CACB — Yes. List all of the places you lived in the last 3

CACB — 107.pdf¶

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/107.pdf

Page 1¶

Fill in this information to identify your case:

Debtor 1 __________________________________________________________________
First Name Middle Name Last Name

Debtor 2 ________________________________________________________________
(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ____________________ DistrictDistrictofof________________________

Case number ___________________________________________ (If known) Check if this is an amended filing

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy 04/25

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Give Details About Your Marital Status and Where You Lived Before

What is your current marital status?

Married Not married

During the last 3 years, have you lived anywhere other than where you live now?

No Yes. List all of the places you lived in the last 3 years. Do not include where you live now.

Debtor 1: Dates Debtor 1 Debtor 2: Dates Debtor 2
lived there lived there

Same as Debtor 1 Same as Debtor 1

__________________________________________ From ________ ___________________________________________ From ________
Number Street Number Street
To ________ To ________
__________________________________________ ___________________________________________

__________________________________________ ___________________________________________
City State ZIP Code City State ZIP Code

Same as Debtor 1 Same as Debtor 1

__________________________________________ From ________ ___________________________________________ From ________ Number Street Number Street To ________ To ________ __________________________________________ ___________________________________________

__________________________________________ ___________________________________________
City State ZIP Code City State ZIP Code

3. Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory? (Community property
states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)
No
Yes. Make sure you fill out Schedule H: Your Codebtors (Official Form 106H).

Part 2: Explain the Sources of Your Income

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

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Page 2¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Did you have any income from employment or from operating a business during this year or the two previous calendar years? Fill in the total amount of income you received from all jobs and all businesses, including part-time activities. If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.

No Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income Gross income Sources of income Gross income
Check all that apply. (before deductions and Check all that apply. (before deductions and
exclusions) exclusions)

Wages, commissions, Wages, commissions, From January 1 of current year until bonuses, tips $________________ bonuses, tips $________________
the date you filed for bankruptcy:
Operating a business Operating a business

Wages, commissions, Wages, commissions, For last calendar year:
bonuses, tips $________________ bonuses, tips $________________
(January 1 to December 31, _________) Operating a business Operating a business
YYYY

Wages, commissions, Wages, commissions, For the calendar year before that:
bonuses, tips bonuses, tips
$________________ $________________
(January 1 to December 31, _________) Operating a business Operating a business
YYYY

Did you receive any other income during this year or the two previous calendar years? Include income regardless of whether that income is taxable. Examples of other income are alimony; child support; Social Security, unemployment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and gambling and lottery winnings. If you are filing a joint case and you have income that you received together, list it only once under Debtor 1.

List each source and the gross income from each source separately. Do not include income that you listed in line 4.

No Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income Gross income from Sources of income Gross income from
Describe below. each source Describe below. each source
(before deductions and (before deductions and
exclusions) exclusions)

__________________ $_________________ _____________________ $_________________ From January 1 of current year until
the date you filed for bankruptcy: __________________ $_________________ _____________________ $_________________
__________________ $_________________ _____________________ $_________________

For last calendar year: __________________ $_________________ _____________________ $_________________
(January 1 to December 31, ) __________________ $___________ _____________________ $_________________
YYYY
__________________ $_________________ _____________________ $_________________

For the calendar year before that: __________________ $_________________ _____________________ $_________________
(January 1 to December 31, ) __________________ $___________ _____________________ $_________________
YYYY
__________________ $_________________ _____________________ $_________________

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 2

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Page 3¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Part 3: List Certain Payments You Made Before You Filed for Bankruptcy

Are either Debtor 1’s or Debtor 2’s debts primarily consumer debts?

No. Neither Debtor 1 nor Debtor 2 has primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8) as “incurred by an individual primarily for a personal, family, or household purpose.” During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $8,575* or more?

No. Go to line 7. Yes. List below each creditor to whom you paid a total of $8,575* or more in one or more payments and the total amount you paid that creditor. Do not include payments for domestic support obligations, such as child support and alimony. Also, do not include payments to an attorney for this bankruptcy case. * Subject to adjustment on 4/01/28 and every 3 years after that for cases filed on or after the date of adjustment.

Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts. During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more?

No. Go to line 7.
Yes. List below each creditor to whom you paid a total of $600 or more and the total amount you paid that
creditor. Do not include payments for domestic support obligations, such as child support and
alimony. Also, do not include payments to an attorney for this bankruptcy case.

