Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

Voluntary Petition 

B1 (Official Form 1) (1/08) 

United States Bankruptcy Court 

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

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

(include married, maiden, and trade names): 

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

(include married, maiden, and trade names): 

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

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

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

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

Type of Debtor 

(Form of Organization) 

(Check one box) 

Corporation (includes LLC and LLP) 

Individual (includes Joint Debtors) 

See Exhibit D on page 2 of this form. 

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

check this box and state type of entity below.) 

Partnership Stockbroker

Railroad 

Commodity Broker 

Nature of Debts 

(Check one box) 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 

Chapter 11 Debtors 

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

THIS SPACE IS FOR 

 COURT USE ONLY 

Statistical/Administrative Information 

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

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

distribution to unsecured creditors. 

Estimated Number of Creditors 

1-49 50-99 100-199 200-999 1000-

5000 

Estimated Assets 

$0 to 

$50,000 

$50,001 to 

$100,000 

$500,001 

to $1 

million 

$1,000,001 

 to $10 

million 

More than 

 $1 billion 

Estimated Liabilities 

Chapter 9 

Chapter 7 

Chapter 13 

Chapter of Bankruptcy Code Under Which

the Petition is Filed (Check one box) 

Chapter 12 

Chapter 11 

Filing Fee (Check one box) 

Full Filing Fee attached 

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

signed application for the court's consideration certifying that the debtor is unable 

to pay fee except in installments. Rule 1006(b). See Official Form No. 3A. 

Clearing Bank 

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): 

 ZIPCODE ZIPCODE 

 ZIPCODE 

 ZIPCODE 

 ZIPCODE 

Nature of Business 

Health Care Business 

Single Asset Real Estate as defined in 

11 U.S.C. § 101 (51B) 

Debtor is a tax-exempt organization 

under Title 26 of the United States 

Code (the Internal Revenue Code) 

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

Debtor’s aggregate noncontingent liquidated debts (excluding debts 

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

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

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

5,001-

10,000

10,001-

25,000 

50,001-

100,000 

25,001-

50,000 

Over 

100,000 

Check all applicable boxes 

Acceptances of the plan were solicited prepetition from one or 

more classes, in accordance with 11 U.S.C. § 1126(b). 

A plan is being filed with this petition. 

Check one box: 

Check if: 

 (Check one box) 

Other 

Chapter 15 Petition for 

Recognition of a Foreign 

Main Proceeding

Tax-Exempt Entity 

(Check box, if applicable) 

Chapter 15 Petition for 

Recognition of a Foreign 

Nonmain Proceeding 

$100,001 to 

$500,000 

$10,000,001 

 to $50 

million 

$50,000,001 

to $100 

million 

$100,000,001 

to $500 

million 

$500,000,001 

to $1 billion 

$0 to 

$50,000 

$50,001 to 

$100,000 

$500,001 

to $1 

million 

$1,000,001 

 to $10 

million 

More than 

 $1 billion 

$100,001 to 

$500,000 

$10,000,001 

 to $50 

million 

$50,000,001 

to $100 

million 

$100,000,001 

to $500 

million 

$500,000,001 

to $1 billion 

Northern District of Illinois

Sample, Michael R. 

1332

60081

Mchenry

9005 Daniel Lane

Spring Grove, IL

None

8256

Mchenry

Sample, Michelle M. 

60081

9005 Daniel Lane

Spring Grove, IL

None

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 1 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B1 (Official Form 1) (1/08) Page 2 

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

Voluntary Petition Name of Debtor(s): 

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

Location 

Where Filed: 

Relationship: Judge: 

Case Number: Date Filed: 

Case Number: Date Filed: 

District: 

Name of Debtor: 

Exhibit A 

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

10K and 10Q) with the Securities and Exchange Commission pursuant to 

Section 13 or 15(d) of the Securities Exchange Act of 1934 and is requesting 

relief under chapter 11) 

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

Exhibit B 

(To be completed if debtor is an individual 

whose debts are primarily consumer debts) 

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

the petitioner that [he or she] may proceed under chapter 7, 11, 12, or 13 of title 11, United 

States Code, and have explained the relief available under each such chapter. 

I further certify that I delivered to the debtor the notice required by 11 U.S.C. § 342(b). 

Signature of Attorney for Debtor(s) Date 

X 

Exhibit C 

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

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

No 

(Check any applicable box) 

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

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

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

Information Regarding the Debtor - Venue 

Debtor is a debtor in a foreign proceeding and has its principal place of business or principal assets in the United Sates 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 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. 

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. 

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

(Check all applicable boxes) 

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

Debtor claims that under applicable non bankruptcy 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. 

(Name of landlord that obtained judgment) 

(Address of landlord) 

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

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

If this is a joint petition: 

Location 

Where Filed: 

Case Number: Date Filed: 

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

Michael R. Sample & Michelle M. Sample

NONE

N.A.

NONE

/s/ John H. Redfield

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 2 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B1 (Official Form 1) (1/08) Page 3 

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

Voluntary Petition Name of Debtor(s): 

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

Signature of Debtor 

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. 

Signatures

X 

Signature of Joint Debtor 

X 

Telephone Number (If not represented by attorney) 

Date 

Signature of Attorney*

Signature of Attorney for Debtor(s) 

X 

Printed Name of Attorney for Debtor(s) 

Firm Name 

Address 

Telephone Number 

Date 

Signature of Debtor (Corporation/Partnership) 

Signature of Authorized Individual 

X 

Printed Name of Authorized Individual 

Title of Authorized Individual 

Date 

Signature of Non-Attorney Petition Preparer 

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

as defined in 11 U.S.C. § 110, 2) I prepared this document for compensation, 

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

and information required under 11 U.S.C. § 110(b), 110(h), and 342(b); and, 

3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110 

setting a maximum fee for services chargeable by bankruptcy petition 

preparers, I have given the debtor notice of the maximum amount before any 

document for filing for a debtor or accepting any fee from the debtor, as 

required in that section. Official Form 19 is attached.

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

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

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

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

Address 

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. 

Signature of bankruptcy petition preparer or officer, principal, responsible 

person, or partner whose Social Security number is provided above. 

X 

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. 

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 a Foreign Representative 

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

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

proceeding, and that I am authorized to file this petition. 

(Signature of Foreign Representative) 

(Printed Name of Foreign Representative) 

(Date) 

X 

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

Code. Certified copies of the documents required by § 1515 of title 11 are 

attached. 

(Check only one box.) 

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. 

Date 

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

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

information in the schedules is incorrect. 

Michael R. Sample & Michelle M. Sample

/s/ Michael R. Sample

/s/ Michelle M. Sample

/s/ John H. Redfield

JOHN H. REDFIELD 2298090

John H. Redfield & Associates, P.C.

