instruments.

X

16. Accounts receivable X

17. Alimony, maintenance, support and 

property settlements to which the debtor is or 

may be entitled

X

18. Other liquidated debts owing debtor 

including tax refunds. Give particulars. X

19. Equitable and future interests, life 

estates, and rights of power exercisable for 

the benefit of the debtor other than those 

listed in Schedule A - Real Property.

X

20. Contingent and Non-contingent interests 

in estate of a decedent, death benefit plan, 

life insurance policy, or trust.

X

21. Other contingent and unliquidated claims 

of every nature, including tax refunds, 

counter claims of the debtor, and rights to 

setoff claims. Give estimated value of each.

X

22. Patents, copyrights and other intellectual 

property. Give particulars. X

23. Licenses, franchises and other general 

intangibles. X

24. Customer list or other compilations 

containing personally identifiable information 

(as defined in 11 USC 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

X

PFG Record # 471053 *471053FFF05schdbz* B6B (Official Form 6B) (12/07) Page 2 of 3

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 Document Page 10 of 39
UNITED STATES BANKRUPTCY COURT

In re NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak, Debtor

SCHEDULE B - PERSONAL PROPERTY

Type of Property

N

O

N

E

Description and Location of Property

H

W

J

C

Current Value of 

Debtor's Interest in 

Property, Without 

Deducting Any 

Secured Claim or 

25. Autos, Truck, Trailers and other vehicles 

and accessories.

2005 Dodge Neon with over 75,000 miles. H $ 1,750

26. Boats, motors and accessories. X

27. Aircraft and accessories. X

28. Office equipment, furnishings, and 

supplies. X

29. Machinery, fixtures, equipment, and 

supplie used in business. X

30. Inventory X

31. Animals X

32. Crops-Growing or Harvested. Give 

particulars. X

33. Farming equipment and implements. X

34. Farm supplies, chemicals, and feed. X

35. Other personal property of any kind not 

already listed. Itemize. X

$5,450 Total 

(Report also on Summary of Schedules) 

PFG Record # 471053 *471053FFF05schdbz* B6B (Official Form 6B) (12/07) Page 3 of 3

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak, Debtor

SCHEDULE C - PROPERTY CLAIMED EXEMPT

Check if debtor claims a homestead exemption 

that exceeds $136,875

Debtor claims the exemptions to which debtor is entitled under:

(Check one box)

11 U.S.C. § 522(b)(2) 

11 U.S.C. § 522(b)(3) 

Description of Property Specify Law Providing Each 

Exemption

Current Value of 

Property without 

Deducting 

Exemption

Value of 

Claimed 

Exemption

02. 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.

checking account with TCF Bank. 735 ILCS 5/12-1001(b) $ 700 $ 700

 

 

checking account with TCF Bank. 735 ILCS 5/12-1001(b) $ 1,800 $ 1,800

 

 

04. Household goods and furnishings, including audio, video, and 

computer equipment.

Household goods; TV, VCR, stereo, sofa, vacuum, table, $ 1,000

chairs, lamps, TV Stand, bedroom sets, washer/dryer, 

stove, refrigerator, microwave, pots/pans, dishes/flatware

735 ILCS 5/12-1001(b) $ 1,000

 

 

05. Books, pictures and other art objects, antiques, stamp, coin, 

record, tape, compact disc, and other collections or collectibles.

Books, Compact Discs, Tapes/Records, Family Pictures 735 ILCS 5/12-1001(a) $ 100 $ 100

 

 

06. Wearing Apparel

Necessary wearing apparel. 735 ILCS 5/12-1001(a),(e) $ 50 $ 50

 

 

07. Furs and jewelry.

Earrings, watch, costume jewelry 735 ILCS 5/12-1001(b) $ 50 $ 50

 

 

25. Autos, Truck, Trailers and other vehicles and accessories.

2005 Dodge Neon with over 75,000 miles. 735 ILCS 5/12-1001(c) $ 2,400 $ 1,750

 

 

PFG Record # 471053 B6C (Official Form 6C) (12/07) Page 1 of 1

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 Document Page 12 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION In re

James Anthony Medziak, Debtor

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 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.

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

Creditor's Name and Mailing Address 

Including Zip and Account Number

(See Instructions Above)

* Date Claim was Incured

* Nature of Lien

*Value of Property Subject to Lien

*Description of Property

Amount of 

Claim 

Without 

Deducting 

Codebtor

Value of 

H

W

J

C

Contingent

Unsecured

Portion, If 

Any

Unliquidated

Disputed

[x] None

Total

(if applicatble, 

report also on 

Statistical 

Summary of 

Certain Liabilities 

and Related 

Data.) 

