CACB — Chapter 13

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/Ch13%20Petition%20Package.pdf

United States Bankruptcy Court Central District of California

Chapter 13

Petition Package

Requirements and Forms for Individuals Filing a Chapter 13 Bankruptcy Case in the Central District of California

Revised December 1, 2025

Check the Court’s website www.cacb.uscourts.gov to verify that you are using the latest version of the Petition Package

Table of Contents Page Introduction ................................................................................................. 1

Requirements for Filing a Chapter 13 Bankruptcy Case ............................. 2

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) -- Voluntary Petition (Official Form 101) requires debtors that are not represented by an attorney to declare that they have read this form. Do not file this form. .................................................................................... 5

Requirements for Master Mailing List of Creditors....................................... 9

Example of Format for Master Mailing List of Creditors ............................. 10

Definition of Terms .................................................................................... 11

Introduction

This Chapter 13 Petition Package includes the basic information and forms required to file a voluntary chapter 13 bankruptcy case in the Central District of California, as specified in The Central Guide Section 1-06. Individual debtors should also refer to the Instructions for Bankruptcy Forms for Individuals, available on the Court’s website under Petition Forms. Since bankruptcy is a complex process, debtors considering filing a chapter 13 bankruptcy case are encouraged to consult with a bankruptcy attorney. Only individuals may file chapter 13 bankruptcy cases [11 U.S.C. § 109].

This Petition Package, and all forms in it, are available for free on the Court’s web site http://www.cacb.uscourts.gov. The online versions of the forms in this Petition Package are pdf fillable and can be completed and saved to any computer that has Adobe Acrobat Reader (Adobe Acrobat Reader is available for free at http://get.adobe.com/reader).

Please note that court staff is prohibited from giving legal advice.

Before filing a bankruptcy case, debtors are also encouraged to visit the Court’s web site www.cacb.uscourts.gov to review the “Don’t Have an Attorney” web page. This web page has easy to understand information and videos about the bankruptcy process and other helpful information.

Attorneys filing through CM/ECF should refer to The Central Guide, Section 1-09.

Page 1 Chapter 13 Petition Package

Requirements for Filing a Chapter 13 Bankruptcy Case

To file a chapter 13 bankruptcy case in the Central District of California, debtors:

1. MUST complete an approved credit counseling course within 180 days BEFORE filing the bankruptcy case. Upon completion of the credit counseling course, a certificate of completion will be issued. A copy of the certificate of completion must be filed with the court up to 14 days after the bankruptcy petition filing (with limited exceptions).

   For a list of approved credit counseling agencies, visit the U.S. Department of Justice’s website at www.justice.gov/ust/eo/bapcpa/ccde/cc_approved.htm.

2. MUST pay the chapter 13 filing fee. Consult The Central Guide for the filing fee amount and payment methods.

3. MUST file the following documents at the bankruptcy court in the following order.

   At a minimum, documents in this box (A, B, and C) MUST BE FILED, when applicable, or the bankruptcy filing will not be accepted.

   A. Statement About Your Social Security Numbers (Official Form 121) If filing electronically, see The Central Guide, Section 1-09, TCG Supplement, Paragraph 1.6(b). If filing electronically, this document must be filed separately from the other documents in this package.

   B. Voluntary Petition for Individuals Filings for Bankruptcy (Official Form 101 ) – this completed form must be signed by the debtor(s).

   C. Master Mailing List of Creditors - this is not a form, it is a list of creditors’ names and addresses. Please see the Requirements for Master Mailing List of Creditors on page 9.

   D. Initial Statement About an Eviction Judgment Against You (Official Form 101A) – this form must be filed with your Voluntary Petition IF you marked “Yes” to both questions in #11 on the Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101). The Court requires that filers of this statement also provide a copy of the eviction judgment and a check made payable to the landlord. Page 2 Chapter 13 Petition Package

The Following Documents Must be Filed with the Voluntary Petition or within 14 Days After Filing the Voluntary Petition

The following documents, if applicable, MUST also be filed at the bankruptcy court with the Voluntary Petition, or within 14 days after the filing of the Voluntary Petition. If the following documents are not filed within 14 days after the filing of the Voluntary Petition, the bankruptcy case may be dismissed. If that happens, you will lose whatever filing fee you paid, and your creditors will be able to resume collection activities against you.

E. Debt Repayment Plan – if the credit counseling agency provided the debtor with a debt repayment plan, the debt repayment plan must be filed.

F. Statement of Related Cases (LBR form F 1015-2.1.STMT.RELATED.CASES)

G. Summary of Your Assets and Liabilities and Certain Statistical Information (Official Form 106Sum)

H. Schedules A/B through J-2

Schedule A/B: Property (Official Form 106A/B) Schedule C: The Property You Claim as Exempt (Official Form 106C) Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D) Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F) Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G) Schedule H: Your Codebtors (Official Form 106H) Schedule I: Your Income (Official Form 106I) Schedule J: Your Expenses (Official Form 106J) Schedule J-2: Expenses for Separate Household of Debtor 2 (Official Form 106J-2) You must file Official Form 106J-2 if you answered “yes” to both questions on Official Form 106J, Part 1.

I. Declaration About an Individual Debtor’s Schedules (Official Form 106Dec)

J. Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107)

K. Disclosure of Compensation of Bankruptcy Petition Preparer (Official Form B2800 – this form must be filed only if the debtor paid a non-attorney bankruptcy petition preparer to prepare any of the documents in listed in this Petition Package [11 U.S.C. § 110].

Page 3 Chapter 13 Petition Package

L. Bankruptcy Petition Preparer’s Notice, Declaration and Signature (Official Form 119 ) - this form must be filed only if the debtor paid a non-attorney bankruptcy petition preparer prepared any of the bankruptcy filing documents. [11 U.S.C. § 110].

M. Disclosure of Compensation of Attorney for Debtor (Official Form 2030 ) – this form is required only when an attorney represents the debtor and/or prepared the bankruptcy filing documents.

N. Declaration by Debtor(s) as to Whether Debtor(s) Income was Received From an Employer withint 60 Days of the Petition Date [11 U.S.C., § 521(a)(1)(B)] (LBR form F 1002-1.EMP.INCOME.DEC) If filing electronically, this document must be filed separately from the other documents in this package.

O. Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period (Official Form 122C-1)

P. Chapter 13 Statement of Your Disposable Income (Official Form 122C-2)

Q. Verification of Master Mailing List of Creditors [LBR 1007-1(a)] (LBR form F 1007-1.MAILING.LIST.VERIFICATION)

R. Certificate of Credit Counseling - a certificate of credit counseling is issued by the credit counseling agency after the debtor has completed a credit counseling course. If filing electronically, this document must be filed separately from the other documents in this package.

S. Chapter 13 Plan (LBR form F 3015-1.01.CHAPTER13.PLAN) If filing electronically, this document must be filed separately from the other documents in this package. The Following Documents Must be Filed with the Voluntary Petition or within 30 Days After Filing the Voluntary Petition

T. Statement About Payment of an Eviction Judgment Against You (Official Form 101B) – if you filed Official Form 101A (see E), this form must be filed within 30 days after the filing of the Voluntary Petition if the debtor wishes to stay in their residence for more than 30 days after filing the Voluntary Petition. Optional Form with No Deadline for Filing

U. Debtor’s Request to Activate Electronic Noticing (DeBN) (local form F 9036‐1.1 DeBN ACTIVATE) – this is an optional form for individual debtors to request orders and court-generated notices by email (at no cost) through the DeBN program, instead of by U.S. mail. If filing electronically, this document must be filed separately from the other documents in this package.