102 S. Wynstone Park Dr, Ste 201

North Barrington, IL 60010

847-382-1220

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 3 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B1 D (Official Form 1, Exhibit D ) (12/09) 

UNITED STATES BANKRUPTCY COURT

In re______________________________________ Case No._____________ 

 Debtor(s) (if known) 

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITH 

CREDIT COUNSELING REQUIREMENT 

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

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

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

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

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

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

collection activities. 

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

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

any documents as directed. 

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

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

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

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

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

developed through the agency. 

 

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

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

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

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

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

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

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

Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

Michael R. Sample & Michelle M. Sample

Northern District of Illinois

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 4 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B1 D (Official Form 1, Exh. D) (12/09) – Cont. Page 2 

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

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

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

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

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

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

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

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

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

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

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

without first receiving a credit counseling briefing. 

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. 

Date: _________________

Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

Signature of Debtor: /s/ Michael R. Sample

MICHAEL R. SAMPLE

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 5 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B1 D (Official Form 1, Exhibit D ) (12/09) 

UNITED STATES BANKRUPTCY COURT

In re______________________________________ Case No._____________ 

 Debtor(s) (if known) 

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITH 

CREDIT COUNSELING REQUIREMENT 

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

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

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

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

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

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

collection activities. 

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

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

any documents as directed. 

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

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

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

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

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

developed through the agency. 

 

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

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

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

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

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

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

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

Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

Michael R. Sample & Michelle M. Sample

Northern District of Illinois

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 6 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B1 D (Official Form 1, Exh. D) (12/09) – Cont. Page 2 

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

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

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

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

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

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

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

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

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

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

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

without first receiving a credit counseling briefing. 

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. 

Date: _________________

Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

Signature of Joint Debtor: /s/ Michelle M. Sample

MICHELLE M. SAMPLE

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 7 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

FORM 6. SCHEDULES

Summary of Schedules 

Statistical Summary of Certain Liabilities and Related Data (28 U.S.C. § 159) 

Schedule A - Real Property 

Schedule B - Personal Property 

Schedule C - Property Claimed as Exempt 

Schedule D - Creditors Holding Secured Claims 

Schedule E - Creditors Holding Unsecured Priority Claims 

Schedule F - Creditors Holding Unsecured Nonpriority Claims 

Schedule G - Executory Contracts and Unexpired Leases 

Schedule H - Codebtors 

Schedule I - Current Income of Individual Debtor(s) 

Schedule J - Current Expenditures of Individual Debtor(s)

Unsworn Declaration under Penalty of Perjury

GENERAL INSTRUCTIONS: The first page of the debtor’s schedules and the first page of any 

amendments thereto must contain a caption as in Form 16B. Subsequent pages should be 

identified with the debtor’s name and case number. If the schedules are filed with the petition, 

the case number should be left blank

Schedules D, E, and F have been designed for the listing of each claim only once. Even when a 

claim is secured only in part or entitled to priority only in part, it still should be listed only once. 

A claim which is secured in whole or it part should be listed on Schedule D only, and a claim 

which is entitled to priority in whole or in part should be listed on Schedule E only. Do not list 

the same claim twice. If a creditor has more than one claim, such as claims arising from separate 

transactions, each claim should be scheduled separately.

Review the specific instructions for each schedule before completing the schedule.

B6 Cover (Form 6 Cover) (12/07) 

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 8 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

SCHEDULE A - REAL PROPERTY

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

In re Case No.

Debtor (If known)

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

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

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

“Description and Location of Property.” 

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

Unexpired Leases. 

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

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

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

Property Claimed as Exempt.

DESCRIPTION AND LOCATION 

 OF PROPERTY 

NATURE OF DEBTOR’S 

 INTEREST IN PROPERTY 

HUSBAND, WIFE, JOINT 

OR COMMUNITY 

CURRENT VALUE 

 OF DEBTOR’S 

INTEREST IN 

PROPERTY, WITHOUT 

DEDUCTING ANY 

SECURED CLAIM 

OR EXEMPTION 

AMOUNT OF 

SECURED 

CLAIM

(Report also on Summary of Schedules.) 

Total 

Michael R. Sample & Michelle M. Sample

Residence J Joint Tenants 319,000.00 367,000.00

9005 Daniel Lane

Spring Grove, IL 60081

319,000.00

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 9 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

SCHEDULE B - PERSONAL PROPERTY

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

In re Case No.

Debtor (If known)

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

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

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

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

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

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

Unexpired Leases. 

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

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

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

TYPE OF PROPERTY

N 

O 

N 

E 

HUSBAND, WIFE, JOINT 

OR COMMUNITY 

DESCRIPTION AND LOCATION 

OF PROPERTY

CURRENT VALUE OF

DEBTOR’S INTEREST

IN PROPERTY, 

WITHOUT 

DEDUCTING ANY 

SECURED CLAIM 

OR EXEMPTION

Michael R. Sample & Michelle M. Sample

1. Cash on hand. Cash on hand J 20.00

2. Checking, savings or other financial 

accounts, certificates of deposit, or shares in 

banks, savings and loan, thrift, building and 

loan, and homestead associations, or credit 

unions, brokerage houses, or cooperatives.

Harris Bank checking account J 0.00

State Bank of the Lake checking account J 200.00

State Bank of the Lake savings account J 800.00

3. Security deposits with public utilities, 

telephone companies, landlords, and others.

X

4. Household goods and furnishings, including

audio, video, and computer equipment. Household Goods J 1,000.00

5. Books. Pictures and other art objects, 

antiques, stamp, coin, record, tape, compact disc,

and other collections or collectibles.

X

6. Wearing apparel. X

7. Furs and jewelry. X

8. Firearms and sports, photographic, and 

other hobby equipment.

X

9. Interests in insurance policies. Name 

insurance company of each policy and itemize 

surrender or refund value of each.

X

10. Annuities. Itemize and name each issuer. X

11. Interests in an education IRA as defined in 

26 U.S.C. § 530(b)(1) or under a qualified State 

tuition plan as defined in 26 U.S.C. § 529(b)(1). 

Give particulars. (File separately the record(s) of

any such interest(s). 11 U.S.C. § 521(c).)

X

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

pension or profit sharing plans. Give particulars. 401(k) H 30,000.00

401(k) W 8,000.00

Pension H Unknown

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 10 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

SCHEDULE B - PERSONAL PROPERTY

B6B (Official Form 6B) (12/07) -- Cont. 

In re Case No.

