Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 1 of 32
Official Form 1 (1/08)

United States Bankruptcy Court Voluntary Petition

NORTHERN DISTRICT OF ILLINOIS

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

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

(include married, maiden, and trade names):

NONE

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

(if more than one, state all): 8103

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

772 River Mill Parkway

Wheeling IL

County of Residence or of the

Principal Place of Business: Cook

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

Location of Principal Assets of Business Debtor

(if different from street address above):

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

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

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

Street Address of Joint Debtor

Mailing Address of Joint Debtor

(include married, maiden, and trade names):

(if more than one, state all):

(No. & Street, City, and State):

County of Residence or of the

Principal Place of Business:

(if different from street address):

SAME

NOT APPLICABLE

Holub, Anna 

ZIPCODE

ZIPCODE

60090

ZIPCODE

ZIPCODE

ZIPCODE

Railroad

Stockbroker

Commodity Broker

Other (if debtor is not one of the above

Partnership Chapter 13

Chapter 12 Chapter 15 Petition for Recognition

Chapter 9

Chapter 11

Chapter 7

Chapter of Bankruptcy Code Under Which 

the Petition is Filed (Check one box)

Nature of Debts

Filing Fee (Check one box)

(Check one box)

Full Filing Fee attached

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

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

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

Chapter 11 Debtors:

Check one box:

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

Debtor is 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.

Clearing Bank

entities, check this box and state type of

entity below

of a Foreign Nonmain Proceeding

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

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

Nature of Business

(Check

Health Care Business

Single Asset Real Estate as defined

in 11 U.S.C. § 101 (51B)

(Form of organization)

Corporation (includes LLC and LLP)

Individual (includes Joint Debtors)

Type of Debtor

(Check

Chapter 15 Petition for Recognition

of a Foreign Main Proceeding

Check if:

 one box.)

 one box.)

Check all applicable boxes:

A plan is being filed with this petition

Acceptances of the plan were solicited prepetition from one or more

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

Debts are primarily consumer debts, defined

in 11 U.S.C. § 101(8) as "incurred by an

individual primarily for a personal, family,

Debts are primarily

business debts.

or household purpose"

See Exhibit D on page 2 of this form.

Other

Tax-Exempt Entity

(Check box, if applicable.)

Debtor is a tax-exempt organization

under Title 26 of the United States

Code (the Internal Revenue Code).

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

Statistical/Administrative Information THIS SPACE IS FOR COURT USE ONLY

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

Estimated Assets

Estimated Liabilities

100,000

100-199

5,000

200-999

10,000 25,000 50,000 100,000

1-49 50-99 1,000- 5,001- 10,001- 25,001- 50,001- Over

$1,000,001

to $10

million

$500,001

to $1

million

$0 to

$50,000

$50,001 to

$100,000

$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

More than

$1 billion

$0 to

$50,000

$50,001 to

$100,000

$100,001 to

$500,000

$500,001

to $1

million

$1,000,001

to $10

million

$10,000,001

to $50

million

$50,000,001

to $100

million

$100,000,001

to $500

million

$500,000,001

to $1 billion

More than

$1 billion

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 2 of 32
Official Form 1 (1/08) FORM B1, Page 2

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

(Check any applicable box)

Name of Debtor:

District:

Case Number:

Relationship:

Date Filed:

Judge:

NONE

Location Where Filed: Case Number: Date Filed:

NONE

Voluntary Petition

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

Name of Debtor(s):

Anna Holub

or safety?

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

No

X

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

/s/ Jeff Whitehead 01/09/2010

Signature of Attorney for Debtor(s) Date

Exhibit C

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

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

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

required by 11 U.S.C. §342(b).

Debtor is a debtor in a foreign proceeding and has its principal place of business or principal assets in the United States in this District, or has no

principal place of business or assets in the United States but is a defendant in an action proceeding [in a federal or state court] in this District, or

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

Exhibit D

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

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

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

If this is a joint petition:

Location Where Filed: Case Number: Date Filed:

have informed the petitioner that [he or she] may proceed under chapter 7, 11, 12

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

each such chapter. I further certify that I have delivered to the debtor the notice

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

(Check all applicable boxes.)

(Name of landlord that obtained judgment)

(Address of landlord)

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

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

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

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

period after the filing of the petition.

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

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 3 of 32
Official Form 1 (1/08) FORM B1, Page 3

Anna Holub

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

Code, specified in this petition.

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

proceed under chapter 7.

understand the relief available under each such chapter, and choose to

under chapter 7, 11, 12, or 13 of title 11, United States Code,

and has chosen to file under chapter 7] I am aware that I may proceed

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

petition is true and correct.

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

X

X

Date

Signature of Debtor

Signature of Joint Debtor

Telephone Number (if not represented by attorney)

01/09/2010

/s/ Anna Holub

Signatures

[If no attorney represents me and no bankruptcy petition preparer

11 U.S.C. §342(b)

signs the petition] I have obtained and read the notice required by

X

(Date)

(Signature of Foreign Representative)

(Printed name of 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 a Foreign Representative

Voluntary Petition

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

Name of Debtor(s):

01/09/2010

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

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

are attached.