Page 4 Chapter 13 Petition Package

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010)

Chapter 7: Liquidation This notice is for you if: You are an individual filing for bankruptcy, $245 filing fee and $78 administrative fee + $15 trustee surcharge Your debts are primarily consumer debts. $338 total fee Consumer debts are defined in 11 U.S.C. § 101(8) as “incurred by an individual Chapter 7 is for individuals who have financial primarily for a personal, family, or difficulty preventing them from paying their household purpose.” debts and who are willing to allow their non- exempt property to be used to pay their creditors. The primary purpose of filing under chapter 7 is to have your debts discharged. The The types of bankruptcy that are bankruptcy discharge relieves you after available to individuals bankruptcy from having to pay many of your pre-bankruptcy debts. Exceptions exist for Individuals who meet the qualifications may file particular debts, and liens on property may still under one of four different chapters of the be enforced after discharge. For example, a Bankruptcy Code: creditor may have the right to foreclose a home mortgage or repossess an automobile. Chapter 7 — Liquidation However, if the court finds that you have Chapter 11 — Reorganization committed certain kinds of improper conduct described in the Bankruptcy Code, the court Chapter 12 — Voluntary repayment plan may deny your discharge. for family farmers or fishermen You should know that even if you file chapter 7 and you receive a discharge, some Chapter 13 — Voluntary repayment plan debts are not discharged under the law. for individuals with regular Therefore, you may still be responsible to pay: income most taxes; You should have an attorney review your most student loans; decision to file for bankruptcy and the choice of domestic support and property settlement chapter. obligations;

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 1

most fines, penalties, forfeitures, and your income is more than the median income criminal restitution obligations; and for your state of residence and family size, depending on the results of the Means Test, the certain debts that are not listed in your U.S. trustee, bankruptcy administrator, or bankruptcy papers. creditors can file a motion to dismiss your case You may also be required to pay debts arising under § 707(b) of the Bankruptcy Code. If a from: motion is filed, the court will decide if your case should be dismissed. To avoid dismissal, fraud or theft; you may choose to proceed under another fraud or defalcation while acting in breach chapter of the Bankruptcy Code. of fiduciary capacity; If you are an individual filing for chapter 7 intentional injuries that you inflicted; and bankruptcy, the trustee may sell your property death or personal injury caused by to pay your debts, subject to your right to operating a motor vehicle, vessel, or exempt the property or a portion of the aircraft while intoxicated from alcohol or proceeds from the sale of the property. The drugs. property, and the proceeds from property that your bankruptcy trustee sells or liquidates that If your debts are primarily consumer debts, the you are entitled to, is called exempt property. court can dismiss your chapter 7 case if it finds Exemptions may enable you to keep your that you have enough income to repay home, a car, clothing, and household items or creditors a certain amount. You must file to receive some of the proceeds if the property Chapter 7 Statement of Your Current Monthly is sold. Income (Official Form 122A–1) if you are an individual filing for bankruptcy under Exemptions are not automatic. To exempt chapter 7. This form will determine your property, you must list it on Schedule C: The current monthly income and compare whether Property You Claim as Exempt (Official Form your income is more than the median income 106C). If you do not list the property, the that applies in your state. trustee may sell it and pay all of the proceeds to your creditors. If your income is not above the median for your state, you will not have to complete the other chapter 7 form, the Chapter 7 Means Chapter 11: Reorganization Test Calculation (Official Form 122A–2). $1,167 filing fee If your income is above the median for your + $571 administrative fee state, you must file a second form —the $1,738 total fee Chapter 7 Means Test Calculation (Official Form 122A–2). The calculations on the form— Chapter 11 is often used for reorganizing a sometimes called the Means Test—deduct business, but is also available to individuals. from your income living expenses and The provisions of chapter 11 are too payments on certain debts to determine any complicated to summarize briefly. amount available to pay unsecured creditors. If

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 2

Read These Important Warnings

Because bankruptcy can have serious long-term financial and legal consequences, including loss of your property, you should hire an attorney and carefully consider all of your options before you file. Only an attorney can give you legal advice about what can happen as a result of filing for bankruptcy and what your options are. If you do file for bankruptcy, an attorney can help you fill out the forms properly and protect you, your family, your home, and your possessions. Although the law allows you to represent yourself in bankruptcy court, you should understand that many people find it difficult to represent themselves successfully. The rules are technical, and a mistake or inaction may harm you. If you file without an attorney, you are still responsible for knowing and following all of the legal requirements. You should not file for bankruptcy if you are not eligible to file or if you do not intend to file the necessary documents. Bankruptcy fraud is a serious crime; you could be fined and imprisoned if you commit fraud in your bankruptcy case. 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.

Under chapter 13, you must file with the court Chapter 12: Repayment plan for family
a plan to repay your creditors all or part of the farmers or fishermen
money that you owe them, usually using your
$200 filing fee future earnings. If the court approves your

• $78 administrative fee plan, the court will allow you to repay your
  $278 total fee debts, as adjusted by the plan, within 3 years or
  5 years, depending on your income and other Similar to chapter 13, chapter 12 permits factors. family farmers and fishermen to repay their

debts over a period of time using future After you make all the payments under your earnings and to discharge some debts that are plan, many of your debts are discharged. The not paid. debts that are not discharged and that you may still be responsible to pay include: domestic support obligations, Chapter 13: Repayment plan for most student loans, individuals with regular income certain taxes, debts for fraud or theft, $235 filing fee debts for fraud or defalcation while acting

• $78 administrative fee in a fiduciary capacity,
  $313 total fee most criminal fines and restitution
  obligations, Chapter 13 is for individuals who have regular

income and would like to pay all or part of certain debts that are not listed in your their debts in installments over a period of time bankruptcy papers, and to discharge some debts that are not paid. certain debts for acts that caused death or You are eligible for chapter 13 only if your personal injury, and debts are not more than certain dollar amounts certain long-term secured debts. set forth in 11 U.S.C. § 109.

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 3

A married couple may file a bankruptcy case together—called a joint case. If you file a joint Warning: File Your Forms on Time case and each spouse lists the same mailing Section 521(a)(1) of the Bankruptcy Code address on the bankruptcy petition, the requires that you promptly file detailed information bankruptcy court generally will mail you and about your creditors, assets, liabilities, income, your spouse one copy of each notice, unless expenses and general financial condition. The court may dismiss your bankruptcy case if you do you file a statement with the court asking that not file this information within the deadlines set by each spouse receive separate copies. the Bankruptcy Code, the Bankruptcy Rules, and the local rules of the court. Understand which services you For more information about the documents and their deadlines, go to: could receive from credit http://www.uscourts.gov/forms/bankruptcy-forms counseling agencies

The law generally requires that you receive a credit counseling briefing from an approved credit counseling agency. 11 U.S.C. § 109(h).Bankruptcy crimes have serious If you are filing a joint case, both spouses mustconsequences receive the briefing. With limited exceptions,