Debtor (If known)

TYPE OF PROPERTY

N 

O 

N 

E 

HUSBAND, WIFE, JOINT 

OR COMMUNITY 

DESCRIPTION AND LOCATION 

OF PROPERTY

CURRENT VALUE OF

DEBTOR’S INTEREST

IN PROPERTY, 

WITHOUT 

DEDUCTING ANY 

SECURED CLAIM 

OR EXEMPTION

(Continuation Sheet)

Michael R. Sample & Michelle M. Sample

13. Stock and interests in incorporated and 

unincorporated businesses. Itemize.

X

14. Interests in partnerships or joint ventures. 

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 settlement to which the debtor is or 

may be entitled. Give particulars.

X

18. Other liquidated debts owing debtor 

including tax refunds. Give particulars.

X

19. Equitable or future interests, life estates, and

rights or powers exercisable for the benefit of 

the debtor other than those listed in Schedule A -

Real Property.

X

20. Contingent and noncontingent interests in 

estate or a decedent, death benefit plan, life 

insurance policy, or trust.

X

21. Other contingent and unliquidated claims of 

every nature, including tax refunds, 

counterclaims of the debtor, and rights of 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. Give particulars.

X

24. Customer lists or other compilations 

containing personally identifiable information 

(as defined in 11 U.S.C. §101(41A)) provided to

the debtor by individuals in connection with 

obtaining a product or service from the debtor 

primarily for personal, family, or household 

purposes.

X

25. Automobiles, trucks, trailers, and other 

vehicles and accessories. 2007 Chevrolet Trail Blazer W 11,125.00

2007 ATV Yamaha Grizzly 350 H 4,000.00

26. Boats, motors, and accessories. X

27. Aircraft and accessories. X

28. Office equipment, furnishings, and supplies. X

29. Machinery, fixtures, equipment, and 

supplies used in business.

X

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 11 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

SCHEDULE B - PERSONAL PROPERTY

B6B (Official Form 6B) (12/07) -- Cont. 

In re Case No.

Debtor (If known)

TYPE OF PROPERTY

N 

O 

N 

E 

HUSBAND, WIFE, JOINT 

OR COMMUNITY 

DESCRIPTION AND LOCATION 

OF PROPERTY

CURRENT VALUE OF

DEBTOR’S INTEREST

IN PROPERTY, 

WITHOUT 

DEDUCTING ANY 

SECURED CLAIM 

OR EXEMPTION

(Continuation Sheet)

$

(Include amounts from any continuation 

sheets attached. Report total also on 

Summary of Schedules.)

continuation sheets attached Total

Michael R. Sample & Michelle M. Sample

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

55,145.00 0

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 12 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

B6C (Official Form 6C) (12/07) 

In re Case No.

Debtor (If known)

Debtor claims the exemptions to which debtor is entitled under: 

(Check one box)

DESCRIPTION OF PROPERTY

SPECIFY LAW 

PROVIDING EACH 

EXEMPTION

VALUE OF 

CLAIMED 

EXEMPTION

CURRENT 

VALUE OF PROPERTY 

WITHOUT DEDUCTING

EXEMPTION

11 U.S.C. § 522(b)(2)

11 U.S.C. § 522(b)(3)

Check if debtor claims a homestead exemption that exceeds 

$136,875.

Michael R. Sample & Michelle M. Sample

Residence (Husb)1735 I.L.C.S 5§12-901 0.00 319,000.00

(Wife)1735 I.L.C.S 5§12-901 0.00

Cash on hand (Husb)735 I.L.C.S 5§12-1001(b) 10.00 20.00

(Wife)735 I.L.C.S 5§12-1001(b) 10.00

Harris Bank checking account (Husb)735 I.L.C.S 5§12-1001(b) 0.00 0.00

(Wife)735 I.L.C.S 5§12-1001(b) 0.00

Household Goods (Husb)735 I.L.C.S 5§12-1001(b) 500.00 1,000.00

(Wife)735 I.L.C.S 5§12-1001(b) 500.00

401(k) (Husb)735 I.L.C.S 5§12-1006 30,000.00 30,000.00

401(k) (Wife)735 I.L.C.S 5§12-1006 8,000.00 8,000.00

Pension (Husb)735 I.L.C. 5/12-803 Unknown Unknown

2007 Chevrolet Trail Blazer (Wife)735 I.L.C.S 5§12-1001(c) 0.00 11,125.00

State Bank of the Lake checking account (Husb)735 I.L.C.S 5§12-1001(b) 100.00 200.00

(Wife)735 I.L.C.S 5§12-1001(b) 100.00

State Bank of the Lake savings account (Husb)735 I.L.C.S 5§12-1001(b) 400.00 800.00

(Wife)735 I.L.C.S 5§12-1001(b) 400.00

Total exemptions claimed: 40,020.00

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 13 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6D (Official Form 6D) (12/07)

In re _______________________________________________, 

Debtor (If known) 

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS 

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

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

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

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

 List creditors in alphabetical order to the extent practicable. If a minor child is 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 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 secured claims to report on this Schedule D. 

CREDITOR’S NAME, 

MAILING ADDRESS 

INCLUDING ZIP CODE, 

AND ACCOUNT NUMBER 

(See Instructions Above.) 

DATE CLAIM WAS INCURRED,

NATURE OF LIEN, AND 

DESCRIPTION AND 

VALUE OF PROPERTY 

SUBJECT TO LIEN

AMOUNT 

OF 

CLAIM 

WITHOUT 

DEDUCTING 

VALUE OF 

COLLATERAL 

UNSECURED

PORTION, 

IF ANY 

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

VALUE $ 

VALUE $ 

VALUE $ 

CODEBTOR 

HUSBAND, WIFE, JOINT 

ORCOMMUNITY 

CONTINGENT 

UNLIQUIDATED 

DISPUTED 

_______continuation sheets attached (Total of this page) 

Total 

(Use only on last page) 

(Report also on 

Summary of Schedules) 

Subtotal $ 

(If applicable, report 

also on Statistical 

Summary of Certain 

Liabilities and Related 

Data.)

$ 

$ $ 

Michael R. Sample & Michelle M. Sample Case No. _________________________________ 

Chase/WaMu

P.O. Box 100576

Florence SC 29502

3013925437

J

Lien: 1st Mortgage

Security: Residence

319,000.00

299,000.00 0.00

GE Money Bank

P.O. Box 960061

Orlando, FL 32896

H

Security: 2007 ATV Yamaha 

Grizzly 350

4,000.00

4,000.00 0.00

Harris Bank

200 W. Monroe, Fl 19

Chicago, IL 60606

J

Security: Residence

319,000.00

68,000.00

48,000.00

This amount

based upon

existence of

Superior Liens

1 371,000.00 48,000.00

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 14 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6D (Official Form 6D) (12/07) – Cont. 