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

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

order granting recognition of the foreign main proceeding is attached.

(Check only one box.)

Signature of Attorney for Debtor(s)

Chicago IL 60607

312-648-0473

Law Office of Jeff Whitehead

Jeff Whitehead 

Signature of Attorney*

Signature of Non-Attorney Bankruptcy Petition Preparer

Telephone Number

Firm Name

Date

Address

Printed Name of Attorney for Debtor(s)

X 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

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

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

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.

If more than one person prepared this document, attach additional

sheets conforming to the appropriate official form for each person.

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. X

01/09/2010

700 W. Van Buren, #1506

/s/ Jeff Whitehead

Signature of Debtor (Corporation/Partnership)

I declare under penalty of perjury that the information provided

in this petition is true and correct, and that I have been

authorized to file this petition on behalf of the debtor.

bankruptcy petition preparers, I have given the debtor notice of the

maximum amount before preparing any document for filing for a debtor

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

Form 19 is attached.

The debtor requests the relief in accordance with the chapter of

title 11, United States Code, specified in this petition.

and the notices and information required under 11 U.S.C. §§ 110(b), 110

(h), and 342(b); and, (3) if rules or guidelines have been promulgated

pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services

Signature of Authorized Individual

Printed Name of Authorized Individual

Title of Authorized Individual

01/09/2010

Date

X

Signature of bankruptcy petition preparer or officer, principal,

responsible person, or partner whose Social-Security number is provided

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.

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 4 of 32
Form B 201 (11/03)

UNITED STATES BANKRUPTCY COURT

NOTICE TO INDIVIDUAL CONSUMER DEBTOR

The purpose of this notice is to acquaint you with the four chapters of the federal Bankruptcy Code under which you

may file a bankruptcy petition. The bankruptcy law is complicated and not easily described. Therefore, you should seek

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

with the court. Court employees are prohibited from giving you legal advice.

Chapter 7: Liquidation ($155 filing fee plus $39 administrative fee plus $15 trustee surcharge)

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

Under chapter 7 a trustee takes possession of all your property. You may claim certain of your property as

exempt under governing law. The trustee then liquidates the property and uses the proceeds to pay your

creditors according to priorities of the Bankruptcy Code.

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

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

may be denied by the court, and the purpose for which you filed the bankuptcy petition will be defeated.

Even if you receive a discharge, there are some debts that are not discharged under the law. Therefore, you

may still be responsible for such debts as certain taxes and student loans, alimony and support payments,

criminal restitution, and debts for death or personal injury caused by driving while intoxicated from alcohol or

drugs.

Under certain circumstances you may keep property that you have purchased subject to valid security

interest. Your attorney can expain the options that are available to you.

Chapter 13: Repayment of All or Part of the Debts of an Individual with Regular Income ($155

filing fee plus $39 administrative fee)

Chapter 13 is designed for individuals with regular income who are temporarily unable to pay their debts but

would like to pay them in installments over a period of time. You are only eligible for chapter 13 if your debts do

not exceed certain dollar amounts set forth in the Bankuptcy Code.

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

owe them, using your future earnings. Usually, the period allowed by the court to repay your debts is three

years, but no more than five years. Your plan must be approved by the court before it can take effect.

Under chapter 13, unlike chapter 7, you may keep all your property, both exempt and non-exempt, as long as

you continue to make payments under the plan.

After completion of payments under the plan, your debts are discharged except alimony and support

payments, student loans, certain debts including criminal fines and restitution and debts for death or personal

injury caused by driving while intoxicated from alcohol or drugs, and long term secured obligations.

Chapter 11: Reorganization ($800 filing fee plus $39 administrative fee)

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

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

attorney.

Chapter 12: Family farmer ($200 filing fee plus $39 administrative fee)

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

is in many ways similar to chapter 13. The eligibility requirements are restrictive, limiting its use to those whose income arises

primarily from a family-owned farm.

1.

2.

3.

4.

5.

1.

2.

3.

4.

I, the debtor, affirm that I have read this notice.

(circle one)

DEBTOR COPY COURT COPY

Date Signature of Debtor Case Number

01/09/2010 /s/Anna Holub

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 5 of 32
NOTICE TO CONSUMER DEBTORS 

ON INFORMATION REQUIRED IN BANKRUPTCY CASES 

(Pursuant to 11 U.S.C. 527(a)(2)) 

The bankruptcy code requires you to provide complete and accurate information about your 

debts, property and financial affairs. We take this requirement very seriously. We want you to 

understand these requirements clearly. 

(A) All information that you are required to provide with a bankruptcy petition and 

thereafter during your bankruptcy case is required to be complete, accurate and 

truthful.

(B) In the documents you have me file with the court to commence your 

bankruptcy case and thereafter, you must completely and accurately disclose 

all your assets and all of your liabilities. You must provide the replacement 

value without deducting the costs of sale or marketing as of the date you file of 

each item of personal property (property other than real estate) that is subject 

to a lien or security interest. You must make a reasonable inquiry to establish 

this value. If you acquired the property primarily for personal, family or 

household purposes, “replacement value” means the price a retail merchant 

would charge for an item of that kind given the age and condition of the item at 

the time you file. 