(Report also on 

Summary of 

Schedules.) 

$ - 

PFG Record # 471053 B6D (Official Form 6D) (12/07) Page 1 of 1

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 Document Page 13 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak, Debtor

In re

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 who file a case under chapter 7 or 13 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 

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

Wages, salaries, and commissions

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

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

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).

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 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 10, 2010, and every three years thereafter with respect to cases commenced on or after the date of adju

PFG Record # 471053 B6E (Official Form 6E) (12/07) Page 1 of 1

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UNITED STATES BANKRUPTCY COURT

In re NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak / Debtor

SCHEDULE F - CREDITORS HOLDING UNSECURED NON-PRIORITY 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 filing a case 

under chapter 7, report this total also on the Statistical Summary of Certain Liabilities and Related Data.

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)

Amount of 

Claim

Disputed

Unliquidated

Contingent

 Date Claim Was Incurred and

Consideration For Claim.

If Claim is Subject to Setoff, So State

H

W

J

Codebtor

C

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 85520

Richmond VA 23285

1 Capital One 2004-2009

Reason:

Dates:

$ 1,791

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 15298

Wilmington DE 19850

2 CHASE 2007-2009

Reason:

Dates:

$ 2,322

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 15298

Wilmington DE 19850

3 CHASE 2007-2009

Reason:

Dates:

$ 3,292

Record # 471053 B6F (Official Form 6F) (12/07) Page 1 of 3

Case 09-49486 Doc 1 Filed 12/31/09 Entered 12/31/09 09:40:34 Desc Main

 Document Page 15 of 39
UNITED STATES BANKRUPTCY COURT

In re NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak / Debtor

SCHEDULE F - CREDITORS HOLDING UNSECURED NON-PRIORITY CLAIMS

Creditor's Name, Mailing Address Including 

Zip Code and Account Number

(See Instructions Above)

Amount of 

Claim

Disputed

Unliquidated

Contingent

 Date Claim Was Incurred and

Consideration For Claim.

If Claim is Subject to Setoff, So State

H

W

J

Codebtor

C

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 15298

Wilmington DE 19850

4 Chase-Bp 2005-2009

Reason:

Dates:

$ 345

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 6497

Sioux Falls SD 57117

5 Citgo/CBSD 2002-2003

Reason:

Dates:

$ 96

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 6241

Sioux Falls SD 57117

6 CITI 2004-2009

Reason:

Dates:

$ 1,213

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 6241

Sioux Falls SD 57117

7 CITI 2005-2009

Reason:

Dates:

$ 5,848

Acct #: XXXXX6402

Notice Only Attn: Bankruptcy Dept.

PO Box 740241

Atlanta GA 30374

8 Equifax 2009

Reason:

Dates:

$ 0

Acct #: XXXXX6402

Notice Only Attn: Bankruptcy Dept.

PO Box 2002

Allen TX 75013

9 Experian 2009

Reason:

Dates:

$ 0

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 984100

El Paso TX 79998

10 GEMB/JCP 2007-2009

Reason:

Dates:

$ 297

Record # 471053 B6F (Official Form 6F) (12/07) Page 2 of 3

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 Document Page 16 of 39
UNITED STATES BANKRUPTCY COURT

In re NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

James Anthony Medziak / Debtor

SCHEDULE F - CREDITORS HOLDING UNSECURED NON-PRIORITY CLAIMS

Creditor's Name, Mailing Address Including 

Zip Code and Account Number

(See Instructions Above)

Amount of 

Claim

Disputed

Unliquidated

Contingent

 Date Claim Was Incurred and

Consideration For Claim.

If Claim is Subject to Setoff, So State

H

W

J

Codebtor

C

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 5253

Carol Stream IL 60197

11 HSBC BANK 2007-2009

Reason:

Dates:

$ 1,801

Acct #: XXXXX6402

Credit Card or Credit Use Attn: Bankruptcy Dept.

Po Box 6497

Sioux Falls SD 57117

12 Shell/CITI 2005-2009

Reason:

Dates:

$ 333

Acct #: XXXXX6402

Notice Only Attn: Bankruptcy Dept.

PO Box 1000

Chester PA 19022

13 Transunion 2009

Reason:

Dates:

$ 0

$ 17,338.00 Total Amount of Unsecured Claims

(Report also on Summary of Schedules) 

Record # 471053 B6F (Official Form 6F) (12/07) Page 3 of 3

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 Document Page 17 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

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 Non-Residential Real 

Property. State Contract Number or 

Any Government Contract.