Dates of Total amount paid Amount you still owe Was this payment for…
payment

____________________________________ _________ $_________________ $__________________ Mortgage
Creditor’s Name
Car
____________________________________ _________
Number Street Credit card
Loan repayment
____________________________________ _________
Suppliers or vendors
____________________________________ City State ZIP Code Other ____________

____________________________________ _________ $_________________ $__________________ Mortgage
Creditor’s Name
Car
____________________________________ _________ Number Street Credit card
Loan repayment
____________________________________ _________
Suppliers or vendors
____________________________________ Other ____________
City State ZIP Code

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3

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Page 4¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Within 1 year before you filed for bankruptcy, did you make a payment on a debt you owed anyone who was an insider? Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations, such as child support and alimony.

No Yes. List all payments to an insider.

Dates of Total amount Amount you still Reason for this payment
payment paid owe

____________________________________________ _________ $____________ $____________
Insider’s Name

____________________________________________ _________
Number Street

____________________________________________ _________

____________________________________________
City State ZIP Code

$____________ $____________ ____________________________________________ _________
Insider’s Name

____________________________________________ _________
Number Street

____________________________________________ _________

____________________________________________
City State ZIP Code

Within 1 year before you filed for bankruptcy, did you make any payments or transfer any property on account of a debt that benefited an insider? Include payments on debts guaranteed or cosigned by an insider.

No Yes. List all payments that benefited an insider.

Dates of Total amount Amount you still Reason for this payment
payment paid owe Include creditor’s name

____________________________________________ _________ $____________ $____________
Insider’s Name

____________________________________________ _________
Number Street

____________________________________________ _________

____________________________________________
City State ZIP Code

$____________ $____________ ____________________________________________ _________ Insider’s Name

____________________________________________ _________
Number Street

____________________________________________ _________

____________________________________________
City State ZIP Code

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 4

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Page 5¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

Within 1 year before you filed for bankruptcy, were you a party in any lawsuit, court action, or administrative proceeding? List all such matters, including personal injury cases, small claims actions, divorces, collection suits, paternity actions, support or custody modifications, and contract disputes.

No Yes. Fill in the details.

Nature of the case Court or agency Status of the case

________________________________________
Case title_____________________________ Court Name Pending
On appeal
____________________________________ ________________________________________
Number Street Concluded

Case number ________________________ ________________________________________
City State ZIP Code

Within 1 year before you filed for bankruptcy, was any of your property repossessed, foreclosed, garnished, attached, seized, or levied? Check all that apply and fill in the details below.

No. Go to line 11. Yes. Fill in the information below.

Describe the property Date Value of the property

_________________________________________ __________ $______________ Creditor’s Name

_________________________________________
Number Street Explain what happened

Property was repossessed.
_________________________________________
Property was foreclosed.
Property was garnished.
_________________________________________
City State ZIP Code Property was attached, seized, or levied.

Describe the property Date Value of the property

__________ $______________
_________________________________________
Creditor’s Name

_________________________________________
Number Street
Explain what happened

_________________________________________ Property was repossessed.
Property was foreclosed.
_________________________________________ Property was garnished.
City State ZIP Code
Property was attached, seized, or levied.

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 5

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Page 6¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Within 90 days before you filed for bankruptcy, did any creditor, including a bank or financial institution, set off any amounts from your accounts or refuse to make a payment because you owed a debt? No Yes. Fill in the details.

Describe the action the creditor took Date action Amount
was taken ______________________________________
Creditor’s Name

______________________________________ ____________ $________________ Number Street

City State ZIP Code Last 4 digits of account number: XXXX–___ ___ ___ ___
Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of creditors, a court-appointed receiver, a custodian, or another official? No Yes

Part 5: List Certain Gifts and Contributions

Within 2 years before you filed for bankruptcy, did you give any gifts with a total value of more than $600 per person? No Yes. Fill in the details for each gift.

Gifts with a total value of more than $600 Describe the gifts Dates you gave Value
per person the gifts

______________________________________ _________ $_____________ Person to Whom You Gave the Gift

______________________________________ _________ $_____________

Number Street

City State ZIP Code

Person’s relationship to you ______________

Gifts with a total value of more than $600 Describe the gifts Dates you gave Value

per person the gifts

______________________________________ _________ $_____________ Person to Whom You Gave the Gift

______________________________________ _________ $_____________

Number Street

City State ZIP Code

Person’s relationship to you ______________

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 6

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Page 7¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Within 2 years before you filed for bankruptcy, did you give any gifts or contributions with a total value of more than $600 to any charity?