(C) You must accurately provide after reasonable inquiry, your current monthly 

income, the amounts specified in 11 U.S.C. § 707(b)(2) and in a case under 

Chapter 13, disposable income (determined in accordance with § 707 (b)(2)). 

(D) Information you provide during your case may be audited pursuant to the 

Bankruptcy Code. Failure to provide accurate information may result in 

dismissal of your case or other sanction including a criminal sanction. 

I have received a copy of this notice 

_____________________________ ___________ ___________________________________

Signature of Assisted Person Date Address 

________________________________ ___________________________________

Printed Name of Assisted Person City, State, Zip 

________________________________

Last 4 Digits of Social Security Number 

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 6 of 32
B6 Declaration (Official Form 6 - Declaration) (12/07) 

Case No.

UNITED STATES BANKRUPTCY COURT

In re

/ Debtor

Anna Holub

NORTHERN DISTRICT OF ILLINOIS

EASTERN DIVISION

Chapter 7

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.

SUMMARY OF SCHEDULES

NAME OF SCHEDULE

Attached

(Yes/No)

No. of

Sheets ASSETS LIABILITIES OTHER

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

1

3

1

1

1

4

1

1

1

1

A-Real Property

B-Personal Property

C-Property Claimed as

Exempt

D-Creditors Holding Secured

Claims

E-Creditors Holding

Unsecured Priority Claims

F-Creditors Holding

Unsecured Nonpriority Claims

G-Executory Contracts and

Unexpired Leases

H-Codebtors

I-Current Income of Individual

Debtor(s)

J-Current Expenditures of

Individual Debtor(s)

$ 0.00

$ 14,545.00

$ 15,079.00

$ 0.00

$ 55,719.00

$ 1,576.00

$ 2,235.00

(Total of Claims on Schedule E)

TOTAL 15 $ 14,545.00 $ 70,798.00

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 7 of 32
B6 Declaration (Official Form 6 - Declaration) (12/07)

NORTHERN DISTRICT OF ILLINOIS

UNITED STATES BANKRUPTCY COURT

In re

/ Debtor

Anna Holub

Chapter 7

Case No.

EASTERN DIVISION

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

Type of Liability

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

Amount

$

$

$

$

$

$

0.00

0.00

23,832.00

0.00

0.00

23,832.00

0.00

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

$

chapter 7, 11, or 13, you must report all information requested below.

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

State the following:

Average Income (from Schedule I, Line 16)

Average Expenses (from Schedule J, Line 18)

Current Monthly Income (from Form 22A Line 12; OR, Form 22B Line 11; OR, Form 22C Line 20)

$

$

$

1,576.00

2,235.00

0.00

1. Total from Schedule D, "UNSECURED PORTION, IF ANY" column $ 4,479.00

State the following:

2. Total from Schedule E, "AMOUNT ENTITLED TO PRIORITY" column $ 0.00

3. Total from Schedule E, "AMOUNT NOT ENTITLED TO PRIORITY, IF ANY" column $ 0.00

4. Total from Schedule F $ 55,719.00

5. Total of non-priority unsecured debt (sum of 1, 3, and 4) $ 60,198.00

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.

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 8 of 32
Anna Holub

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

In re

Debtor(s)

Case No.

(if known)

SCHEDULE A-REAL PROPERTY

,

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

Contracts and Unexpired Leases.

Except as directed below, list all real property in which the debtor has any legal, equitable, or future interest, including all property owned as a

cotenant community property, or in which the debtor has a life estate. Include any property in which the debtor holds rights and powers

exercisable for the debtor’s own benefit. If the debtor is married, state whether the husband, wife, both, or the marital community own the property

by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the debtor holds no interest in real property, write

“None” under “Description and Location of Property.”

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--H

Wife--W

Joint--J

Community--C

Current

Value

of Debtor's Interest,

in Property Without

Deducting any

Secured Claim or

Exemption

Amount of

Secured Claim

None None

No continuation sheets attached TOTAL $

(Report also on Summary of Schedules.)

0.00

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 9 of 32
B6B (Official Form 6B) (12/07)

In re Anna Holub

Debtor(s)

SCHEDULE B-PERSONAL PROPERTY

Case No.

(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 the husband, wife, both, or the

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

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

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).

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

and Unexpired Leases.

Description and Location of Property

Husband--H

Wife--W

Joint--J

Community--C

Type of Property

Current

Value

of Debtor's Interest,

in Property Without

Deducting any

Exemption

Secured Claim or

N

o

n

e

1. Cash on hand. Cash on Hand

Location: In debtor's possession

$ 100.00

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.

Checking Account with Bank of America

Location: In bank's possession

$ 100.00

3. Security deposits with public utilities,

telephone companies, landlords, and

others.

X

4. Household goods and furnishings,

including audio, video, and computer

equipment.

Basic Used Household Furnishings

Location: In debtor's possession

$ 500.00

5. Books, pictures and other art objects,

antiques, stamp, coin, record, tape,

compact disc, and other collections or

collectibles.