[x] None

PFG Record # 471053 B6G (Official Form 6G) (12/07) Page 1 of 1

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 Document Page 18 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION In re

James Anthony Medziak, Debtor

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 the Creditor

[x] None

PFG Record # 471053 B6H (Official Form 6H) (12/07) Page 1 of 1

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 Document Page 19 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor Bankruptcy Docket #:

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 Form 22A, 22B, or 22C.

SCHEDULE I - CURRENT INCOME OF INDIVIDUAL DEBTOR(S)

Debtor's Marital 

Status:

DEPENDENTS OF DEBTOR AND SPOUSE ~ RELATIONSHIP AND AGE

Divorced None 

City, State, Zip

Employer Address:

Years Employed

Name of Employer:

Occupation:

DEBTOR EMPLOYMENT SPOUSE EMPLOYMENT

Federal Gov VA Admin

Out-Patient Assistant

2449 Ross Millville Rd

Hamilton, OH 45013 , 

INCOME: (Estimate of average or projected monthly income at time case filed.) DEBTOR SPOUSE

1. Monthly Gross Wages, Salary, and commissions 

(Prorate if not paid monthly.)

$ 554.67 $ 0.00 

2. Estimated Monthly Overtime $ 0.00 $ 0.00 

3. SUBTOTAL $ 554.67 $ 0.00 

4. LESS PAYROLL DEDUCTIONS

a. Payroll Taxes and Social Security

b. Insurance

c. Union Dues

d. Other (Specify)

$ 0.00 

$ 0.00 

$ 0.00 

$ 0.00 

$ 0.00 

$ 0.00 

Pension:

Voluntary 401 Contributions:

Child Support:

Life Insurance, Uniforrms, 401K Loan:

$ 0.00 

$ 0.00 

$ 0.00 

$ 0.00 

5. SUBTOTAL OF PAYROLL DEDUCTIONS

$ 0.00 

$ 0.00 

$ 0.00 

$ 0.00 

$ 0.00 $ 0.00 

6. TOTAL NET MONTHLY TAKE HOME PAY $ 554.67 $ 0.00 

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

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.

$ 0.00 

$ 0.00 

$ 0.00 $ 0.00 

$ 0.00 

$ 0.00 

$ 0.00 

11. Social Security or government assistance (Specify)

12. Pension or retirement income

13. Other monthly income

$ 985.00 $ 0.00 

$ 0.00 $ 0.00 

14. SUBTOTAL OF LINES 7 THROUGH 13

(Specify:)

$ 0.00 

Unemployment Income $ 0.00 $ 0.00 

$ 0.00 & & $ 0.00 

15. AVERAGE MONTHLY INCOME (Add amounts shown on lines 6 and 14) $ 1,539.67 $ 0.00 

16. COMBINED AVERAGE MONTHLY INCOME (Combine column totals fromline 15; 

if there is only one debtor repeat total reported on line 15.)

$ 1,539.67 

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:

Debtor is currently in a Veteran's Work Therapy Program which will end after February 2010 and he will no 

longer receive any income from this source.

B6I (Official Form 6I) (12/07) Page 1 of 1 Record #: 471053

Case 09-49486 Doc 1 Filed 12/31/09 Entered 12/31/09 09:40:34 Desc Main

 Document Page 20 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak / Debtor Bankruptcy Docket #:

Complete this schedule by estimating the average monthly expenses of the debtor and the debtor's family at time case filed. Prorate any 

payments made bi-weekly, quarterly, semi-annually, or annually to show monthly rate.

SCHEDULE J - CURRENT EXPENSES OF INDIVIDUAL DEBTOR(S)

Check box if joint petition is filed & 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. Real Estate taxes included? [ ] Yes [x] No b. Property insurance included? [ ] Yes [x] No

$ 500.00 

2. Utilities: a. Electricity and Heating Fuel

b. Water, Sewer, Garbage

c. Cellphone, Internet

$ 100.00 

d. Other Home Phone and Cable Television $ 140.00 

3. Home Maintenance (repairs and upkeep) $ - 

$ - 

$ 75.00 

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.

$ 400.00 

$ 30.00 

$ 57.00 

$ - 

$ 185.00 

$ 75.00 

Gas, Tolls/Parking, Fees/Licenses, Repair, Bus/Train

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

$ - 

$ - 

$ - 

$ 60.00 

$- 

$- 

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

(Specify) Federal or State Tax Repayments, Real Estate Taxes $ - 

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

a. Auto

b. Reaffirmation Payments

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: Pet 

Care:

$145.00 $ - 

Haircuts, Hygiene, 

Eyecare, Meds

$20.00 $0.00

Newspaper/Mags & 

Postage/Banking

Tuition, Books & 

GLS Repay:

Childcare & 

Babysitting

$ - $165.00

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

the Stastical of Summary of Certain Liabilities and Related Data.