No Yes. Fill in the details for each gift or contribution.

Gifts or contributions to charities Describe what you contributed Date you Value
that total more than $600 contributed

_____________________________________ _________ $_____________
Charity’s Name

_____________________________________ _________ $_____________

_____________________________________
Number Street

_____________________________________
City State ZIP Code

Part 6: List Certain Losses

Within 1 year before you filed for bankruptcy or since you filed for bankruptcy, did you lose anything because of theft, fire, other disaster, or gambling?

No Yes. Fill in the details.

Describe the property you lost and Describe any insurance coverage for the loss Date of your Value of property
how the loss occurred loss lost
Include the amount that insurance has paid. List pending insurance
claims on line 33 of Schedule A/B: Property.

_________ $_____________

Part 7: List Certain Payments or Transfers

Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone you consulted about seeking bankruptcy or preparing a bankruptcy petition? Include any attorneys, bankruptcy petition preparers, or credit counseling agencies for services required in your bankruptcy.

No Yes. Fill in the details.

Description and value of any property transferred Date payment or Amount of payment
transfer was ___________________________________
Person Who Was Paid made

___________________________________
Number Street _________ $_____________

_________ $_____________
___________________________________
City State ZIP Code

____________________________________________
Email or website address

___________________________________
Person Who Made the Payment, if Not You

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 7

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Page 8¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Description and value of any property transferred Date payment or Amount of
transfer was made payment

____________________________________
Person Who Was Paid
_________ $_____________
____________________________________
Number Street

_________ $_____________
____________________________________

____________________________________
City State ZIP Code

________________________________________________
Email or website address

___________________________________
Person Who Made the Payment, if Not You

Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone who promised to help you deal with your creditors or to make payments to your creditors? Do not include any payment or transfer that you listed on line 16.

No Yes. Fill in the details.

Description and value of any property transferred Date payment or Amount of payment
transfer was
____________________________________ made
Person Who Was Paid

____________________________________ _________ $____________
Number Street

____________________________________
_________ $____________
____________________________________
City State ZIP Code

Within 2 years before you filed for bankruptcy, did you sell, trade, or otherwise transfer any property to anyone, other than property transferred in the ordinary course of your business or financial affairs? Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property). Do not include gifts and transfers that you have already listed on this statement. No Yes. Fill in the details.

Description and value of property Describe any property or payments received Date transfer
transferred or debts paid in exchange was made

Person Who Received Transfer

Number Street

City State ZIP Code

Person’s relationship to you _____________

Person Who Received Transfer _________

Number Street

City State ZIP Code

Person’s relationship to you _____________

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 8

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Page 9¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Within 10 years before you filed for bankruptcy, did you transfer any property to a self-settled trust or similar device of which you are a beneficiary? (These are often called asset-protection devices.) No Yes. Fill in the details.

Description and value of the property transferred Date transfer
was made

_________

Name of trust __________________________

Part 8: List Certain Financial Accounts, Instruments, Safe Deposit Boxes, and Storage Units

Within 1 year before you filed for bankruptcy, were any financial accounts or instruments held in your name, or for your benefit, closed, sold, moved, or transferred? Include checking, savings, money market, or other financial accounts; certificates of deposit; shares in banks, credit unions, brokerage houses, pension funds, cooperatives, associations, and other financial institutions. No Yes. Fill in the details.

Last 4 digits of account number Type of account or Date account was Last balance before
instrument closed, sold, moved, closing or transfer
or transferred

Name of Financial Institution XXXX–___ ___ ___ ___ Checking _________ $___________ ____________________________________ Number Street Savings ____________________________________ Money market Brokerage ____________________________________ City State ZIP Code Other__________

____________________________________ XXXX–___ ___ ___ ___ Checking _________ $___________ Name of Financial Institution Savings

Number Street Money market

____________________________________ Brokerage ____________________________________ Other__________ City State ZIP Code
Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for securities, cash, or other valuables? No Yes. Fill in the details.

Who else had access to it? Describe the contents Do you still
have it?

No

Name of Financial Institution Name Yes

Number Street Number Street

_______________________________________
City State ZIP Code

City State ZIP Code

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 9

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Page 10¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Have you stored property in a storage unit or place other than your home within 1 year before you filed for bankruptcy? No Yes. Fill in the details. Who else has or had access to it? Describe the contents Do you still have it? ___________________________________ _______________________________________ No Name of Storage Facility Name Yes ___________________________________ _______________________________________
Number Street Number Street ___________________________________ _______________________________________ City State ZIP Code ___________________________________ City State ZIP Code

Part 9: Identify Property You Hold or Control for Someone Else

Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for, or hold in trust for someone. No Yes. Fill in the details.