Used DVDs and Music CDs

Location: In debtor's possession

$ 100.00

6. Wearing apparel. Basic Used Wearing Apparel

Location: In debtor's possession

$ 500.00

7. Furs and jewelry. Costume Jewelry

Location: In debtor's possession

$ 150.00

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

Page 1 of 3

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 10 of 32
B6B (Official Form 6B) (12/07)

In re Anna Holub

Debtor(s)

SCHEDULE B-PERSONAL PROPERTY

Case No.

(if known)

,

(Continuation Sheet)

Description and Location of Property

Husband--H

Wife--W

Joint--J

Community--C

Type of Property

Current

Value

of Debtor's Interest,

in Property Without

Deducting any

Exemption

Secured Claim or

N

o

n

e

11. Interest 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.

X

13. Stock and interests in incorporated and

unincorporated businesses. Itemize.

Stock at ScottTrade

Location: In debtor's possession

$ 2,495.00

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 settlements to which the debtor

is or may be entitled. Give particulars.

X

18. Other liquidated debts owed to 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 of Real Property.

X

20. Contingent and non-contingent interests

in estate of a decedent, death benefit

plan, life insurance policy, or trust.

X

21. Other contingent and unliquidated claims

of every nature, including tax refunds,

counterclaims of the debtor, and rights to

setoff claims. Give estimated value of

each.

X

22. Patents, copyrights, and other intellectual

property. Give particulars.

X

23. Licenses, franchises, and other general

intangibles. Give particulars.

X

24. Customer lists or other compilations

containing personally identifiable

information (as described 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.

2005 Mercedes C240 in good condition with

70,000 miles

KBB

Location: In debtor's possession

$ 10,600.00

Page 2 of 3

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 11 of 32
B6B (Official Form 6B) (12/07)

In re Anna Holub

Debtor(s)

SCHEDULE B-PERSONAL PROPERTY

Case No.

(if known)

,

(Continuation Sheet)

Description and Location of Property

Husband--H

Wife--W

Joint--J

Community--C

Type of Property

Current

Value

of Debtor's Interest,

in Property Without

Deducting any

Exemption

Secured Claim or

N

o

n

e

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

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

Page 3 of 3

(Report total also on Summary of Schedules.)

Total $ 14,545.00

Include amounts from any continuation sheets attached.

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 12 of 32
B6C (Official Form 6C) (12/07)

In re

Anna Holub

Debtor(s)

SCHEDULE C-PROPERTY CLAIMED AS EXEMPT

Case No.

(if known)

,

Debtor claims the exemptions to which debtor is entitled under:

(Check one box)

11 U.S.C. § 522(b) (2)

11 U.S.C. § 522(b) (3)

Check if debtor claims a homestead exemption that exceeds $136,875.

Description of Property Providing each

Current

Value of Property

Exemption

Specify Law

Without Deducting

Exemptions

Value of

Claimed

Exemption

Cash on Hand 735 ILCS 5/12-1001(b) $ 100.00 $ 100.00

Checking Account 735 ILCS 5/12-1001(b) $ 100.00 $ 100.00

Basic Used Household

Furnishings

735 ILCS 5/12-1001(b) $ 500.00 $ 500.00

Used DVDs and Music CDs 735 ILCS 5/12-1001(b) $ 100.00 $ 100.00

Basic Used Wearing Apparel 735 ILCS 5/12-1001(a) $ 500.00 $ 500.00

Costume Jewelry 735 ILCS 5/12-1001(b) $ 150.00 $ 150.00

Stock 735 ILCS 5/12-1001(b) $ 2,495.00 $ 2,495.00

Page No. 1 of 1

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 13 of 32
Case No.

(if known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

In reAnna Holub ,

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

Debtor(s)

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

claims secured by property of the debtor as of the date of filing of the petition. The complete account number of any account the

debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. List

creditors holding all types of secured interests such as judgment liens, garnishments, statutory liens, mortgages, deeds of trust,

and other security interests.

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

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

child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). If all secured creditors will not fit on this page, use the

continuation sheet provided.

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

“Codebtor,” include the entity on the appropriate schedule of creditors, and complete Schedule H – Codebtors. If a joint petition is

filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an “H,” “W,”

“J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.”

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

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

“X” in more than one of these three columns.)

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

the boxes labeled “Total(s)” on the last sheet of the completed schedule. Report the total from the column labeled “Amount of

Claim Without Deducting Value of Collateral” also on the Summary of Schedules and, if the debtor is an individual with primarily

consumer debts, report the total from the column labeled “Unsecured Portion, if Any” on the Statistical Summary of Certain

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

Creditor's Name and

Mailing Address

H--Husband

W--Wife

J--Joint

C--Community

Date Claim was Incurred, Nature

of Lien, and Description and Market

Value of Property Subject to Lien

Amount of Claim

Without

Deducting Value

of Collateral

Unsecured

Portion, If Any

Including ZIP Code and

Account Number

(See Instructions Above.)