If you knowingly and fraudulently conceal you must receive it within the 180 days before assets or make a false oath or statement you file your bankruptcy petition. This briefing under penalty of perjury—either orally or is usually conducted by telephone or on the in writing—in connection with a Internet. bankruptcy case, you may be fined, In addition, after filing a bankruptcy case, you imprisoned, or both. generally must complete a financial All information you supply in connection management instructional course before you with a bankruptcy case is subject to can receive a discharge. If you are filing a joint examination by the Attorney General acting case, both spouses must complete the course. through the Office of the U.S. Trustee, the Office of the U.S. Attorney, and other You can obtain the list of agencies approved to offices and employees of the U.S. provide both the briefing and the instructional Department of Justice. course from: http://www.uscourts.gov/services- forms/bankruptcy/credit-counseling-and-debtor- Make sure the court has your education-courses. mailing address In Alabama and North Carolina, go to: http://www.uscourts.gov/services-The bankruptcy court sends notices to the forms/bankruptcy/credit-counseling-and-mailing address you list on Voluntary Petition debtor-education-courses.for Individuals Filing for Bankruptcy (Official Form 101). To ensure that you receive If you do not have access to a computer, theinformation about your case, Bankruptcy clerk of the bankruptcy court may be able toRule 4002 requires that you notify the court of help you obtain the list.any changes in your address.

Notice Required by 11 U.S.C. § 342(b) for Individuals Filing for Bankruptcy (Form 2010) page 4

Requirements for Master Mailing List of Creditors

A Master Mailing List of Creditors, with the names and addresses of the creditors, must be filed in all bankruptcy cases and must be submitted in the following format (see Example of Format for Master Mailing List on the next page):

1. Typed on blank, unlined, standard white 8-1/2 x 11 inch medium weight paper using uppercase and lowercase letter quality fonts, no smaller than 10 point nor greater than 14 point, in either Arial, Calibri, Cambria, Courier, Times New Roman, Helvetica, Geneva, or Letter Gothic.

2. Typed in a single column with no letters closer than 1-1/2 inches from any edge of the paper and left justified.

3. Typed with no more than 8 name/address blocks per page. Each block must consist of no more than 4 lines total for each name/address with at least 2 blank lines in between.

4. Master Mailing List pages must list the creditors from schedules D, and E/F of the bankruptcy case filing. Use as many pages as needed. Do not include the debtor, joint debtor, U.S. Trustee, Internal Revenue Service, or Franchise Tax Board on the Master Mailing List.

5. Each line can be no more than 35 characters in length including spaces. The attention line, if any, must be included on the second line of the block. DO NOT INCLUDE ACCOUNT NUMBERS. The city, state (2-letter abbreviation in capital letters only, e.g., CA), and zip code must be on the last line. Nine-digit zip codes should be separated by a hyphen.

6. Do not use punctuation, except for one comma between city and state (for example Los Angeles, CA 90012).

7. If a separate Equity Holders List is filed, it must comply with the above format

   requirements.

   Page 9 Chapter 13 Petition Package

Example of Format for Master Mailing List of Creditors

Acme Auto Repair
1234 S Street
Los Angeles, CA 90005

Acme Hair Repair
Attn Herman
1234 S Ave
Los Angeles, CA 90005-0001

Acme Dental Clinic
745 Tungsten Boulevard
Hollywood, CA 90027

Acme Talent Agency
421 N Copper Canyon Way
Burbank, CA 91505-0002

Loans By Acme
7485 Chromium Circle
Beverly Hills, CA 90210

Acme And Sons Insurance
Attn D Acme
13363 Hierro Street Suite 25
Van Nuys, CA 91401

Acme Bar and Grill
114 Aluminum Alley
Chatsworth, CA 91313

Page 10 Chapter 13 Petition Package

Definition of Terms

Automatic Stay – An injunction that automatically stops lawsuits, foreclosures, garnishments, and most collection activities against the debtor the moment a bankruptcy petition is filed.

Bankruptcy Code – The Bankruptcy Code (also referred to as 11 U.S.C.) is the bankruptcy law portion of the United States Code and is available online at http://law.abi.org/.

The Central Guide– The Central Guide serves as the administrative portion of the Local Bankruptcy Rules. It lists all the documents that must be prepared in order to file bankruptcy. The Central Guide also contains other useful information for the public, including filing fees and procedures, telephone numbers, clerical and mechanical rules, and instructions and guides for public access to court dockets, records, and court technology. The Central Guide is available online at https://www.cacb.uscourts.gov/the-central-guide.

Debtor – An individual, a married couple, or a non-individual that has filed a bankruptcy petition.

FRBP – The Federal Rules of Bankruptcy Procedure (FRPB) govern procedures for bankruptcy proceedings and are available online at http://law.abi.org/.

Local Bankruptcy Rules (LBRs) – The Local Bankruptcy Rules, often referred to as LBRs, are a set of procedures and mandatory requirements for bankruptcy cases and proceedings in the Central District of California. LBRs also give parties and their attorneys instructions for getting their requests in front of the judge and list requirements for attorneys, trustees, and other parties who work for a bankruptcy estate. LBRs are available on the Court’s website at www.cacb.uscourts.gov/local-rules.

LBR Forms – Local Bankruptcy Rules Forms are approved for use by the Bankruptcy Court for the Central District of California and work in conjunction with the Local Bankruptcy Rules. LBR forms numbers are preceded with the letter “F” followed by the applicable LBR number. LBR forms are available online at www.cacb.uscourts.gov/forms/local_bankruptcy_rules_forms.

Non-Individual – A corporation, partnership, unincorporated association, or trust.

Official Forms – Official Forms are approved for use by the United States Courts for national use and are available at www.uscourts.gov/forms/bankruptcy-forms. Many often used Official Forms are also available on the Court’s website at www.cacb.uscourts.gov/forms.

Page 11 Chapter 13 Petition Package

Fill in this information to identify your case:

United States Bankruptcy Court for the: ______________________________ District Districtof __________of _________________ State Case number (If known): _________________________

Official Form 121 Statement About Your Social Security Numbers 12/15

Use this form to tell the court about any Social Security or federal Individual Taxpayer Identification numbers you have used. Do not file this form as part of the public case file. This form must be submitted separately and must not be included in the court’s public electronic records. Please consult local court procedures for submission requirements. To protect your privacy, the court will not make this form available to the public. You should not include a full Social Security Number or Individual Taxpayer Number on any other document filed with the court. The court will make only the last four digits of your numbers known to the public. However, the full numbers will be available to your creditors, the U.S. Trustee or bankruptcy administrator, and the trustee assigned to your case. 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.

Part 1: Tell the Court About Yourself and Your spouse if Your Spouse is Filing With You

For Debtor 1: For Debtor 2 (Only If Spouse Is Filing):

1. Your name _________________________________________________ _________________________________________________ First name First name _________________________________________________ _________________________________________________ Middle name Middle name _________________________________________________ _________________________________________________ Last name Last name

Part 2: Tell the Court About all of Your Social Security or Federal Individual Taxpayer Identification Numbers

2. All Social Security __ __ __ – __ __ – __ __ __ __ __ __ __ – __ __ – __ __ __ __ Numbers you have used __ __ __ – __ __ – __ __ __ __ __ __ __ – __ __ – __ __ __ __ You do not have a Social Security number. You do not have a Social Security number.

3. All federal Individual Taxpayer 9 __ __ – __ __ – __ __ __ __ 9 __ __ – __ __ – __ __ __ __ Identification Numbers (ITIN) you 9 __ __ – __ __ – __ __ __ __ 9 __ __ – __ __ – __ __ __ __ have used You do not have an ITIN. You do not have an ITIN.