19. Describe any increase/decrease in expenditures anticipated to occur within the year following the filing this document:

$ 1,787.00 

None

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.)

$ 1,539.67 

$(247.33)

$ 1,787.00 

d. Total amount to be paid into plan monthly $ - 

B6J (Official Form 6J) (12/07) Page 1 of 1 Record #: 471053

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak Debtor Bankruptcy Docket #:

DECLARATION CONCERNING DEBTOR'S SCHEDULES

DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR

I declare under penalty of perjury that I have read the foregoing summary and schedules, and that they are true and 

correct to the best of my knowledge, information and belief. I have disclosed on the foregoing schedules all property or 

assets I may have an interest in, the correct value of it, and every debt I may be liable for. I accept the risk that some 

debts won't be discharged. I have been advised of the difference between Chapter 7 and Chapter 13, income & expense 

concepts, budgeting, and have made full disclosure.

Debtor's attorney has advised debtor that creditors can object to discharge of their debt on a variety of grounds including 

fraud, recent credit usage, divorce and support obligations and reckless conduct. 

Debtor's attorney has advised debtor that non-dischargeable debts such as taxes, student loans, fines by government 

units and liens on property of debtor are generally unaffected by bankruptcy.

Dated: 12/21/2009 X Date & Sign

James Anthony Medziak 

/s/ James Anthony Medziak 

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. Sections 152 and 3571

if joint case, both spouses must sign. If NOT a joint case the joint debtor will NOT appear.

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

Non-Attorney Petition Preparers were NOT used to prepare any portion of this petition. All documents were produced by 

the Law Offices of Peter Francis Geraci.

DECLARATION UNDER PENALTY OF PERJURY ON BEHALF OF A CORPORATION OR PARTNERSHIP

This is a personal bankruptcy for an individual(s) and NOT a corporation or partnership.

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. Sections 152 and 3571

THIS SECTION ONLY APPLIES TO PETITION PREPARERS AND HAS NOTHING TO DO WITH THIS CASE

THIS SECTION ONLY APPLIES TO CORPORTATIONS & PARTNERSHIPS AND HAS NOTHING TO DO WITH THIS CASE

PFG Record # 471053 B6 Declaration (Official Form 6-Declaration) (12/07) Page 1 of 1

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 Document Page 22 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

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.

01. INCOME FROM EMPLOYMENT OR OPERATION OF BUSINESS:

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

2009: $7,000 employment

2008: $0

2007: $0

Spouse

X

NONE

.

AMOUNT

.

SOURCE

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 1 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

02. INCOME OTHER THAN FROM EMPLOYMENT OR OPERATION OF BUSINESS:

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

2009: $11,820 Pension

2008: $0

2007: $0

Spouse

X

NONE

.

AMOUNT

.

SOURCE

03. PAYMENTS TO CREDITORS:

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

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 proceeding the commencement of this case if the aggregate 

value of all property that constitutes or is affected by such transfer is not less than $600.00. 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 creditor 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.)

X

NONE

Name and Address

of Creditor

Dates of

Payments

Amount

Paid

Amount

Still Owing

b. DEBTOR WHOSE DEBTS ARE NOT PRIMARILY CONSUMER DEBTS: List each payment or other transfer to any creditor made with 90 

days immediately preceding the commencement of the case if the aggregate value of all property that constitutes or is affected by such 

transfer is not less than $5,000 (Married debtors filing under chapter 12 or chapter 13 must include payments and other transfers by each 

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

X

NONE

Name and Address

of Creditor

Dates of

Payment/Transfers

Amount Paid or Value of 

Transfers

Amount

Still Owing

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 2 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

c. ALL DEBTORS: List all payments made within 1 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 be either or both 

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

X

NONE

Name & Address of Creditor 

& Relationship to Debtor

Dates

of Payments

Amount Paid or Value of 

Transfers

Amount

Still Owing

04. SUITS AND ADMINISTRATIVE PROCEEDINGS, EXECUTIONS, GARNISHMENTS AND ATTACHMENTS:

List all lawsuits & administrative proceedings to which the debtor is or was a party within 1 (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.)

X

NONE

CAPTION OF

SUIT AND

CASE NUMBER

NATURE

OF

PROCEEDING

COURT

OF AGENCY

AND LOCATION

STATUS

OF

DISPOSITION

04b. WAGES OR ACCOUNTS GARNISHED: Describe all property that has been attached, garnished or seized under any legal or equitable 

process within (1) one year 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.)

X

NONE

Name and Address of Person 

for Whose Benefit Property 

was Seized

Date

of

Seizure

Description

and Value

of Property

05. REPOSSESSION, FORECLOSURES AND RETURNS:

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.)