Co-DebtorContingentUnliquidatedDisputed

2005 Mercedes C240

Account No:

Creditor # :

Value:

1

11/2005 - 11/2009

Auto Loan

$ 10,600.00

0221 $ 15,079.00 $ 4,479.00

Bank of America

201 N Tryon Street

Charlotte NC 28202

Account No:

Value:

Account No:

Value:

No continuation sheets attached

(Use only on last page)

Total $

(Total of this page)

Subtotal $ $ 15,079.00

$ 15,079.00

$ 4,479.00

$ 4,479.00

(Report also on Summary of

Schedules.)

(If applicable, report also on

Statistical Summary of

Certain Liabilities and

Related Data)

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 14 of 32
B6E (Official Form 6E) (12/07)

Case No.

(if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS

In re Anna Holub ,

Debtor(s)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 Report the total of amounts NOT entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all

amounts not entitled to priority listed on this Schedule E in the box labeled "Total" on the last sheet of the completed schedule. Individual debtors with

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

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

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

Domestic Support Obligations

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

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

provided in 11 U.S.C. § 507(a)(1).

Extensions of credit in an involuntary case

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

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

Wages, salaries, and commissions, 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).

Wages, salaries, and commissions

Contributions to employee benefit plans

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

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

Certain farmers and fishermen

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

Deposits by individuals

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

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

Taxes and Certain Other Debts Owed to Governmental Units

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

Commitments to Maintain the Capital of an Insured Depository Institution

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

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

507(a)(9).

Claims for Death or Personal Injury While Debtor Was Intoxicated

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

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

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

No continuation sheets attached

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 15 of 32
Case No.

(if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS 

In re Anna Holub ,

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

Debtor(s)

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

priority against the debtor or the property of the debtor, as of the date of filing of the petition. The complete account number of any account the

debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a

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

Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). Do not include claims listed in Schedules D and E. If all

creditors will not fit on this page, use the continuation sheet provided.

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

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

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

Community."

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

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

columns.)

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

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,

H--Husband

W--Wife

J--Joint

C--Community

Date Claim was Incurred,

and Consideration for Claim.

If Claim is Subject to Setoff, so State.

Amount of Claim

And Account Number

(See instructions above.)

Co-Debtor

ContingentUnliquidatedDisputed

Account No:

Creditor # : 1

Access Group Inc

5500 Brandywine Pkwy

Wilmington DE 19803

4/2009 - 11/2009

Student Loan

5975 $ 382.00

Account No:

Creditor # : 2

Access Group Inc

5500 Brandywine Pkwy

Wilmington DE 19803

9/2007 - 11/2009

Student Loan

1597 $ 5,500.00

Account No:

Creditor # : 3

Access Group Inc

5500 Brandywine Pkwy

Wilmington DE 19803

7/2008 - 11/2009

Student Loan

3302 $ 1,833.00

Account No:

Creditor # : 4

Access Group Inc

5500 Brandywine Pkwy

Wilmington DE 19803

9/2008 - 11/2009

Student Loan

3865 $ 3,880.00

3 continuation sheets attached

(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

Total $

Subtotal $ $ 11,595.00

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 16 of 32
Case No.

(if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS 

In re Anna Holub ,

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

Debtor(s)

(Continuation Sheet)

Creditor's Name, Mailing Address

including Zip Code,

H--Husband

W--Wife

J--Joint

C--Community

Date Claim was Incurred,

and Consideration for Claim.

If Claim is Subject to Setoff, so State.

Amount of Claim

And Account Number

(See instructions above.)

Co-Debtor

ContingentUnliquidatedDisputed

Account No:

Creditor # : 5

Access Group Inc

5500 Brandywine Pkwy

Wilmington DE 19803

1/2009 - 11/2009

Student Loan

4052 $ 2,130.00

Account No:

Creditor # : 6

Access Group Inc

5500 Brandywine Pkwy

Wilmington DE 19803

3/2009 - 11/2009

Student Loan

5167 $ 1,216.00

Account No:

Creditor # : 7

Bank of America

P.O. Box 1390

Norfolk VA 23501

12/2005 - 11/2009

Credit Card Purchases

3478 $ 5,303.00

Account No:

Creditor # : 8

Bloomingdales

9111 Duke Blvd

Mason OH 45040

11/2008 - 11/2009

Credit Card Purchases

5261 $ 1,622.00

Account No:

Creditor # : 9

Chase

800 Brooksedge Blvd

Westerville OH 43081

7/2007 - 11/2009

Credit Card Purchases

2266 $ 3,803.00

Michael D. Fine

131 S. Dearborn

Chicago IL 60606

Account No:

Representing:

Chase 

2266

1

Creditors Holding Unsecured Nonpriority Claims

Sheet No. of 3 continuation sheets attached to Schedule of 

(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

Total $

Subtotal $ $ 14,074.00

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 17 of 32
Case No.

(if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS 

In re Anna Holub ,

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

Debtor(s)

(Continuation Sheet)

Creditor's Name, Mailing Address

including Zip Code,

H--Husband

W--Wife

J--Joint

C--Community

Date Claim was Incurred,

and Consideration for Claim.

If Claim is Subject to Setoff, so State.

Amount of Claim

And Account Number

(See instructions above.)