In re __________________________________________________, Case No. _________________________________ 

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS 

Debtor (If known) 

CREDITOR’S NAME, 

MAILING ADDRESS 

INCLUDING ZIP CODE, 

AND ACCOUNT NUMBER 

(See Instructions Above.) 

DATE CLAIM WAS INCURRED,

NATURE OF LIEN, AND 

DESCRIPTION AND 

VALUE OF PROPERTY 

SUBJECT TO LIEN

AMOUNT 

OF 

CLAIM 

WITHOUT 

DEDUCTING 

VALUE OF 

COLLATERAL 

UNSECURED 

PORTION, 

IF ANY 

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

VALUE $ 

VALUE $ 

VALUE $ 

VALUE $ 

CODEBTOR 

CONTINGENT 

UNLIQUIDATED 

DISPUTED 

(Total(s) of this page) 

Total(s) 

(Use only on last page) 

$ 

Sheet no. ___ of ___continuation sheets attached to 

Schedule of Creditors Holding Secured Claims 

(Continuation Sheet)

HUSBAND, WIFE, JOINT 

ORCOMMUNITY 

ACCOUNT NO. 

VALUE $ 

Subtotal (s) $ $ 

$ 

(Report also on 

Summary of Schedules) 

(If applicable, report 

also on Statistical 

Summary of Certain 

Liabilities and Related 

Data.)

Michael R. Sample & Michelle M. Sample

Harris Bank

200 W. Monroe, Fl 19

Chicago, IL 60606

W

Security: 2007 Chevrolet Trail 

Blazer

11,125.00

19,488.00

8,363.00

1 1 19,488.00 8,363.00

390,488.00 56,363.00

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 15 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6E (Official Form 6E) (12/07)

In re________________________________________________________________, Case No.______________________________ 

Debtor (if known) 

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS 

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) 

Extensions of credit in an involuntary case 

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

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

Wages, salaries, and commissions 

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

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

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

Contributions to employee benefit plans 

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

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

 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 husband, wife, 

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

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

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

more than one of these three columns.) 

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

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

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

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

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

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

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

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

Data.

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).

Michael R. Sample & Michelle M. Sample

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 16 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6E (Official Form 6E) (12/07) - Cont.

In re________________________________________________________________, Case No.______________________________ 

Debtor (if known) 

Certain farmers and fishermen 

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

Deposits by individuals 

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

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

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).

Taxes and Certain Other Debts Owed to Governmental Units 

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

Commitments to Maintain the Capital of an Insured Depository Institution 

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

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

U.S.C. § 507 (a)(9). 

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

adjustment. 

____ continuation sheets attached

Michael R. Sample & Michelle M. Sample

0

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 17 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

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

In re __________________________________________, Case No. _________________________________ 

Debtor (If known) 

SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS 

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

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

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

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

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

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

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

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

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

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

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

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

Related Data. 

 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 

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

CODEBTOR 

HUSBAND, WIFE, JOINT 

ORCOMMUNITY 

CONTINGENT 

UNLIQUIDATED 

DISPUTED 

_______continuation sheets attached 

Total $ 

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

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

Summary of Certain Liabilities and Related Data.) 

Subtotal $ 

DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM. 

IF CLAIM IS SUBJECT TO SETOFF, 

SO STATE. 

Michael R. Sample & Michelle M. Sample

Capital One

P.O. Box 6492

Carol Stream, IL 60197-6492

5291492408530349

H

Consideration: Credit card debt

6,998.29

Cardmember Service

P.O. Box 15153

Wilmington, DE 19886

4266901027082916

H

Consideration: Credit card debt

2,962.76

Chase

Cardmember Service

P.O. Box 15298

Wilmington, DE 19850

xxxx9028 Consideration: Credit card debt

Unknown

Discover Bank

c/o Baker & Miller

29 N. Wacker Dr, 5th Fl

Chicago, IL 60606

Consideration: Credit card debt

8,127.55

2 18,088.60

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 18 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6F (Official Form 6F) (12/07) - Cont.

In re __________________________________________________, Case No. _________________________________ 

SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS 

Debtor (If known) 

CREDITOR’S NAME, 

MAILING ADDRESS 

INCLUDING ZIP CODE, 

AND ACCOUNT NUMBER 

(See instructions above.) 

DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM. 

IF CLAIM IS SUBJECT TO SETOFF, 

AMOUNT

OF 

CLAIM

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

CODEBTOR 

CONTINGENT 

UNLIQUIDATED 

DISPUTED 

Total 

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

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

Statistical Summary of Certain Liabilities and Related Data.) 

$ 

Sheet no. _____ of _____continuation sheets attached 

to Schedule of Creditors Holding Unsecured 

Nonpriority Claims 

(Continuation Sheet)

HUSBAND, WIFE, JOINT 

ORCOMMUNITY 

ACCOUNT NO. 

Subtotal $ 

Michael R. Sample & Michelle M. Sample

Discover Bank

c/o Weltman, Weinberg & Reis

180 N. LaSalle St., Suite 2400

Chicago, IL 60601

Consideration: Credit card debt

Notice Only

Discover Card

P.O. Box 6103

Carol Stream, IL 60197-6103

xxxx4263

H

Consideration: Credit card debt

2,632.36

Discover Card

P.O. Box 6103

Carol Stream, IL 60197-6103

xxxx5854

W

Consideration: Credit card debt

7,157.37

Fed Loan Servicing

P.O. Box 530210

Atlanta, GA 30353

5579284434 Consideration: Loan

4,000.00

Home Depot

Processing Center

Des Moines, IA 50364-0500

6035320251354344

H

Consideration: Credit card debt

11,347.89

25,137.62 1 2

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 19 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6F (Official Form 6F) (12/07) - Cont.

In re __________________________________________________, Case No. _________________________________ 

SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS 

Debtor (If known) 

CREDITOR’S NAME, 

MAILING ADDRESS 

INCLUDING ZIP CODE, 

AND ACCOUNT NUMBER 

(See instructions above.) 

DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM. 

IF CLAIM IS SUBJECT TO SETOFF, 

AMOUNT

OF 

CLAIM

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

ACCOUNT NO. 

CODEBTOR 

CONTINGENT 

UNLIQUIDATED 

DISPUTED 

Total 

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

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

Statistical Summary of Certain Liabilities and Related Data.) 

$ 

Sheet no. _____ of _____continuation sheets attached 

to Schedule of Creditors Holding Unsecured 

Nonpriority Claims 

(Continuation Sheet)

HUSBAND, WIFE, JOINT 

ORCOMMUNITY 

ACCOUNT NO. 