X

NONE

Name and Address of 

Creditor or Seller

Date of Repossession, Foreclosure 

Sale, Transfer or Return

Description and

Value of Property

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 3 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

06. ASSIGNMENTS AND RECEIVERSHIPS:

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.)

X

NONE

Name and

Address of

Assignee

Date

of

Assignment

Terms of

Assignment or

Settlement

b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within one (1) 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.)

X

NONE

Name and

Address

of Custodian

Name & Location

of Court Case

Title & Number

Date

of

Order

Description

and Value of

Property

07. GIFTS:

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.)

X

NONE

Name and Address of Person 

or

Organization

Relationship

to Debtor,

If Any

Date

of

Gift

Description

and Value

of Gift

08. LOSSES:

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.)

X

NONE

Description and

Value

of Property

Description of Circumstances and, 

if Loss Was Covered in Whole or in 

Part by Insurance, Give Particulars

Date

of

Loss

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 4 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

09. PAYMENTS RELATED TO DEBT COUNSELING OR BANKRUPTCY:

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 (1) year immediately 

preceding the commencement of this case.

Name and

Address

of Payee

Date of Payment,

Name of Payer if

Other Than Debtor

Amount of Money or

Description and

Value of Property

12/2009 Payment/Value:

 1,800.00

Law Offices of Peter 

Francis Geraci

55 E Monroe St 

Suite#3400

 Chicago,IL 60603

09a. PAYMENTS RELATED TO DEBT COUNSELING OR BANKRUPTCY: 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 1 year immediately preceding the commencement of this case.

Name and

Address

of Payee

Date of Payment,

Name of Payer if

Other Than Debtor

Amount of Money or 

description and

Value of Property

MMI/CCCS 2009 $50.00

9009 W. Loop S.

Houston, TX 77096

Phone 866.983.2227

MMI/CCCS 2009 $50.00

9009 W. Loop S.

Houston, TX 77096

Phone 866.983.2227

10. OTHER TRANSFERS

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 with two (2) 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.)

X

NONE

Name and Address of 

Transferee, Relationship

to Debtor

.

.

Date

Describe Property 

Transferred and

Value Received

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 5 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

10b. List all property transferred by the debtor within ten (10) years immediately preceding the commencement of this case to a self-settled 

X trust or similar device of which the debtor is a beneficiary.

NONE

Name of

Trust or

other Device

Date(s)

of

Transfer(s)

Amount and Date

of Sale or

Closing

11. CLOSED FINANCIAL ACCOUNTS:

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 (1) 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.)

X

NONE

Name and

Address of

Institution

Type of Account, Last Four Digits 

of Account Number, and Amount of 

Final Balance

Amount and

Date of Sale or

Closing

12. SAFE DEPOSIT BOXES:

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.)

X

NONE

Name and Address of Bank 

or Other Depository

Names & Addresses of Those With 

Access to Box or depository

Description of

Contents

Date of Transfer or

Surrender, if Any

13. SETOFFS:

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.)

X

NONE

Name and Address

of Creditor

Date

of Setoff

Amount

of Setoff

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 6 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

14. LIST ALL PROPERTY HELD FOR ANOTHER PERSON:

List all property owned by another person that the debtor holds or controls.

X

NONE

Name and Address

of Owner

Description and

Value of Property

Location

of Property

15. PRIOR ADDRESS OF DEBTOR(S):

If debtor has moved within three (3) 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.

X

NONE

.

Address

Name

Used

Dates of

Occupancy

16. SPOUSES and FORMER SPOUSES:

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 (8) 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.

X

NONE

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, ground water, or other medium, including, but not limited to, 

statutes or regulations regulating the cleanup of the 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 or toxic substances, pollutant, or contaminant, etc. under 

environmental Law.

X

NONE

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 7 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

17a. 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:

X

NONE

Site Name

and Address

Name and Address

of Governmental Unit

Date

of Notice

Environmental

Law

17b. List the name and address of every site for which the debtor provided notice to a governmental unit of a release of Hazardous 

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

NONE

Site Name

and Address

Name and Address

of Governmental Unit

Date

of Notice

Environmental

Law

17c. 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.

X

NONE

Name and Address of 

Governmental Unit

Docket

Number

Status of

Disposition

18 NATURE, LOCATION AND NAME OF BUSINESS

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 (6) years 

immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities 

within six (6) 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 

(6) 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 

(6) years immediately preceding the commencement of this case.

X

NONE

Name & Last Four Digits of 

Soc. Sec. No./Complete EIN or 

Other TaxPayer I.D. No.

.

.

Address

Nature

of

Business

Beginning

and

Ending Dates

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 8 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

b. Identify any business listed in subdivision a., above, that is "single asset real estate" as defined in 11 USC 101.