Where is the property? Describe the property Value

Owner’s Name $__________
_________________________________________

___________________________________ Number Street Number Street _________________________________________

___________________________________ City State ZIP Code City State ZIP Code

Part 10: Give Details About Environmental Information

For the purpose of Part 10, the following definitions apply:

Environmental law means any federal, state, or local statute or regulation concerning pollution, contamination, releases of hazardous or toxic substances, wastes, or material into the air, land, soil, surface water, groundwater, or other medium, including statutes or regulations controlling the cleanup of these substances, wastes, or material.

Site means any location, facility, or property as defined under any environmental law, whether you now own, operate, or utilize it or used to own, operate, or utilize it, including disposal sites.

Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, contaminant, or similar term.

Report all notices, releases, and proceedings that you know about, regardless of when they occurred.

Has any governmental unit notified you that you may be liable or potentially liable under or in violation of an environmental law?

No Yes. Fill in the details.

Governmental unit Environmental law, if you know it Date of notice

____________________________________ _______________________________ _________
Name of site Governmental unit

____________________________________ _______________________________
Number Street Number Street

_______________________________
____________________________________ City State ZIP Code

____________________________________
City State ZIP Code

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 10

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Page 11¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Have you notified any governmental unit of any release of hazardous material?

No Yes. Fill in the details.

Governmental unit Environmental law, if you know it Date of notice

____________________________________ _______________________________ _________ Name of site Governmental unit

____________________________________ _______________________________
Number Street Number Street

____________________________________ _______________________________
City State ZIP Code

____________________________________
City State ZIP Code

Have you been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders. No Yes. Fill in the details. Status of the Court or agency Nature of the case case

Case title______________________________ ________________________________ Pending Court Name On appeal

Number Street Concluded

Case number City State ZIP Code

Part 11: Give Details About Your Business or Connections to Any Business

Within 4 years before you filed for bankruptcy, did you own a business or have any of the following connections to any business? A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time A member of a limited liability company (LLC) or limited liability partnership (LLP) A partner in a partnership An officer, director, or managing executive of a corporation An owner of at least 5% of the voting or equity securities of a corporation No. None of the above applies. Go to Part 12. Yes. Check all that apply above and fill in the details below for each business. Describe the nature of the business Employer Identification number ____________________________________ Do not include Social Security number or ITIN. Business Name EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___ ____________________________________ Number Street Name of accountant or bookkeeper Dates business existed ____________________________________ From _______ To _______ ____________________________________ City State ZIP Code Describe the nature of the business Employer Identification number ____________________________________ Do not include Social Security number or ITIN. Business Name ____________________________________ EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___ Number Street Name of accountant or bookkeeper Dates business existed ____________________________________ From _______ To _______ ____________________________________ City State ZIP Code

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 11

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Page 12¶

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Employer Identification number
Describe the nature of the business
Do not include Social Security number or ITIN. ____________________________________
Business Name
EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
____________________________________
Number Street
Name of accountant or bookkeeper Dates business existed

____________________________________

____________________________________ From _______ To _______
City State ZIP Code

Within 2 years before you filed for bankruptcy, did you give a financial statement to anyone about your business? Include all financial institutions, creditors, or other parties.

No Yes. Fill in the details below.

Date issued

____________________________________ ____________
Name MM / DD / YYYY

____________________________________
Number Street

____________________________________

____________________________________
City State ZIP Code

Part 12: Sign Below

I have read the answers on this Statement of Financial Affairs and any attachments, and I declare under penalty of perjury that the
answers are true and correct. I understand that making a false statement, concealing property, or obtaining money or property by fraud
in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both.
18 U.S.C. §§ 152, 1341, 1519, and 3571.

______________________________________________ _____________________________
Signature of Debtor 1 Signature of Debtor 2

Date ________________ Date _________________

Did you attach additional pages to Your Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107)?

No Yes

Did you pay or agree to pay someone who is not an attorney to help you fill out bankruptcy forms?

No Yes. Name of person_____________________________________________________________. Attach the Bankruptcy Petition Preparer’s Notice, Declaration, and Signature (Official Form 119).

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 12

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