Subtotal $ 

Michael R. Sample & Michelle M. Sample

HSBC

c/o California Recovery

5777 Madison Ave, STe 960

Sacramento, CA 95841

5480430038050917

H

Consideration: Credit card debt

2,168.05

Union Plus Credit Card

P.O. Box 17051

Baltimore, MD 21297

5480430038050917

H

Consideration: Credit card debt

1,702.00

US Bank

c/o National Recovery

416 S Main St.

Ottawa, KS 66067

4428282602017253

H

Consideration: Credit card debt

20,614.63

US Bank

P.O. Box 790408

St. Louis, MO 63179-0408

4428282602017253

H

Consideration: Credit card debt

17,567.06

2 2 42,051.74

85,277.96

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 20 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6G (Official Form 6G) (12/07) 

In re Case No.

Debtor (if known)

SCHEDULE G - EXECUTORY CONTRACTS AND UNEXPIRED LEASES

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

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

names and complete mailing addresses of all other parties to each lease or contract described. If a minor child is a party to one of the leases or 

contracts, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, 

guardian." Do not disclose the child’s name. See 11 U.S.C. § 112 and Fed. R. Bankr. P. 1007(m). 

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

NAME AND MAILING ADDRESS, INCLUDING ZIP CODE, 

OF OTHER PARTIES TO LEASE OR CONTRACT.

DESCRIPTION OF CONTRACT OR LEASE AND NATURE OF

DEBTOR’S INTEREST. STATE WHETHER LEASE IS FOR 

NONRESIDENTIAL REAL PROPERTY. STATE CONTRACT 

NUMBER OF ANY GOVERNMENT CONTRACT.

Michael R. Sample & Michelle M. Sample

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 21 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6H (Official Form 6H) (12/07) 

In re Case No.

Debtor (if known)

SCHEDULE H - CODEBTORS

NAME AND ADDRESS OF CODEBTOR NAME AND ADDRESS OF CREDITOR

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 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. Bankr. P. 1007(m). 

Check this box if debtor has no codebtors.

Michael R. Sample & Michelle M. Sample

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 22 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B6I (Official Form 6I) (12/07)

Debtor (if known)

SCHEDULE I - CURRENT INCOME OF INDIVIDUAL DEBTOR(S) 

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

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

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

DEPENDENTS OF DEBTOR AND SPOUSE 

AGE(S): 

Debtor’s Marital 

Status: 

Employment: DEBTOR 

Occupation 

Name of Employer 

How long employed 

SPOUSE 

Address of Employer 

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.) 

2. Estimated monthly overtime 

3. SUBTOTAL 

4. LESS PAYROLL DEDUCTIONS 

5. SUBTOTAL OF PAYROLL DEDUCTIONS 

6.. TOTAL NET MONTHLY TAKE HOME PAY 

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

16. COMBINED AVERAGE MONTHLY INCOME (Combine column totals 

 from line 15) 

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

RELATIONSHIP(S): 

a. Payroll taxes and social security 

b. Insurance 

c. Union Dues 

d. Other (Specify:___________________________________________________________) 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

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

 (Attach detailed statement) 

8. Income from real property 

9. Interest and dividends 

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

 debtor’s use or that of dependents listed above.

11. Social security or other government assistance 

 ( Specify) 

12. Pension or retirement income 

13. Other monthly income 

 (Specify) 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

$ _____________ $ _____________ 

 $ _____________ $ _____________

 $ _____________ $ _____________

 $ _____________ $ _____________

 $ _____________ $ _____________

 $ _____________ $ _____________

14. SUBTOTAL OF LINES 7 THROUGH 13 

In re Case 

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

on Statistical Summary of Certain Liabilities and Related Data) 

$ _____________

Michael R. Sample & Michelle M. Sample

Married son, son 14 years, 9 years

Unemployed Health Aid

Gavin Junior High

6 months

Ingleside, IL

(D)Unemployment

None

0.00 1,998.00

0.00 0.00

0.00 1,998.00

313.90 367.28

0.00 4.06

0.00 0.00

0.00 0.00

313.90 371.34

-313.90 1,626.66

0.00 0.00

0.00 0.00

0.00 0.00

0.00 0.00

2,296.20 0.00

0.00 0.00

0.00 0.00

0.00 0.00

2,296.20 0.00

1,982.30 1,626.66

3,608.96

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 23 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

SCHEDULE J - CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S)

 Complete this schedule by estimating the average or projected monthly expenses of the debtor and the debtor’s family at time case 

filed. Prorate any payments made biweekly, quarterly, semi-annually, or annually to show monthly rate. The average monthly expenses 

calculated on this form may differ from the deductions from income allowed on Form 22A or 22C. 

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

labeled “Spouse.”

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

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

 b. Is property insurance included? Yes ________ No ________ 

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

 b. Water and sewer $ ______________ 

 c. Telephone $ ______________ 

 d. Other ___________________________________________________________________ $ ______________ 

3. Home maintenance (repairs and upkeep) $ ______________ 

4. Food $ ______________ 

5. Clothing $ ______________ 

6. Laundry and dry cleaning $ ______________ 

7. Medical and dental expenses $ ______________ 

8. Transportation (not including car payments) $ ______________ 

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

10.Charitable contributions $ ______________ 

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

 a. Homeowner’s or renter’s $ ______________ 

 b. Life $ ______________ 

 c. Health $ ______________ 

 d.Auto $ ______________ 

 e. Other $ ______________ 

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

(Specify) $ ______________ 

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

 a. Auto $______________ 

 b. Other $ ______________ 

 c. Other $ ______________ 

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

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

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

17. Other $______________ 

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

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

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

20. STATEMENT OF MONTHLY NET INCOME 

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

 b. Average monthly expenses from Line 18 above $ ______________ 

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

$______________

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

In re Case No.

Debtor (if known)

Michael R. Sample & Michelle M. Sample

Cell phones

Property Taxes

ATV

2nd Mortgage

1,970.00

300.00

20.00

118.00

107.00

100.00

700.00

100.00

0.00

75.00

250.00

0.00

0.00

58.00

0.00

0.00

100.00

0.00

666.00

406.00

125.00

496.00

0.00

0.00

0.00

0.00

5,591.00

None

(Includes spouse income of $1,626.66. See Schedule I) 3,608.96

(Net includes Debtor/Spouse combined Amounts)

5,591.00

-1,982.04

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 24 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

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

United States Bankruptcy Court 

In re Case No. 