Part 3: Sign Below

Under penalty of perjury, I declare that the information Under penalty of perjury, I declare that the information
I have provided in this form is true and correct. I have provided in this form is true and correct.

_______________________________________ _______________________________________
Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY

Official Form 121 Statement About Your Social Security Numbers

Fill in this information to identify your case:

United States Bankruptcy Court for the:

__________ District of __________

Case number (If known): _________________________ Chapter you are filing under:
Chapter 7 Check if this is an
Chapter 11 amended filing Chapter 12
Chapter 13

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy 06/24

The bankruptcy forms use you and Debtor 1 to refer to a debtor filing alone. A married couple may file a bankruptcy case together—called a joint case—and in joint cases, these forms use you to ask for information from both debtors. For example, if a form asks, “Do you own a car,” the answer would be yes if either debtor owns a car. When information is needed about the spouses separately, the form uses Debtor 1 and Debtor 2 to distinguish between them. In joint cases, one of the spouses must report information as Debtor 1 and the other as Debtor 2. The same person must be Debtor 1 in all of the forms. 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: Identify Yourself

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case):

1. Your full name __________________________________________________ __________________________________________________ Write the name that is on your First name First name government-issued picture identification (for example, __________________________________________________ __________________________________________________ your driver’s license or Middle name Middle name passport). __________________________________________________ __________________________________________________ Last name Last name Bring your picture identification to your meeting ___________________________ ___________________________ with the trustee. Suffix (Sr., Jr., II, III) Suffix (Sr., Jr., II, III)

2. All other names you __________________________________________________ __________________________________________________ have used in the last 8 First name First name years __________________________________________________ __________________________________________________ Middle name Middle name Include your married or maiden names and any __________________________________________________ __________________________________________________ Last name Last name assumed, trade names and doing business as names. __________________________________________________ __________________________________________________ First name First name

Do NOT list the name of any
separate legal entity such as __________________________________________________ __________________________________________________
Middle name Middle name a corporation, partnership, or
LLC that is not filing this __________________________________________________ __________________________________________________
petition. Last name Last name
__________________________________________________ __________________________________________________
Business name (if applicable) Business name (if applicable)
__________________________________________________ __________________________________________________
Business name (if applicable) Business name (if applicable)

3. Only the last 4 digits of xxx – xx – ____ ____ ____ ____ xxx – xx – ____ ____ ____ ____ your Social Security number or federal OR OR Individual Taxpayer Identification number 9 xx – xx – ____ ____ ____ ____ 9 xx – xx – ____ ____ ____ ____ (ITIN)

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 1

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

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case):

4. Your Employer ___ ___ – ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___ ___ ___ ___ Identification Number EIN EIN (EIN), if any. ___ ___ – ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___ ___ ___ ___ EIN EIN

5. Where you live If Debtor 2 lives at a different address:

   _________________________________________________ _________________________________________________
   Number Street Number Street

   _________________________________________________ _________________________________________________

   _________________________________________________ _________________________________________________
   City State ZIP Code City State ZIP Code

   _________________________________________________ _________________________________________________
   County County

   If your mailing address is different from the one If Debtor 2’s mailing address is different from
   above, fill it in here. Note that the court will send yours, fill it in here. Note that the court will send
   any notices to you at this mailing address. any notices to this mailing address.

   _________________________________________________ _________________________________________________
   Number Street Number Street

   _________________________________________________ _________________________________________________
   P.O. Box P.O. Box

---

City State ZIP Code City State ZIP Code

6. Why you are choosing Check one: Check one: this district to file for Over the last 180 days before filing this petition, Over the last 180 days before filing this petition, bankruptcy I have lived in this district longer than in any I have lived in this district longer than in any other district. other district. I have another reason. Explain. I have another reason. Explain. (See 28 U.S.C. § 1408.) (See 28 U.S.C. § 1408.) ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 2

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

Part 2: Tell the Court About Your Bankruptcy Case

7. The chapter of the Check one. (For a brief description of each, see Notice Required by 11 U.S.C. § 342(b) for Individuals Filing Bankruptcy Code you for Bankruptcy (Form 2010)). Also, go to the top of page 1 and check the appropriate box. are choosing to file Chapter 7 under Chapter 11 Chapter 12 Chapter 13

8. How you will pay the fee I will pay the entire fee when I file my petition. Please check with the clerk’s office in your local court for more details about how you may pay. Typically, if you are paying the fee yourself, you may pay with cash, cashier’s check, or money order. If your attorney is submitting your payment on your behalf, your attorney may pay with a credit card or check with a pre-printed address. I need to pay the fee in installments. If you choose this option, sign and attach the Application for Individuals to Pay The Filing Fee in Installments (Official Form 103A). I request that my fee be waived (You may request this option only if you are filing for Chapter 7. By law, a judge may, but is not required to, waive your fee, and may do so only if your income is less than 150% of the official poverty line that applies to your family size and you are unable to pay the fee in installments). If you choose this option, you must fill out the Application to Have the Chapter 7 Filing Fee Waived (Official Form 103B) and file it with your petition.

9. Have you filed for No bankruptcy within the Yes. District __________________________ When _______________ Case number ___________________________ last 8 years? MM / DD / YYYY District __________________________ When _______________ Case number ___________________________ MM / DD / YYYY District __________________________ When _______________ Case number ___________________________ MM / DD / YYYY

10. Are any bankruptcy No cases pending or being Yes. Debtor _________________________________________________ Relationship to you _____________________ filed by a spouse who is

not filing this case with District __________________________ When _______________ Case number, if known____________________ you, or by a business MM / DD / YYYY partner, or by an affiliate? Debtor _________________________________________________ Relationship to you _____________________

District __________________________ When _______________ Case number, if known____________________

MM / DD / YYYY

11. Do you rent your No. Go to line 12. residence? Yes. Has your landlord obtained an eviction judgment against you? No. Go to line 12. Yes. Fill out Initial Statement About an Eviction Judgment Against You (Form 101A) and file it as part of this bankruptcy petition.

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 3

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

Part 3: Report About Any Businesses You Own as a Sole Proprietor

12. Are you a sole proprietor No. Go to Part 4. of any full- or part-time business? Yes. Name and location of business A sole proprietorship is a business you operate as an _______________________________________________________________________________________ Name of business, if any individual, and is not a

separate legal entity such as a corporation, partnership, or _______________________________________________________________________________________ LLC. Number Street If you have more than one _______________________________________________________________________________________ sole proprietorship, use a separate sheet and attach it to this petition. _______________________________________________ _______ __________________________ City State ZIP Code

Check the appropriate box to describe your business:

Health Care Business (as defined in 11 U.S.C. § 101(27A)) Single Asset Real Estate (as defined in 11 U.S.C. § 101(51B)) Stockbroker (as defined in 11 U.S.C. § 101(53A)) Commodity Broker (as defined in 11 U.S.C. § 101(6))

None of the above

13. Are you filing under If you are filing under Chapter 11, the court must know whether you are a small business debtor so that it Chapter 11 of the can set appropriate deadlines. If you indicate that you are a small business debtor, you must attach your Bankruptcy Code, and most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or if any of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B). are you a small business debtor? For a definition of small No. I am not filing under Chapter 11. business debtor, see No. I am filing under Chapter 11, but I am NOT a small business debtor according to the definition in 11 U.S.C. § 101(51D). the Bankruptcy Code. Yes. I am filing under Chapter 11, I am a small business debtor according to the definition in the Bankruptcy Code, and I do not choose to proceed under Subchapter V of Chapter 11. Yes. I am filing under Chapter 11, I am a small business debtor according to the definition in the Bankruptcy Code, and I choose to proceed under Subchapter V of Chapter 11.