Co-Debtor

ContingentUnliquidatedDisputed

Account No:

Creditor # : 10

CITI

PO Box 6241

Sioux Falls SD 57117

8/2008 - 11/2009

Student Loan

9881 X J $ 4,144.00

Account No:

Creditor # : 11

Citibank CBSD NA

P.O. Box 6241

Sioux Falls South Dakota 57117-

6241

7/2008 - 11/2009

Student Loan

9881 X J $ 2,247.00

Account No:

Creditor # : 12

Citibank CBSD NA

P.O. Box 6241

Sioux Falls South Dakota 57117-

6241

10/2003 - 11/2009

Credit Card Purchases

9214 $ 4,415.00

Account No:

Creditor # : 13

CM PPNTRS

2400 Reynolda Rd

Winston Salem NC 27106

7/2008 - 11/2009

Student Loan

0641 $ 2,500.00

Account No:

Creditor # : 14

GEMB

PO Box 981439

El Paso TX 79998

5/2009 - 11/2009

Credit Card Purchases

0223 $ 158.00

Account No:

Creditor # : 15

HSBC

PO Box 80053

Salinas California 93912-0053

3/2007 - 11/2009

Credit Card Purchases

1439 $ 539.00

2

Creditors Holding Unsecured Nonpriority Claims

Sheet No. of 3 continuation sheets attached to Schedule of 

(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

Total $

Subtotal $ $ 14,003.00

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 18 of 32
Case No.

(if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS 

In re Anna Holub ,

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

Debtor(s)

(Continuation Sheet)

Creditor's Name, Mailing Address

including Zip Code,

H--Husband

W--Wife

J--Joint

C--Community

Date Claim was Incurred,

and Consideration for Claim.

If Claim is Subject to Setoff, so State.

Amount of Claim

And Account Number

(See instructions above.)

Co-Debtor

ContingentUnliquidatedDisputed

Account No:

Creditor # : 16

HSBC

PO Box 15521

Wilmington DE 19805

11/2005 - 11/2009

Credit Card Purchases

5060 $ 1,608.00

Account No:

Creditor # : 17

Macy's / DSNB

9111 Duke Blvd

Mason OH 45040-8999

3/2004 - 11/2009

Credit Card Purchases

8940 $ 1,586.00

Account No:

Creditor # : 18

Nordstrom FSB

PO Box 13589

Scottsdale AZ 85267-3589

9/2003 - 11/2009

Credit Card Purchases

8312 $ 12,075.00

Account No:

Creditor # : 19

WFNNB/VCTRIA

PO Box 182128

Columbus Ohio 43218-3081

11/2003 - 11/2009

Credit Card Purchases

5640 $ 778.00

Account No:

Account No:

$ 55,719.00

3

Creditors Holding Unsecured Nonpriority Claims

Sheet No. of 3 continuation sheets attached to Schedule of 

(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

Total $

Subtotal $ $ 16,047.00

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 19 of 32
B6G (Official Form 6G) (12/07)

In re Anna Holub / Debtor

SCHEDULE G-EXECUTORY CONTRACTS AND UNEXPIRED LEASES

Case No.

(if known)

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

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, 

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

debtor's interests 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

11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

Including Zip Code, of

Description of Contract or Lease and

Nature of Debtor's Interest.

Other Parties to Lease

Name and Mailing Address,

State whether Lease is for Nonresidential Real Property.

or Contract. State Contract Number of any Government Contract.

Page 1 of 1

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 20 of 32
B6H (Official Form 6H) (12/07)

In re Anna Holub / Debtor

SCHEDULE H-CODEBTORS

Case No.

(if known)

Check this box if the debtor has no codebtors.

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

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

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

Wisconsin) within the eight year period immediately preeceding the commencement of the case, identify the name of the debtors spouse and of

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

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

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

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

Name and Address of Codebtor Name and Address of Creditor

Pavlo Holub CITI

PO Box 6241

Sioux Falls SD 57117

Citibank CBSD NA

P.O. Box 6241

Sioux Falls South Dakota 57117-6241

Page 1 of 1

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 21 of 32
B6I (Official Form 6I) (12/07)

In re Anna Holub , Case No.

Debtor(s) (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.

Debtor's Marital 

Status:

DEPENDENTS OF DEBTOR AND SPOUSE

RELATIONSHIP(S): AGE(S):

Single

EMPLOYMENT: DEBTOR SPOUSE

Occupation

Name of Employer

How Long Employed

Address of Employer

Unemployed

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

0.00

1. Monthly gross wages, salary, and commissions (Prorate if not paid monthly) $

2. Estimate monthly overtime

3. SUBTOTAL

$

$ $

$

$

4. LESS PAYROLL DEDUCTIONS

a. Payroll taxes and social security

b. Insurance

c. Union dues

$

$

$

$

$

$

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

d. Other (Specify): $ 0.00 $ 0.00

5. SUBTOTAL OF PAYROLL DEDUCTIONS

6. TOTAL NET MONTHLY TAKE HOME PAY

$

$

$

$

0.00

0.00 0.00

0.00

7. Regular income from operation of business or profession or farm (attach detailed statement) 

8. Income from real property

9. Interest and dividends

10. Alimony, maintenance or support payments payable to the debtor for the debtor's use or that

of dependents listed above.