X

NONE

.

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:

List all bookkeepers and accountants who within two (2) years immediately preceding the filing of this bankruptcy case kept or supervised 

the keeping of books of account and records of the debtor.

X

NONE

Name

and Address

Dates Services

Rendered

19b. List all firms or individuals who within two (2) years immediately preceding the filing of this bankruptcy case have audited the books of 

X account and records, or prepared a financial statement of the debtor.

NONE

.

Name

.

Address

Dates Services

Rendered

19c. 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 

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

NONE

.

Name

.

Address

19d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was 

X issued by the debtor within two (2) years immediately preceding the commencement of this case.

NONE

Name and

Address

Date

Issued

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

20. INVENTORIES

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.

X

NONE

Date

of

Inventory

Inventory

Supervisor

Dollar Amount of Inventory 

(specify cost, market of other 

basis)

b. List the name and address of the person having possession of the records of each of the inventories reported in a., above.

X

NONE

Date

of Inventory

Name and Addresses of Custodian 

of Inventory Records

21. CURRENT PARTNERS, OFFICERS, DIRECTORS AND SHAREHOLDERS:

a. If the debtor is a partnership, list nature and percentage of interest of each member of the partnership.

X

NONE

Name

and Address

Nature

of Interest

Percentage of

Interest

21b. If the debtor is a corporation, list all officers & directors of the corporation; and each stockholder who directly or indirectly owns, 

X controls, or holds 5% or more of the voting or equity securities of the corporation.

NONE

Name

and Address

.

Title

Nature and Percentage of 

Stock Ownership

22. FORMER PARTNERS, OFFICERS, DIRECTORS AND SHAREHOLDERS:

If the debtor is a partnership, list the nature and percentage of partnership interest of each member of the partnership.

X

NONE

.

Name

.

Address

Date of

Withdrawal

22b. If the debtor is a corporation, list all officers, or directors whose relationship with the corporation terminated within one (1) year 

X immediately preceding the commencement of this case.

NONE

Name

and Address

.

Title

Date of

Termination

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 10 of 12

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

22b. If the debtor is a corporation, list all officers, or directors whose relationship with the corporation terminated within one (1) year 

X immediately preceding the commencement of this case.

NONE

Name

and Address

.

Title

Date of

Termination

23. WITHDRAWALS FROM A PARTNERSHIP OR DISTRIBUTION BY A COPORATION:

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.

X

NONE

Name and Address of 

Recipient, Relationship to 

Debtor

Date and

Purpose of

Withdrawal

Amount of Money or 

Description and value of 

Property

24. TAX CONSOLIDATION GROUP:

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 (6) years immediately preceding the commencement of the 

case.

X

NONE

Name of

Parent Corporation

Taxpayer

Identification Number (EIN)

25. PENSION FUNDS:

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 (6) years immediately preceding the commencement of the case.

X

NONE

Name of

Pension Fund

TaxPayer

Identification Number (EIN)

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 11 of 12

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 Document Page 33 of 39
UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

STATEMENT OF FINANCIAL AFFAIRS

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

financial affairs and any attachment thereto and that they are true and correct.

X Date & Sign

James Anthony Medziak 

Dated: 12/21/2009 /s/ James Anthony Medziak 

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. Sections 152 and 3571

DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR

PFG Record # 471053 B7 (Official Form 7) (12/07) Page 12 of 12

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James Anthony Medziak / Debtor

UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION In re

DEBTOR'S STATEMENT OF INTENTION

PART A - Debts secured by property of the estate. (Part A must be fully completed for EACH 

debt which is secured by property of the estate. Attach additional pages if necessary.)

 Property No. 0

Creditor's Name:

NONE

 Describe Property Securing Debt:

PART B - Personal property subject to unexpired leases. (All three columns of Part B must 

be completed for each unexpired lease. Attach additional pages if necessary.)

Lease will be 

assumed pursuant to 

11 U.S.C. § 365(p)(2):

□ Yes □ No

 Property No. 0

Lessor's Name:

NONE

 Describe Property Securing Debt:

 

I declare under penalty of perjury that the above indicates my intention as to any property of my estate 

securing a debt and/or personal property subject to an unexpired lease.

James Anthony Medziak X Date & Sign Dated: 12/21/2009 /s/ James Anthony Medziak 

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For legal services, Debtor(s) agrees to pay and I have agreed to accept

Prior to the filing of this Statement, Debtor(s) has paid and I have received

James Anthony Medziak, 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 above named 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:

The compensation paid or promised by the Debtor(s), to the undersigned, is as follows:

$1,800

The Filing Fee has been paid. Balance Due

2. The source of the compensation paid to me was:

3. The source of compensation to be paid to me on the unpaid balance, if any, remaining is:

The undersigned has received no transfer, assignment or pledge of property from the debtor(s) except the following for the 

value stated: None.