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 4

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

Part 4: Report if You Own or Have Any Hazardous Property or Any Property That Needs Immediate Attention

14. Do you own or have any No property that poses or is Yes. What is the hazard? ________________________________________________________________________ alleged to pose a threat

of imminent and
identifiable hazard to ________________________________________________________________________
public health or safety?

Or do you own any property that needs If immediate attention is needed, why is it needed? _______________________________________________ immediate attention? For example, do you own ________________________________________________________________________ perishable goods, or livestock that must be fed, or a building that needs urgent repairs? Where is the property? ________________________________________________________________________ Number Street

________________________________________________________________________

________________________________________ _______ ____________________
City State ZIP Code

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 5

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

Part 5: Explain Your Efforts to Receive a Briefing About Credit Counseling

About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case):15. Tell the court whether you have received a briefing about credit You must check one: You must check one: counseling. I received a briefing from an approved credit I received a briefing from an approved credit counseling agency within the 180 days before I counseling agency within the 180 days before I The law requires that you filed this bankruptcy petition, and I received a filed this bankruptcy petition, and I received a receive a briefing about credit certificate of completion. certificate of completion. counseling before you file for Attach a copy of the certificate and the payment Attach a copy of the certificate and the payment bankruptcy. You must plan, if any, that you developed with the agency. plan, if any, that you developed with the agency. truthfully check one of the following choices. If you I received a briefing from an approved credit I received a briefing from an approved credit cannot do so, you are not counseling agency within the 180 days before I counseling agency within the 180 days before I eligible to file. filed this bankruptcy petition, but I do not have a filed this bankruptcy petition, but I do not have a certificate of completion. certificate of completion. If you file anyway, the court Within 14 days after you file this bankruptcy petition, Within 14 days after you file this bankruptcy petition, can dismiss your case, you you MUST file a copy of the certificate and payment you MUST file a copy of the certificate and payment will lose whatever filing fee plan, if any. plan, if any. you paid, and your creditors can begin collection activities I certify that I asked for credit counseling I certify that I asked for credit counseling again. services from an approved agency, but was services from an approved agency, but was unable to obtain those services during the 7 unable to obtain those services during the 7 days after I made my request, and exigent days after I made my request, and exigent circumstances merit a 30-day temporary waiver circumstances merit a 30-day temporary waiver of the requirement. of the requirement.

To ask for a 30-day temporary waiver of the To ask for a 30-day temporary waiver of the
requirement, attach a separate sheet explaining requirement, attach a separate sheet explaining
what efforts you made to obtain the briefing, why what efforts you made to obtain the briefing, why
you were unable to obtain it before you filed for you were unable to obtain it before you filed for
bankruptcy, and what exigent circumstances bankruptcy, and what exigent circumstances
required you to file this case. required you to file this case.

Your case may be dismissed if the court is Your case may be dismissed if the court is
dissatisfied with your reasons for not receiving a dissatisfied with your reasons for not receiving a
briefing before you filed for bankruptcy. briefing before you filed for bankruptcy.
If the court is satisfied with your reasons, you must If the court is satisfied with your reasons, you must
still receive a briefing within 30 days after you file. still receive a briefing within 30 days after you file.
You must file a certificate from the approved You must file a certificate from the approved
agency, along with a copy of the payment plan you agency, along with a copy of the payment plan you
developed, if any. If you do not do so, your case developed, if any. If you do not do so, your case
may be dismissed. may be dismissed.
Any extension of the 30-day deadline is granted Any extension of the 30-day deadline is granted
only for cause and is limited to a maximum of 15 only for cause and is limited to a maximum of 15
days. days.
I am not required to receive a briefing about I am not required to receive a briefing about
credit counseling because of: credit counseling because of:
Incapacity. I have a mental illness or a mental Incapacity. I have a mental illness or a mental
deficiency that makes me deficiency that makes me
incapable of realizing or making incapable of realizing or making
rational decisions about finances. rational decisions about finances.
Disability. My physical disability causes me Disability. My physical disability causes me
to be unable to participate in a to be unable to participate in a
briefing in person, by phone, or briefing in person, by phone, or
through the internet, even after I through the internet, even after I
reasonably tried to do so. reasonably tried to do so.
Active duty. I am currently on active military Active duty. I am currently on active military
duty in a military combat zone. duty in a military combat zone.

If you believe you are not required to receive a If you believe you are not required to receive a
briefing about credit counseling, you must file a briefing about credit counseling, you must file a
motion for waiver of credit counseling with the court. motion for waiver of credit counseling with the court.

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 6

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

Part 6: Answer These Questions for Reporting Purposes

16a. Are your debts primarily consumer debts? Consumer debts are defined in 11 U.S.C. § 101(8)

16. What kind of debts do as “incurred by an individual primarily for a personal, family, or household purpose.” you have? No. Go to line 16b. Yes. Go to line 17. 16b. Are your debts primarily business debts? Business debts are debts that you incurred to obtain money for a business or investment or through the operation of the business or investment. No. Go to line 16c. Yes. Go to line 17. 16c. State the type of debts you owe that are not consumer debts or business debts. _______________________________________________________________

17. Are you filing under No. I am not filing under Chapter 7. Go to line 18. Chapter 7?

Do you estimate that after Yes. I am filing under Chapter 7. Do you estimate that after any exempt property is excluded and any exempt property is administrative expenses are paid that funds will be available to distribute to unsecured creditors? excluded and No administrative expenses Yes are paid that funds will be available for distribution to unsecured creditors? 18. How many creditors do 1-49 1,000-5,000 25,001-50,000 you estimate that you 50-99 5,001-10,000 50,001-100,000 owe? 100-199 10,001-25,000 More than 100,000 200-999

19. How much do you $0-$50,000 $1,000,001-$10 million $500,000,001-$1 billion estimate your assets to $50,001-$100,000 $10,000,001-$50 million $1,000,000,001-$10 billion be worth? $100,001-$500,000 $50,000,001-$100 million $10,000,000,001-$50 billion $500,001-$1 million $100,000,001-$500 million More than $50 billion

20. How much do you $0-$50,000 $1,000,001-$10 million $500,000,001-$1 billion estimate your liabilities $50,001-$100,000 $10,000,001-$50 million $1,000,000,001-$10 billion to be? $100,001-$500,000 $50,000,001-$100 million $10,000,000,001-$50 billion $500,001-$1 million $100,000,001-$500 million More than $50 billion

Part 7: Sign Below

I have examined this petition, and I declare under penalty of perjury that the information provided is true and

For you correct.

If I have chosen to file under Chapter 7, I am aware that I may proceed, if eligible, under Chapter 7, 11,12, or 13
of title 11, United States Code. I understand the relief available under each chapter, and I choose to proceed
under Chapter 7.

If no attorney represents me and I did not pay or agree to pay someone who is not an attorney to help me fill out
this document, I have obtained and read the notice required by 11 U.S.C. § 342(b).