Chapter 

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, D, E, F, 

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

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

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

NAME OF SCHEDULE 

ATTACHED 

(YES/NO) 

A – Real Property 

$ 

AMOUNTS SCHEDULED 

NO. OF SHEETS ASSETS LIABILITIES OTHER 

B – Personal Property 

G - Executory Contracts and 

 Unexpired Leases 

F - Creditors Holding Unsecured 

 Nonpriority Claims 

C – Property Claimed 

 as exempt 

J - Current Expenditures of Individual 

 Debtors(s) 

H - Codebtors 

I - Current Income of 

 Individual Debtor(s) 

D – Creditors Holding 

 Secured Claims

E - Creditors Holding Unsecured 

 Priority Claims 

 (Total of Claims on Schedule E)

TOTAL $ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Northern District of Illinois

Michael R. Sample & Michelle M. Sample

7

YES 1

YES 3

YES 1

YES 2

YES 2

YES 3

YES 1

YES 1

YES 1

YES 1

16

319,000.00

55,145.00

374,145.00

390,488.00

0.00

85,277.96

475,765.96

3,608.96

5,591.00

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 25 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

Official Form 6 - Statistical Summary (12/07)

United States Bankruptcy Court 

In re Case No. 

Chapter 

Debtor 

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

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

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

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

information here. 

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

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

Type of Liability Amount 

Domestic Support Obligations (from Schedule E) 

Taxes and Certain Other Debts Owed to Governmental Units (from 

Schedule E) 

Claims for Death or Personal Injury While Debtor Was Intoxicated (from 

Schedule E) (whether disputed or undisputed) 

Student Loan Obligations (from Schedule F) 

Domestic Support, Separation Agreement, and Divorce Decree 

Obligations Not Reported on Schedule E 

Obligations to Pension or Profit-Sharing, and Other Similar Obligations 

(from Schedule F) 

TOTAL 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Average Income (from Schedule I, Line 16) 

Average Expenses (from Schedule J, Line 18) 

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

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

$ 

$ 

$ 

State the Following: 

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

ANY” column 

2. Total from Schedule E, “AMOUNT ENTITLED TO 

PRIORITY” column. 

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

PRIORITY, IF ANY” column 

$ 

State the Following: 

4. Total from Schedule F 

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

$ 

$ 

$ 

$ 

Northern District of Illinois

Michael R. Sample & Michelle M. Sample

7

0.00

0.00

0.00

4,000.00

0.00

0.00

4,000.00

3,608.96

5,591.00

1,998.00

56,363.00

0.00

0.00

85,277.96

141,640.96

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 26 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

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

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, consisting of _______ sheets, and that they 

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

[If joint case, both spouses must sign.] 

In re Case No.

Debtor (If known)

Date Signature:

Debtor:

(Joint Debtor, if any)

Date Signature:

 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 setting a maximum fee for services chargeable 

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

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

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual:

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

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 

18 U.S.C. § 156. 

Printed or Typed Name and Title, if any, 

of Bankruptcy Petition Preparer

Social Security No.

(Required by 11 U.S.C. § 110.)

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

who signs this document.

Address 

X

Signature of Bankruptcy Petition Preparer Date

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

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

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

 I, the __________________________________ [the president or other officer or an authorized agent of the corporation or a member 

or an authorized agent of the partnership ] of the ___________________________________ [corporation or partnership] named as debtor 

in this case, declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of _______sheets (total 

shown on summary page plus 1),and that they are true and correct to the best of my knowledge, information, and belief. 

Date Signature:

[Print or type name of individual signing on behalf of debtor.]

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

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

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

Michael R. Sample & Michelle M. Sample

/s/ Michael R. Sample

/s/ Michelle M. Sample

18

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 27 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

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

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

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

their relatives; corporations of which the debtor is an officer, director, or person in control; officers, directors, and any owner of 5 

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

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

 

 1. Income from employment or operation of business 

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 

B7 (Official Form 7) (12/07) 

In Re Case No. (if known) 

UNITED STATES BANKRUPTCY COURT 

Northern District of Illinois

Michael R. Sample & Michelle M. Sample

None

2010(db)

2009(db) 62,000.00 Employment

2008(db) 61,000.00 Employment

2010(jdb) 999.99 Employment

2009(jdb) 14,000.00 Employment

2008(jdb) 28,000.00 Employment

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 28 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

None

2. Income other than from employment or operation of business

 State the amount of income received by the debtor other than from employment, trade, profession, or

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 (db) 4472.00 Unemployment

2010(db) 1118.00 Unemployment

None 3. 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 preceding the

commencement of this case unless the aggregate value of all property that constitutes or is affected by such

transfer is less than $600. Indicate with an asterisk (*) any payments that were made to a creditor on account of

a domestic support obligation or as part of an alternative repayment schedule under a plan by an approved

nonprofit budgeting and 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.) 

NAME AND ADDRESS OF CREDITOR DATES OF 

PAYMENTS

AMOUNT 

PAID

AMOUNT STILL 

OWING

None b. Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor

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

property that constitutes or is affected by such transfer is less than $5,475. If the debtor is an individual,

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

obligation or as part of an alternativerepayment schedule under a plan by an approved nonprofit budgeting and

credit counseling agency. (Married debtors filing under chapter 12 or chapter 13 must include payments and

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

and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR

AND RELATIONSHIP TO DEBTOR

DATES OF 

PAYMENTS

AMOUNT 

PAID

AMOUNT STILL 

OWING

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 29 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

None

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

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

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

separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR

AND RELATIONSHIP TO DEBTOR

DATES OF 

PAYMENTS

AMOUNT PAID AMOUNT STILL 

OWING

None

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

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

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

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

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

CAPTION OF SUIT

AND CASE NUMBER

NATURE OF PROCEEDING COURT OR

AGENCY AND LOCATION

STATUS OR 

DISPOSITION

Discover Bank v. 

Michelle Sample

Case No. 09 SC 1505

Civil Action Circuit Court, 22nd Judicial 

Circuit,

McHenry County, Illinois

Judgment

Discover Bank v. 

Michael R. Sample

Case No. 09 SC 2271

Civil Action Circuit Court, 22nd Judicial 

Circuit,

McHenry County, Illinois

Judgment

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

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

12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint

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

NAME AND ADDRESS OF

PERSON FOR WHOSE BENEFIT

PROPERTY WAS SEIZED

DATE OF 

SEIZURE

DESCRIPTION AND

VALUE OF PROPERTY

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 30 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

None

5. Repossessions, 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.)

NAME AND

ADDRESS OF

CREDITOR OR SELLER

DATE OF REPOSESSION,

FORECLOSURE SALE,

TRANSFER OR RETURN

DESCRIPTION AND

VALUE OF PROPERTY

None

6. 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.)