4. The undersigned has not shared or agreed to share with any other entity, other than with members of the undersigned's law 

firm, any compensation paid or to be paid without the client's consent, except as follows: None.

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.

$0

$1,800

Attorney Name: Wylie W Mok Bar No: IL 6293407

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR - 2016B

LAW OFFICES OF PETER FRANCIS GERACI

55 E. Monroe Street #3400

Chicago IL 60603

312.332.1800 (PH) 312.332.6354 (FAX)

UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

Bankruptcy Docket #:

In re

Dated: 12/30/2009 /s/ Wylie W Mok

Respectfully Submitted, 

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

Fee does NOT include missed court dates & amendments to schedules, contested matters, motions, objections to discharge 

or other matters except the first meeting of creditors. 

Debtor(s) Other: (specify)

Debtor(s) Other: (specify)

5. The Service rendered or to be rendered include the following:

(a) Analysis of the financial situation, and rendering advice and assistance to the client in determining whether to file a petition

under Title 11, U.S.C. 

(b) Preparation and filing of the petition, schedules, statement of affairs and other documents required by the court.

(c) Representation of the client at the first scheduled meeting of creditors.

(d) Advice as required.

PFG Record # 471053 *471053FFF03stmnt2z* Form B203 (12/94) Page 1 of 1

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UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

In re

James Anthony Medziak, Debtor

VERIFICATION OF CREDITOR MATRIX

The above named Debtor(s) hereby verify that the attached list of creditors is true and correct to the best of our knowledge.

X Date & Sign

James Anthony Medziak 

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.

Dated: 12/21/2009 /s/ James Anthony Medziak 

* Joint debtors must provide information for both spouses. Penalty for making a false statement or concealing property: 

Fine up to $500,000 or up to 5 years imprisonment or both. 18 U.S.C. 152 and 3571.

PFG Record # 471053 *471053FFFVerMatrixz*

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Form B 201A, Notice to Consumer Debtor(s) In re James Anthony Medziak Debtor

UNITED STATES BANKRUPTCY COURT

NOTICE TO CONSUMER DEBTOR(S) UNDER §342(b)

OF THE BANKRUPTCY CODE

In accordance with § 342(b) of the Bankruptcy Code, this notice to individuals with primarily consumer 

debts: (1) Describes briefly the services available from credit counseling services; (2) Describes briefly the 

purposes, benefits and costs of the four types of bankruptcy proceedings you may commence; and (3) Informs you 

about bankruptcy crimes and notifies you that the Attorney General may examine all information you supply in 

connection with a bankruptcy case.

You are cautioned that bankruptcy law is complicated and not easily described. Thus, you may wish to seek 

the advice of an attorney to learn of your rights and responsibilities should you decide to file a petition. Court 

employees cannot give you legal advice.

Notices from the bankruptcy court are sent to the mailing address you list on your bankruptcy petition. In

order to ensure that you receive information about events concerning your case, Bankruptcy Rule 4002 requires that 

you notify the court of any changes in your address. If you are filing a joint case (a single bankruptcy case for two 

individuals married to each other), and each spouse lists the same mailing address on the bankruptcy petition, you 

and your spouse will generally receive a single copy of each notice mailed from the bankruptcy court in a jointlyaddressed envelope, unless you file a statement with the court requesting that each spouse receive a separate copy of 

all notices.

1. Services Available from Credit Counseling Agencies

With limited exceptions, § 109(h) of the Bankruptcy Code requires that all individual debtors who file

for bankruptcy relief on or after October 17, 2005, receive a briefing that outlines the available opportunities 

for credit counseling and provides assistance in performing a budget analysis. The briefing must be given 

within 180 days before the bankruptcy filing. The briefing may be provided individually or in a group (including 

briefings conducted by telephone or on the Internet) and must be provided by a nonprofit budget and credit 

counseling agency approved by the United States trustee or bankruptcy administrator. The clerk of the bankruptcy 

court has a list that you may consult of the approved budget and credit counseling agencies. Each debtor in a joint 

case must complete the briefing.

In addition, after filing a bankruptcy case, an individual debtor generally must complete a financial

management instructional course before he or she can receive a discharge. The clerk also has a list of approved 

financial management instructional courses. Each debtor in a joint case must complete the course.