I request relief in accordance with the chapter of title 11, United States Code, specified in this petition.

I understand 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

Executed on _________________ Executed on __________________
MM / DD / YYYY MM / DD / YYYY

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 7

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

I, the attorney for the debtor(s) named in this petition, declare that I have informed the debtor(s) about eligibility

For your attorney, if you are to proceed under Chapter 7, 11, 12, or 13 of title 11, United States Code, and have explained the relief represented by one available under each chapter for which the person is eligible. I also certify that I have delivered to the debtor(s) the notice required by 11 U.S.C. § 342(b) and, in a case in which § 707(b)(4)(D) applies, certify that I have no If you are not represented knowledge after an inquiry that the information in the schedules filed with the petition is incorrect. by an attorney, you do not need to file this page. _________________________________ Date _________________ Signature of Attorney for Debtor MM / DD / YYYY

_________________________________________________________________________________________________
Printed name

_________________________________________________________________________________________________
Firm name

_________________________________________________________________________________________________
Number Street

_________________________________________________________________________________________________

______________________________________________________ ____________ ______________________________
City State ZIP Code

Contact phone _____________________________________ Email address ______________________________

______________________________________________________ ____________
Bar number State

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 8

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

For you if you are filing this The law allows you, as an individual, to represent yourself in bankruptcy court, but you bankruptcy without an should understand that many people find it extremely difficult to represent attorney themselves successfully. Because bankruptcy has long-term financial and legal consequences, you are strongly urged to hire a qualified attorney. If you are represented by an attorney, you do not To be successful, you must correctly file and handle your bankruptcy case. The rules are very need to file this page. technical, and a mistake or inaction may affect your rights. For example, your case may be dismissed because you did not file a required document, pay a fee on time, attend a meeting or hearing, or cooperate with the court, case trustee, U.S. trustee, bankruptcy administrator, or audit firm if your case is selected for audit. If that happens, you could lose your right to file another case, or you may lose protections, including the benefit of the automatic stay.

You must list all your property and debts in the schedules that you are required to file with the
court. Even if you plan to pay a particular debt outside of your bankruptcy, you must list that debt
in your schedules. If you do not list a debt, the debt may not be discharged. If you do not list
property or properly claim it as exempt, you may not be able to keep the property. The judge can
also deny you a discharge of all your debts if you do something dishonest in your bankruptcy
case, such as destroying or hiding property, falsifying records, or lying. Individual bankruptcy
cases are randomly audited to determine if debtors have been accurate, truthful, and complete.
Bankruptcy fraud is a serious crime; you could be fined and imprisoned.

If you decide to file without an attorney, the court expects you to follow the rules as if you had
hired an attorney. The court will not treat you differently because you are filing for yourself. To be
successful, you must be familiar with the United States Bankruptcy Code, the Federal Rules of
Bankruptcy Procedure, and the local rules of the court in which your case is filed. You must also
be familiar with any state exemption laws that apply.

Are you aware that filing for bankruptcy is a serious action with long-term financial and legal
consequences?
No
Yes

Are you aware that bankruptcy fraud is a serious crime and that if your bankruptcy forms are
inaccurate or incomplete, you could be fined or imprisoned?
No
Yes

Did you pay or agree to pay someone who is not an attorney to help you fill out your bankruptcy forms?
No
Yes. Name of Person_____________________________________________________________________.
Attach Bankruptcy Petition Preparer’s Notice, Declaration, and Signature (Official Form 119).

By signing here, I acknowledge that I understand the risks involved in filing without an attorney. I
have read and understood this notice, and I am aware that filing a bankruptcy case without an
attorney may cause me to lose my rights or property if I do not properly handle the case.

_______________________________________________ ______________________________
Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY

Contact phone ______________________________________ Contact phone ________________________________

Cell phone ______________________________________ Cell phone ________________________________

Email address ______________________________________ Email address ________________________________

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 9 Print Save As... Add Attachment Reset

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: ____________________________ DistrictDistrictof of______________________ (State) Case number ___________________________________________ (If known)

Official Form 101A Initial Statement About an Eviction Judgment Against You 12/15

File this form with the court and serve a copy on your landlord when you first file bankruptcy only if:

you rent your residence; and your landlord has obtained a judgment for possession in an eviction, unlawful detainer action, or similar proceeding (called eviction judgment) against you to possess your residence.

Landlord’s name __________________________________________________

Landlord’s address __________________________________________________
Number Street

_______________________________ _________ ___________
City State ZIP Code

If you want to stay in your rented residence after you file your case for bankruptcy, also complete the certification below.

Certification About Applicable Law and Deposit of Rent

I certify under penalty of perjury that:

Under the state or other nonbankruptcy law that applies to the judgment for possession (eviction judgment),
I have the right to stay in my residence by paying my landlord the entire delinquent amount.

I have given the bankruptcy court clerk a deposit for the rent that would be due during the 30 days after I file
the Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101).
____________________________________________ ____________________________________________
Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY

Stay of Eviction: (a) First 30 days after bankruptcy. If you checked both boxes above, signed the form to certify that both apply,
and served your landlord with a copy of this statement, the automatic stay under 11 U.S.C. § 362(a)(3) will
apply to the continuation of the eviction against you for 30 days after you file your Voluntary Petition for
Individuals Filing for Bankruptcy (Official Form 101).

(b) Stay after the initial 30 days. If you wish to stay in your residence after that 30-day period and continue to
receive the protection of the automatic stay under 11 U.S.C. § 362(a)(3), you must pay the entire delinquent
amount to your landlord as stated in the eviction judgment before the 30-day period ends. You must also fill
out Statement About Payment of an Eviction Judgment Against You (Official Form 101B), file it with the
bankruptcy court, and serve your landlord a copy of it before the 30-day period ends.

Check the Bankruptcy Rules ( http://www.uscourts.gov/rules-policies/current-rules-practice-procedure) and the local court’s website (to find your court’s website, go to http://www.uscourts.gov/court-locator) for any specific requirements that you might have to meet to serve this statement. 11 U.S.C. §§ 362(b)(22) and 362(l)

Official Form 101A Initial Statement About an Eviction Judgment Against You

STATEMENT OF RELATED CASES INFORMATION REQUIRED BY LBR 1015-2 UNITED STATES BANKRUPTCY COURT, CENTRAL DISTRICT OF CALIFORNIA

1. A petition under the Bankruptcy Act of 1898 or the Bankruptcy Reform Act of 1978 has previously been filed by or against the debtor, his/her spouse, his or her current or former domestic partner, an affiliate of the debtor, any copartnership or joint venture of which debtor is or formerly was a general or limited partner, or member, or any corporation of which the debtor is a director, officer, or person in control, as follows: (Set forth the complete number and title of each such of prior proceeding, date filed, nature thereof, the Bankruptcy Judge and court to whom assigned, whether still pending and, if not, the disposition thereof. If none, so indicate. Also, list any real property included in Schedule A/B that was filed with any such prior proceeding(s).)

2. (If petitioner is a partnership or joint venture) A petition under the Bankruptcy Act of 1898 or the Bankruptcy Reform Act of 1978 has previously been filed by or against the debtor or an affiliate of the debtor, or a general partner in the debtor, a relative of the general partner, general partner of, or person in control of the debtor, partnership in which the debtor is a general partner, general partner of the debtor, or person in control of the debtor as follows: (Set forth the complete number and title of each such prior proceeding, date filed, nature of the proceeding, the Bankruptcy Judge and court to whom assigned, whether still pending and, if not, the disposition thereof. If none, so indicate. Also, list any real property included in Schedule A/B that was filed with any such prior proceeding(s).)