11. Social security or government assistance

$

$

$

$

$

$

$ $

(Specify): Unemployment Compensation $ $

12. Pension or retirement income

0.00 0.00

0.00 0.00

0.00 0.00

0.00 0.00

1,576.00 0.00

$ 0.00 $ 0.00

(Specify): $ 0.00 $ 0.00

13. Other monthly income

16. COMBINED AVERAGE MONTHLY INCOME:

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

Statistical Summary of Certain Liabilities and Related Data)

15. AVERAGE MONTHLY INCOME 

1,576.00

(Add amounts shown on lines 6 and 14) $ 1,576.00 $ 0.00

14. SUBTOTAL OF LINES 7 THROUGH 13 $ 1,576.00 $ 0.00

(Combine column totals

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

$

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

Page No. 1 of 1

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 22 of 32
B6J(Official Form 6J)(12/07)

Case No.

(if known)

SCHEDULE J-CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR

In re Anna Holub ,

Debtor(s)

 Complete this schedule by estimating the average or projected monthly expenses of the debtor and the debtor's family. Prorate any payments

made bi-weekly, 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 22 A 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?

b. Is property insurance included?

$

$

2. Utilities: a. Electricity and heating fuel

b. Water and sewer

c. Telephone

d. Other

$

$

$

300.00

100.00

0.00

150.00

50.00

$ 0.00

Cable

Yes

Yes

No

No

 Other

..................................................................................................................................................

..............................................................................................................................................................

...................................................................................................................................................................

.....................................................................................................................

3. Home maintenance (repairs and upkeep)

4. Food

5. Clothing

7. Medical and dental expenses

6. Laundry and dry cleaning

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

8. Transportation (not including car payments)

10. Charitable contributions

a. Homeowner's or renter's

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

b. Life

c. Health

d. Auto

e. Other

 Other

$ 0.00

$ 350.00

$

$ 50.00

100.00

$ 50.00

$

$ 75.00

250.00

$ 0.00

$ 0.00

$ 0.00

100.00

$ 0.00

$

$ 0.00

$ 0.00

..............................................................................................................................................

.................................................................................................................................................................................

........................................................................................................................................................

..................................................................................................................

....................................................................................................................................................

......................................................................................................................................................................

........................................................................................................................................................................

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

(Specify) $

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

a. Auto $

$

$

0.00

610.00

0.00

0.00

b. Other:

c. Other:

........................................................................................................................................................................

........................................................................................................................................................................

$ 0.00

$ 0.00

$ 0.00

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: Personal Grooming

Other:

$

$

50.00

0.00

0.00

..................................................................................................................................

....................................................................................

...............................................................................................................................................................................

18. AVERAGE MONTHLY EXPENSES Total lines 1-17. Report also on Summary of Schedules $ 2,235.00

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

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

a. Average monthly income from Line 16 of Schedule I

b. Average monthly expenses from Line 18 above

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

20. STATEMENT OF MONTHLY NET INCOME

$ 1,576.00

$

$

2,235.00

(659.00)

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 23 of 32
B6 Declaration (Official Form 6 - Declaration) (12/07)

In re

DECLARATION CONCERNING DEBTOR'S SCHEDULES

Debtor

Case No.

(if known)

DECLARATION UNDER PENALTY OF PERJURY BY AN INDIVIDUAL DEBTOR

Anna Holub

I declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of 16 sheets, and that they are true and

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

Date: 1/9/2010 Signature

Anna Holub

/s/ Anna Holub

[If joint case, both spouses must sign.]

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.

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 24 of 32
Form 7 (12/07)

Anna Holub Case No.

EASTERN DIVISION

NORTHERN DISTRICT OF ILLINOIS

UNITED STATES BANKRUPTCY COURT

In re:

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 diclose 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 the six years immediately preceding the filing of this bankruptcy case,

any of the following: an officer, director, managing executive, or owner of 5 percent or more of the voting or equity securities of a corporation; a

partner, other than a limited partner, of a partnership; a sole proprietor or self-employed full-time or part-time. An individual debtor my also 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 corporation 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.)

None

 AMOUNT SOURCE

2009: $273.00

2008:$24,643.00

2007:$52,486.00

Income from Employment.

Income from Employment.

Income from Employment.

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, 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.)

None

AMOUNT SOURCE 

2009: $20,214.00 Income from Unemployment Compensation.

Statement of Affairs - Page 1

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 25 of 32
Form 7 (12/07)

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.)

None

NAME AND ADDRESS OF CREDITOR DATES OF

PAYMENTS AMOUNT PAID

AMOUNT

STILL OWING

Creditor: Bank of America

Address: 201 N Tryon Street

Charlotte, NC 28202

11/1/2009

10/1/2009

9/1/2009

$610.00

$610.00

$610.00

$15,079.00

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 this case unless the aggregate value of all property that constitutes or is affected by such transfer is less than $5,475. If the debtor is

an individual, indicate with an asterisk (*) any payments that were made to a creditor on account of a domestic support obligation or as part of an alternative

repayment schedule under a plan by an approved nonprofit budgeting and creditor counseling agency. (Married debtors filingunder 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.)