NAME AND 

ADDRESS 

OF ASSIGNEE

DATE OF ASSIGNMENT TERMS OF 

ASSIGNMENT 

OR SETTLEMENT

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

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

chapter 13 must include information concerning property of either or both spouses whether or not a joint petition

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

NAME AND 

ADDRESS 

OF CUSTODIAN

NAME AND LOCATION

OF COURT CASE TITLE

& NUMBER

DATE OF 

ORDER

DESCRIPTION AND

VALUE OF PROPERTY

None

7. 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.)

NAME AND

ADDRESS OF

PERSON OR ORGANIZATION

RELATIONSHIP 

TO DEBTOR, IF ANY

DATE OF 

GIFT

DESCRIPTION AND

VALUE OF GIFT

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 31 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

None

8. 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.)

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

None

9. 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 year immediately preceding the commencement of this case.

NAME AND ADDRESS

OF PAYEE

DATE OF PAYMENT,

NAME OF PAYOR IF

OTHER THAN DEBTOR

AMOUNT OF MONEY OR

DESCRIPTION AND

VALUE OF PROPERTY

John H. Redfield

John H. Redfield & Associates, 

P.C.

102 S. Wynstone Park Dr, Ste 201

North Barrington, IL 60010

December 2009 $1,500.00

None

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 within two years immediately preceding the

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

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

is not filed.)

NAME AND ADDRESS OF TRANSFEREE,

RELATIONSHIP TO DEBTOR

DATE DESCRIBE PROPERTY

TRANSFERRED AND

VALUE RECEIVED

None

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

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

NAME OF TRUST OR OTHER DEVICE DATE(S) OF 

TRANSFER(S)

AMOUNT OF MONEY OR

DESCRIPTION AND

VALUE OF PROPERTY

OR DEBTOR'S INTEREST

IN PROPERTY

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 32 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

None

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 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 either or both spouses whether or not a joint petition is

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

NAME AND 

ADDRESS 

OF INSTITUTION

TYPE OF ACCOUNT, LAST FOUR

DIGITS OF ACCOUNT NUMBER,

AND AMOUNT OF FINAL BALANCE

AMOUNT AND

DATE OF SALE

OR CLOSING

None

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.)

NAME AND

ADDRESS OF BANK

OR OTHER DEPOSITORY

NAMES AND ADDRESSES OF

THOSE WITH ACCESS TO BOX

OR DEPOSITORY

DESCRIPTION OF 

CONTENTS

DATE OF

TRANSFER OR

SURRENDER, IF ANY

None

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.)

NAME AND ADDRESS OF CREDITOR DATE 

OF 

SETOFF

AMOUNT 

OF 

SETOFF

None

14. Property held for another person

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

NAME AND

ADDRESS OF OWNER

DESCRIPTION AND

VALUE OF PROPERTY

LOCATION OF PROPERTY

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 33 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

None

15. Prior address of debtor

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

all premises which the debtor occupied during that period and vacated prior to the commencement of this case.

If a joint petition is filed, report also any separate address of either spouse.

ADDRESS NAME USED DATES OF OCCUPANCY

None

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

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

NAME

17. Environmental Sites

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

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

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

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

wastes, or material.

"Site" means any location, facility, or property as defined under any Environmental Law, whether or

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

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

substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law

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

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

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

SITE NAME 

AND ADDRESS

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

DATE OF 

NOTICE

ENVIRONMENTAL 

LAW

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 34 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

None

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

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

SITE NAME 

AND ADDRESS

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

DATE OF 

NOTICE

ENVIRONMENTAL 

LAW

None

c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental

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

that is or was a party to the proceeding, and the docket number.

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

DOCKET NUMBER STATUS OR DISPOSITION

None

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, partnership, sole proprietorship, or was self-employed in a

trade, profession, or other activity either full- or part-time within six years immediately preceding the

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

within the six years immediately preceding the commencement of this case.

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

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

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

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

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

percent or more of the voting or equity securities within the six years immediately preceding the commencement

of this case.

NAME LAST FOUR DIGITS OF

SOCIAL-SECURITY OR

OTHER INDIVIDUAL

TAXPAYER-I.D. NO.

(ITIN)/ COMPLETE EIN

ADDRESS NATURE OF BUSINESS BEGINNING AND

ENDING DATES

None

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

in 11 U.S.C. § 101.

NAME ADDRESS

[Questions 19 - 25 are not applicable to this case]

* * * * * *

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 35 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

[If completed by an individual or individual and spouse]

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

attachments thereto and that they are true and correct.

Date Signature

of Debtor MICHAEL R. SAMPLE

/s/ Michael R. Sample

Date Signature

of Joint Debtor MICHELLE M. SAMPLE

/s/ Michelle M. Sample

_____ continuation sheets attached 0

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

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

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

compensation and have provided the debtor with a copy of this document and the notices and required under 11U.S.C. §§ 110(b), 110(h), and 342(b);

(3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110 setting a maximum fee for services chargeable by bankruptcy petition

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

debtor, as required in that section.

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

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

partner who signs this document.

Address

X

Signature of Bankruptcy Petition Preparer Date

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

not an individual:

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

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

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

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 36 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B8 (Official Form 8) (12/08) 

UNITED STATES BANKRUPTCY COURT

In re Case No. 

Chapter 7 

CHAPTER 7 INDIVIDUAL 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.) 

Debtor 

Property No. 2 (if necessary)

Creditor's Name: Describe Property Securing Debt: 

Property will be (check one): 

Surrendered Retained 

If retaining the property, I intend to (check at least one): 

Redeem the property 

Reaffirm the debt 

Other. Explain _______________________________________________(for example, avoid lien 

using 11 U.S.C. §522(f)). 

Property is (check one): 

Claimed as exempt Not claimed as exempt 

Property No. 1 

Creditor's Name: Describe Property Securing Debt: 

Property will be (check one): 

Surrendered Retained 

If retaining the property, I intend to (check at least one): 

Redeem the property 

Reaffirm the debt 

Other. Explain _______________________________________________(for example, avoid lien 

using 11 U.S.C. §522(f)). 

Property is (check one):

Claimed as exempt Not claimed as exempt 

, 

Northern District of Illinois

Michael R. Sample & Michelle M. Sample

Chase/WaMu

P.O. Box 100576

Florence SC 29502

Residence

retain, keep current

Harris Bank

200 W. Monroe, Fl 19

Chicago, IL 60606

Residence

retain, keep current

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 37 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

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.) 