3. (If petitioner is a corporation) A petition under the Bankruptcy Act of 1898 or the Bankruptcy Reform Act of 1978 has previously been filed by or against the debtor, or any of its affiliates or subsidiaries, a director of the debtor, an officer of the debtor, a person in control of the debtor, a partnership in which the debtor is general partner, a general partner of the debtor, a relative of the general partner, director, officer, or person in control of the debtor, or any persons, firms or corporations owning 20% or more of its voting stock as follows: (Set forth the complete number and title of each such prior proceeding, date filed, nature of proceeding, the Bankruptcy Judge and court to whom assigned, whether still pending, and if not, the disposition thereof. If none, so indicate. Also, list any real property included in Schedule A/B that was filed with any such prior proceeding(s).)

4. (If petitioner is an individual) A petition under the Bankruptcy Reform Act of 1978, including amendments thereof, has been filed by or against the debtor within the last 180 days: (Set forth the complete number and title of each such prior proceeding, date filed, nature of proceeding, the Bankruptcy Judge and court to whom assigned, whether still pending, and if not, the disposition thereof. If none, so indicate. Also, list any real property included in Schedule A/B that was filed with any such prior proceeding(s).)

I declare, under penalty of perjury, that the foregoing is true and correct.

Executed at , California Signature of Debtor 1

Date: Signature of Debtor 2

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

October 2018 Page 1 F 1015-2.1.STMT.RELATED.CASES

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

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information 12/15

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. Fill out all of your schedules first; then complete the information on this form. If you are filing amended schedules after you file your original forms, you must fill out a new Summary and check the box at the top of this page.

Part 1: Summarize Your Assets

Your assets Value of what you own

1. Schedule A/B: Property (Official Form 106A/B) 1a. Copy line 55, Total real estate, from Schedule A/B .......................................................................................................... $ ________________

   1b. Copy line 62, Total personal property, from Schedule A/B ............................................................................................... $ ________________

   1c. Copy line 63, Total of all property on Schedule A/B ......................................................................................................... $ ________________

Part 2: Summarize Your Liabilities

Your liabilities Amount you owe

2. Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D) 2a. Copy the total you listed in Column A, Amount of claim, at the bottom of the last page of Part 1 of Schedule D ............ $ ________________

3. Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F) $ ________________ 3a. Copy the total claims from Part 1 (priority unsecured claims) from line 6e of Schedule E/F ............................................

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F ....................................... + $ ________________

Your total liabilities $ ________________

Part 3: Summarize Your Income and Expenses

4. Schedule I: Your Income (Official Form 106I) Copy your combined monthly income from line 12 of Schedule I .......................................................................................... $ ________________

5. Schedule J: Your Expenses (Official Form 106J) Copy your monthly expenses from line 22c of Schedule J .................................................................................................... $ ________________

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2

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

Part 4: Answer These Questions for Administrative and Statistical Records

6. Are you filing for bankruptcy under Chapters 7, 11, or 13?
No. You have nothing to report on this part of the form. Check this box and submit this form to the court with your other schedules.
Yes

7. What kind of debt do you have?
Your debts are primarily consumer debts. Consumer debts are those “incurred by an individual primarily for a personal,
family, or household purpose.” 11 U.S.C. § 101(8). Fill out lines 8-9g for statistical purposes. 28 U.S.C. § 159.
Your debts are not primarily consumer debts. You have nothing to report on this part of the form. Check this box and submit
this form to the court with your other schedules.

8. From the Statement of Your Current Monthly Income: Copy your total current monthly income from Official
Form 122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14. $ _________________

9. Copy the following special categories of claims from Part 4, line 6 of Schedule E/F:

Total claim

From Part 4 on Schedule E/F, copy the following:

9a. Domestic support obligations (Copy line 6a.) $_____________________

9b. Taxes and certain other debts you owe the government. (Copy line 6b.) $_____________________

9c. Claims for death or personal injury while you were intoxicated. (Copy line 6c.) $_____________________

9d. Student loans. (Copy line 6f.) $_____________________

9e. Obligations arising out of a separation agreement or divorce that you did not report as $_____________________
priority claims. (Copy line 6g.)

9f. Debts to pension or profit-sharing plans, and other similar debts. (Copy line 6h.) + $_____________________

9g. Total. Add lines 9a through 9f. $_____________________

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 2 of 2 Print Save As... Add Attachment Reset

Fill in this information to identify your case and this filing:

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: ____________________ DistrictDistrictof ___________of __________

Case number ___________________________________________ Check if this is an amended filing Official Form 106A/B Schedule A/B: Property 12/15

In each category, separately list and describe items. List an asset only once. If an asset fits in more than one category, list the asset in the category where you think it fits best. 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: Describe Each Residence, Building, Land, or Other Real Estate You Own or Have an Interest In

1. Do you own or have any legal or equitable interest in any residence, building, land, or similar property? No. Go to Part 2. Yes. Where is the property? What is the property? Check all that apply. Do not deduct secured claims or exemptions. Put Single-family home the amount of any secured claims on Schedule D: 1.1. _________________________________________ Duplex or multi-unit building Creditors Who Have Claims Secured by Property. Street address, if available, or other description Condominium or cooperative Current value of the Current value of the Manufactured or mobile home entire property? portion you own? _________________________________________ Land $________________ $_______________ Investment property _________________________________________ Timeshare Describe the nature of your ownership City State ZIP Code interest (such as fee simple, tenancy by Other __________________________________ the entireties, or a life estate), if known. Who has an interest in the property? Check one. __________________________________________ Debtor 1 only _________________________________________ County Debtor 2 only Debtor 1 and Debtor 2 only Check if this is community property (see instructions) At least one of the debtors and another Other information you wish to add about this item, such as local property identification number: _______________________________ If you own or have more than one, list here: What is the property? Check all that apply. Do not deduct secured claims or exemptions. Put Single-family home the amount of any secured claims on Schedule D: 1.2. ________________________________________ Duplex or multi-unit building Creditors Who Have Claims Secured by Property. Street address, if available, or other description Condominium or cooperative Current value of the Current value of the Manufactured or mobile home entire property? portion you own? ________________________________________ Land $________________ $_________________ Investment property ________________________________________ Timeshare Describe the nature of your ownership City State ZIP Code interest (such as fee simple, tenancy by Other __________________________________ the entireties, or a life estate), if known. Who has an interest in the property? Check one. __________________________________________ Debtor 1 only ________________________________________ County Debtor 2 only Debtor 1 and Debtor 2 only Check if this is community property At least one of the debtors and another (see instructions) Other information you wish to add about this item, such as local property identification number: _______________________________

Official Form 106A/B Schedule A/B: Property page 1

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

What is the property? Check all that apply. Do not deduct secured claims or exemptions. Put
Single-family home the amount of any secured claims on Schedule D: 1.3. ________________________________________ Creditors Who Have Claims Secured by Property.
Street address, if available, or other description Duplex or multi-unit building
Condominium or cooperative Current value of the Current value of the
entire property? portion you own?
________________________________________ Manufactured or mobile home
Land $________________ $_________________
Investment property ________________________________________
City State ZIP Code Timeshare Describe the nature of your ownership
interest (such as fee simple, tenancy by
Other __________________________________ the entireties, or a life estate), if known.
Who has an interest in the property? Check one. __________________________________________
________________________________________ Debtor 1 only
County Debtor 2 only
Debtor 1 and Debtor 2 only Check if this is community property
At least one of the debtors and another (see instructions)

Other information you wish to add about this item, such as local
property identification number: _______________________________

2. Add the dollar value of the portion you own for all of your entries from Part 1, including any entries for pages $_________________ you have attached for Part 1. Write that number here. ......................................................................................