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.)

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.)

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.)

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.)

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.)

None

Statement of Affairs - Page 2

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 26 of 32
Form 7 (12/07)

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.)

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.)

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.)

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.

None

NAME AND ADDRESS OF PAYEE

DATE OF PAYMENT,

NAME OF PAYER IF OTHER THAN DEBTOR

AMOUNT OF MONEY OR 

DESCRIPTION AND VALUE OF PROPERTY

Payee: Jeff Whitehead

Address:

700 W. Van Buren, #1506

Chicago, IL 60607

Date of Payment:1/1/2010

Payor: Anna Holub

$1200.00

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.)

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 benificiary.

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 or for either or both

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

None

Statement of Affairs - Page 3

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 27 of 32
Form 7 (12/07)

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.)

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.)

None

14. Property held for another person

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

15. Prior address of debtor

If the debtor has moved within three years immediately preceding the commencement of this case, list all premises which the debtor occupied during that

period and vacated prior to the commencement of this case. If a joint petition is filed, report also any separate address of either spouse.

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.

None

17. Environmental Information

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

"Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances,

wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the

cleanup of these substances, wastes, or material.

"Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the

debtor,

including, but not limited to disposal sites.

"Hazardous Material" means anything defined as hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or

similar termunder an Environmental Law:

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:

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.

None

Statement of Affairs - Page 4

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 28 of 32
Form 7 (12/07)

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.

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, partner in a partnership, sole proprietor, or was self

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

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

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

all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within six years immediately preceding the

commencment of this case.

 If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of

all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within six years immediately preceding the

commencment of this case.

None

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.

they are true and correct.

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

[If completed by an individual or individual and spouse]

Signature

of Debtor

of Joint Debtor

Signature

(if any)

Date

Date

01/09/2010 /s/ Anna Holub

Statement of Affairs - Page 5

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 29 of 32
B 8 (Official Form 8) (12/08)

In re Anna Holub

/ Debtor

Case No.

Chapter 7

EASTERN DIVISION

NORTHERN DISTRICT OF ILLINOIS

UNITED STATES BANKRUPTCY COURT

CHAPTER 7 STATEMENT OF INTENTION

Part A - Debts Secured by property of the estate. (Part A must be completed for EACH debt which is secured by property of the estate.

Attach additional pages if necessary.)

Property No.

Describe Property Securing Debt :

None

Creditor's Name :

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

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.)

Property No.

Lessor's Name: Lease will be assumed

pursuant to 11 U.S.C. §

365(p)(2):

Yes No

Describe Leased Property:

None

Date: Debtor:

Signature of Debtor(s)

01/09/2010 /s/ Anna Holub

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

and/or personal property subject to an unexpired lease.

Date: Joint Debtor:

Page 1 of 1

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 30 of 32
Rule 2016(b) (8/91)

UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF ILLINOIS

EASTERN DIVISION

In re Case No.

Chapter

Anna Holub

7

Attorney for Debtor: Jeff Whitehead

/ Debtor

STATEMENT PURSUANT TO RULE 2016(B)

The undersigned, pursuant to Rule 2016(b), Bankruptcy Rules, states that:

1. The undersigned is the attorney for the debtor(s) in this case.

2.

a)

connection with this case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Prior to the filing of this statement, debtor(s) have paid . . . . . . . . . . . . . . . $

The unpaid balance due and payable is . . . . . . . . . . . . . . . . . . . . . . . . . . . $

b)

c)

The compensation paid or agreed to be paid by the debtor(s), to the undersigned is:

For legal services rendered or to be rendered in contemplation of and in

1,200.00

1,200.00

0.00

3. $ 299.00 of the filing fee in this case has been paid.

4.

a)

file a petition under title 11 of the United States Code.

b)

c)

Analysis of the financial situation, and rendering advice and assistance to the debtor(s) in determining whether to

The Services rendered or to be rendered include the following:

Preparation and filing of the petition, schedules, statement of financial affairs and other documents required by the

Representation of the debtor(s) at the meeting of creditors.

court.

5.

services performed, and

The source of payments made by the debtor(s) to the undersigned was from earnings, wages and compensation for

None other

6.

be from earnings, wages and compensation for services performed, and

The source of payments to be made by the debtor(s) to the undersigned for the unpaid balance remaining, if any, will

None other

7.

the value stated:

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

None

8.

law firm, any compensation paid or to be paid except as follows:

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

None

Dated:

Attorney for Petitioner:

01/09/2010 Respectfully submitted,

Jeff Whitehead

Law Office of Jeff Whitehead

700 W. Van Buren, #1506

Chicago IL 60607

X /s/ Jeff Whitehead

312-648-0473

jeffwhitehead_2000@yahoo.com

Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 31 of 32
Case 10-00720 Doc 1 Filed 01/09/10 Entered 01/09/10 20:19:02 Desc Main

 Document Page 32 of 32