B8 (Official Form 8) (12/08) 

Property No. 1 

Lessor's Name: Describe Leased Property: 

YES 

Lease will be Assumed pursuant 

to 11 U.S.C. §365(p)(2)): 

NO

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

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

______continuation sheets attached (if any) 

Date:_____________________________

Signature of Debtor

Signature of Joint Debtor

Property No. 2 (if necessary)

Lessor's Name: Describe Leased Property: 

YES 

Lease will be Assumed pursuant 

to 11 U.S.C. §365(p)(2)): 

NO

Property No. 3 (if necessary) 

Lessor's Name: Describe Leased Property: 

YES 

Lease will be Assumed pursuant 

to 11 U.S.C. §365(p)(2)): 

NO

Page 2 

NO Leased Property

/s/ Michael R. Sample

/s/ Michelle M. Sample

1

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 38 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B8 (Official Form8)(12/08) Page 3

CHAPTER 7 INDIVIDUAL DEBTOR'S STATEMENT OF INTENTION

(Continuation Sheet)

PART A - Continuation

Property No: 3

Creditor's Name: Describe Property Securing Debt:

Property will be (check one):

Surrendered Retained

If retaining the property, I intend to (check at least one):

Redeem the property

Reaffirm the debt

Other. Explain (for example, avoid lien

using 11 U.S.C.§522(f)).

Property is (check one):

Claimed as exempt Not claimed as exempt

Harris Bank

200 W. Monroe, Fl 19

Chicago, IL 60606

2007 Chevrolet Trail Blazer

Property No: 4

Creditor's Name: Describe Property Securing Debt:

Property will be (check one):

Surrendered Retained

If retaining the property, I intend to (check at least one):

Redeem the property

Reaffirm the debt

Other. Explain (for example, avoid lien

using 11 U.S.C.§522(f)).

Property is (check one):

Claimed as exempt Not claimed as exempt

GE Money Bank

P.O. Box 960061

Orlando, FL 32896

2007 ATV Yamaha Grizzly 350

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 39 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

B 201B (Form 201B) (12/09) 

CERTIFICATION OF NOTICE TO CONSUMER DEBTOR(S) 

UNDER § 342(b) OF THE BANKRUPTCY CODE 

Certification of [Non-Attorney] Bankruptcy Petition Preparer 

 I, the [non-attorney] bankruptcy petition preparer signing the debtor's petition, hereby certify that I delivered to the 

debtor the attached notice, as required by § 342(b) of the Bankruptcy Code 

In re Case No.

Debtor (If known)

X

Signature of Debtor Date 

Signature of Joint Debtor, (if any) Date 

Instructions: Attach a copy of Form B 201A, Notice to Consumer Debtor(s) Under § 342(b) of the Bankruptcy Code. 

Use this form to certify that the debtor has received the notice required by 11 U.S.C. § 342(b) only if the certification has 

NOT been made on the Voluntary Petition, Official Form B1. Exhibit B on page 2 of Form B1 contains a certification by 

the debtor's attorney that the attorney has given the notice to the debtor. The Declarations made by debtors and bankruptcy 

petition preparers on page 3 of Form B1 also include this certification. 

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

Address: 

Social Security number (If the bankruptcy petition 

preparer is not an individual, state the Social Security 

number of the officer, principal, responsible person, 

or partner of the bankruptcy petition preparer.) 

(Required by 11 U.S.C. § 110.) 

Signature of Bankruptcy Petition Preparer or officer, 

Principal, responsible person, or partner whose Social 

Security number is provided above.

Certification of the Debtor

X

 I, (We), the debtor(s), affirm that I (we) have received and read the attached notice, as required by § 342(b) of the Bankruptcy 

Code 

X

United States Bankruptcy Court 

Printed Names(s) of Debtor(s) 

Case No. (if known) 

Northern District of Illinois

Michael R. Sample & Michelle M. Sample

Michael R. Sample & Michelle M. Sample /s/ Michael R. Sample

/s/ Michelle M. Sample

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 40 of 43
Capital One

P.O. Box 6492

Carol Stream, IL 60197-6492

Cardmember Service

P.O. Box 15153

Wilmington, DE 19886

Chase

Cardmember Service

P.O. Box 15298

Wilmington, DE 19850

Chase/WaMu

P.O. Box 100576

Florence SC 29502

Discover Bank

c/o Baker & Miller

29 N. Wacker Dr, 5th Fl

Chicago, IL 60606

Discover Bank

c/o Weltman, Weinberg & Reis

180 N. LaSalle St., Suite 2400

Chicago, IL 60601

Discover Card

P.O. Box 6103

Carol Stream, IL 60197-6103

Discover Card

P.O. Box 6103

Carol Stream, IL 60197-6103

Fed Loan Servicing

P.O. Box 530210

Atlanta, GA 30353

GE Money Bank

P.O. Box 960061

Orlando, FL 32896

Harris Bank

200 W. Monroe, Fl 19

Chicago, IL 60606

Harris Bank

200 W. Monroe, Fl 19

Chicago, IL 60606

Home Depot

Processing Center

Des Moines, IA 50364-0500

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 41 of 43
HSBC

c/o California Recovery

5777 Madison Ave, STe 960

Sacramento, CA 95841

Union Plus Credit Card

P.O. Box 17051

Baltimore, MD 21297

US Bank

c/o National Recovery

416 S Main St.

Ottawa, KS 66067

US Bank

P.O. Box 790408

St. Louis, MO 63179-0408

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 42 of 43
Bankruptcy2010 ©1991-2010, New Hope Software, Inc., ver. 4.5.2-745 - 32537 - Adobe PDF

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR 

1. Pursuant to 11 U .S.C. § 329(a) and Fed. Bankr. P. 2016(b), I certify that I am the attorney for the 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 follow s: 

For legal services, I have agreed to accept ............................................................ $ ______________ 

Prior to the filing of this statement I have received .................................................. $ ______________ 

2. The source of compensation paid to me was:

Balance Due ....................................................................................................... $ ______________

Debtor Other (specify) 

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

Debtor Other (specify) 

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

associates of my law firm. 

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

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

of my law firm. A copy of the agreement, together with a list of the names of the people sharing in the compensation, is attached. 

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 the bankruptcy proceeding. 

____________________________________ __________________________________________________

 Date Signature of Attorney 

 __________________________________________________ 

 Name of law firm 

B203 

12/94 United States Bankruptcy Court 

In re 

Debtor(s) 

Case No. ____________________ 

Chapter ____________________ 

Northern District of Illinois

Michael R. Sample & Michelle M. Sample

7

1,500.00

1,500.00

0.00

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

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

c. Representation of the debtor at the meeting of creditors and confirmation hearing, and any adjourned hearings thereof;

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

Does not include representation in adversary and contested matters.

/s/ John H. Redfield

John H. Redfield & Associates, P.C.

Case 10-70111 Doc 1 Filed 01/14/10 Entered 01/14/10 10:52:14 Desc Main

 Document Page 43 of 43