2. The Four Chapters of the Bankruptcy Code Available to Individual Consumer Debtors

Chapter 7: Liquidation ($245 filing fee, $39 administrative fee, $15 trustee surcharge: Total fee $299

Chapter 7 is designed for debtors in financial difficulty who do not have the ability to pay their existing

debts. Debtors whose debts are primarily consumer debts are subject to a “means test” designed to determine 

whether the case should be permitted to proceed under chapter 7. If your income is greater than the median income 

for your state of residence and family size, in some cases, the United States trustee (or bankruptcy administrator), 

the trustee, or creditors have the right to file a motion requesting that the court dismiss your case under § 707(b) of 

the Code. It is up to the court to decide whether the case should be dismissed.

Under chapter 7, you may claim certain of your property as exempt under governing law. A trustee may have 

the right to take possession of and sell the remaining property that is not exempt and use the sale proceeds to pay 

your creditors.

The purpose of filing a chapter 7 case is to obtain a discharge of your existing debts. If, however, you are

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Form B 201A, Notice to Consumer Debtor(s) In re James Anthony Medziak Debtor Page 2

found to have committed certain kinds of improper conduct described in the Bankruptcy Code, the court may deny your 

discharge and, if it does, the purpose for which you filed the bankruptcy petition will be defeated.

Even if you receive a general discharge, some particular debts are not discharged under the law. Therefore, you may 

still be responsible for most taxes and student loans; debts incurred to pay nondischargeable taxes; domestic support and 

property settlement obligations; most fines, penalties, forfeitures, and criminal restitution obligations; certain debts which are 

not properly listed in your bankruptcy papers; and debts for death or personal injury caused by operating a motor vehicle, 

vessel, or aircraft while intoxicated from alcohol or drugs. Also, if a creditor can prove that a debt arose from fraud, breach of 

fiduciary duty, or theft, or from a willful and malicious injury, the bankruptcy court may determine that the debt is not 

discharged.

Chapter 13: Repayment of All or Part of the Debts of an Individual with Regular Income ($235 filing

fee, $39 administrative fee: Total fee $274)

Chapter 13 is designed for individuals with regular income who would like to pay all or part of their debts in installments 

over a period of time. You are only eligible for chapter 13 if your debts do not exceed certain dollar amounts set forth in the 

Bankruptcy Code.

Under chapter 13, you must file with the court a plan to repay your creditors all or part of the money that you owe 

them, using your future earnings. The period allowed by the court to repay your debts may be three years or five years, 

depending upon your income and other factors. The court must approve your plan before it can take effect.

After completing the payments under your plan, your debts are generally discharged except for domestic support 

obligations; most student loans; certain taxes; most criminal fines and restitution obligations; certain debts which are not 

properly listed in your bankruptcy papers; certain debts for acts that caused death or personal injury; and certain long term 

secured obligations.

Chapter 11: Reorganization ($1000 filing fee, $39 administrative fee: Total fee $1039)

Chapter 11 is designed for the reorganization of a business but is also available to consumer debtors. Its provisions are 

quite complicated, and any decision by an individual to file a chapter 11 petition should be reviewed with an attorney.

Chapter 12: Family Farmer or Fisherman ($200 filing fee, $39 administrative fee: Total fee $239)

Chapter 12 is designed to permit family farmers and fishermen to repay their debts over a period of time from

future earnings and is similar to chapter 13. The eligibility requirements are restrictive, limiting its use to those whose 

income arises primarily from a family-owned farm or commercial fishing operation.

3. Bankruptcy Crimes and Availability of Bankruptcy Papers to Law Enforcement Officials

A person who knowingly and fraudulently conceals assets or makes a false oath or statement under penalty

of perjury, either orally or in writing, in connection with a bankruptcy case is subject to a fine, imprisonment, or both. All 

information supplied by a debtor in connection with a bankruptcy case is subject to examination by the Attorney General 

acting through the Office of the United States Trustee, the Office of the United States Attorney, and other components and 

employees of the Department of Justice.

WARNING: Section 521(a)(1) of the Bankruptcy Code requires that you promptly file detailed information regarding your creditors, assets, 

liabilities, income, expenses and general financial condition. Your bankruptcy case may be dismissed if this information is not filed with the court 

within the time deadlines set by the Bankruptcy Code, the Bankruptcy Rules, and the local rules of the court. The documents and the deadlines for 

filing them are listed on Form B200, which is posted at http://www.uscourts.gov/bkforms/bankruptcy_forms.html#procedure.

Dated: 12/21/2009 /s/ James Anthony Medziak 

James Anthony Medziak 

I (We), the debtor(s), affirm that I (we) have received and read this notice.

Attorney: Wylie W Mok Bar No: IL 6293407

Dated: 12/30/2009 /s/ Wylie W Mok

Sign & Date 

Here

Sign & Date 

Here

PFG Record # 471053

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