Part 2: Describe Your Vehicles

Do you own, lease, or have legal or equitable interest in any vehicles, whether they are registered or not? Include any vehicles you own that someone else drives. If you lease a vehicle, also report it on Schedule G: Executory Contracts and Unexpired Leases.

3. Cars, vans, trucks, tractors, sport utility vehicles, motorcycles No Yes

Who has an interest in the property? Check one. Do not deduct secured claims or exemptions. Put 3.1. Make: ______________ Debtor 1 only theCreditorsamountWhoof anyHavesecuredClaimsclaimsSecuredon byScheduleProperty.D: Model: ______________ Debtor 2 only Year: ____________ Debtor 1 and Debtor 2 only Current value of the Current value of the entire property? portion you own? Approximate mileage: ____________ At least one of the debtors and another Other information: Check if this is community property (see $________________ $________________ instructions)

If you own or have more than one, describe here:

Who has an interest in the property? Check one. Do not deduct secured claims or exemptions. Put 3.2. Make: ______________
Debtor 1 only theCreditorsamountWhoof anyHavesecuredClaimsclaimsSecuredon byScheduleProperty.D: Model: ______________
Debtor 2 only
Year: ____________ Current value of the Current value of the Debtor 1 and Debtor 2 only
entire property? portion you own? Approximate mileage: ____________ At least one of the debtors and another
Other information:
Check if this is community property (see $________________ $________________
instructions)

Official Form 106A/B Schedule A/B: Property page 2

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

Who has an interest in the property? Check one. Do not deduct secured claims or exemptions. Put 3.3. Make: ______________
Debtor 1 only theCreditorsamountWhoof anyHavesecuredClaimsclaimsSecuredon byScheduleProperty.D: Model: ______________
Debtor 2 only
Year: ____________ Debtor 1 and Debtor 2 only Current value of the Current value of the
entire property? portion you own? Approximate mileage: ____________ At least one of the debtors and another
Other information:
Check if this is community property (see $________________ $________________
instructions)

Who has an interest in the property? Check one. Do not deduct secured claims or exemptions. Put 3.4. Make: ______________
Debtor 1 only theCreditorsamountWhoof anyHavesecuredClaimsclaimsSecuredon byScheduleProperty.D: Model: ______________
Debtor 2 only
Year: ____________ Debtor 1 and Debtor 2 only Current value of the Current value of the
entire property? portion you own? Approximate mileage: ____________ At least one of the debtors and another
Other information:
Check if this is community property (see $________________ $________________
instructions)

4. Watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories Examples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle accessories No Yes

Who has an interest in the property? Check one. Do not deduct secured claims or exemptions. Put 4.1. Make: ____________________ Debtor 1 only theCreditorsamountWhoof anyHavesecuredClaimsclaimsSecuredon byScheduleProperty.D: Model: ____________________ Debtor 2 only Year: ____________ Debtor 1 and Debtor 2 only Current value of the Current value of the Other information: At least one of the debtors and another entire property? portion you own?

Check if this is community property (see $________________ $________________
instructions)

If you own or have more than one, list here:
Who has an interest in the property? Check one. Do not deduct secured claims or exemptions. Put 4.2. Make: ____________________
Debtor 1 only theCreditorsamountWhoof anyHavesecuredClaimsclaimsSecuredon byScheduleProperty.D: Model: ____________________
Debtor 2 only
Year: ____________ Current value of the Current value of the Debtor 1 and Debtor 2 only entire property? portion you own?
Other information: At least one of the debtors and another

Check if this is community property (see $________________ $________________
instructions)

5. Add the dollar value of the portion you own for all of your entries from Part 2, including any entries for pages $_________________ you have attached for Part 2. Write that number here ........................................................................................................................

Official Form 106A/B Schedule A/B: Property page 3

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

Part 3: Describe Your Personal and Household Items

Current value of theDo you own or have any legal or equitable interest in any of the following items? portion you own?
Do not deduct secured claims
or exemptions.

6. Household goods and furnishings Examples: Major appliances, furniture, linens, china, kitchenware No Yes. Describe. ........ $___________________

7. Electronics Examples: Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music collections; electronic devices including cell phones, cameras, media players, games

No Yes. Describe. ......... $___________________

8. Collectibles of value Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects; stamp, coin, or baseball card collections; other collections, memorabilia, collectibles

No Yes. Describe. ......... $___________________

9. Equipment for sports and hobbies Examples: Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes and kayaks; carpentry tools; musical instruments

No Yes. Describe. ......... $___________________

10. Firearms Examples: Pistols, rifles, shotguns, ammunition, and related equipment No Yes. Describe. .......... $___________________

11. Clothes Examples: Everyday clothes, furs, leather coats, designer wear, shoes, accessories No Yes. Describe. .......... $___________________

12. Jewelry Examples: Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems, gold, silver

No Yes. Describe. .......... $___________________

13. Non-farm animals Examples: Dogs, cats, birds, horses No Yes. Describe. .......... $___________________

14. Any other personal and household items you did not already list, including any health aids you did not list No Yes. Give specific $___________________ information. ..............

15. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached $______________________ for Part 3. Write that number here ....................................................................................................................................................

Official Form 106A/B Schedule A/B: Property page 4

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

Part 4: Describe Your Financial Assets

Do you own or have any legal or equitable interest in any of the following? Current value of the portion you own? Do not deduct secured claims or exemptions.

16. Cash Examples: Money you have in your wallet, in your home, in a safe deposit box, and on hand when you file your petition

No Yes ................................................................................................................................................................ Cash: ....................... $__________________

17. Deposits of money Examples: Checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerage houses, and other similar institutions. If you have multiple accounts with the same institution, list each.

No Yes ..................... Institution name:

17.1. Checking account: _________________________________________________________ $__________________

17.2. Checking account: _________________________________________________________ $__________________

17.3. Savings account: _________________________________________________________ $__________________

17.4. Savings account: _________________________________________________________ $__________________

17.5. Certificates of deposit: _________________________________________________________ $__________________

17.6. Other financial account: _________________________________________________________ $__________________
17.7. Other financial account: _________________________________________________________ $__________________
17.8. Other financial account: _________________________________________________________ $__________________
17.9. Other financial account: _________________________________________________________ $__________________

18. Bonds, mutual funds, or publicly traded stocks Examples: Bond funds, investment accounts with brokerage firms, money market accounts No Yes ................. Institution or issuer name:

_________________________________________________________________________________________ $__________________ _________________________________________________________________________________________ $__________________ _________________________________________________________________________________________ $__________________

19. Non-publicly traded stock and interests in incorporated and unincorporated businesses, including an interest in an LLC, partnership, and joint venture No Name of entity: % of ownership:

Yes. Give specific _____________________________________________________________________ % $_______ information about them......................... _____________________________________________________________________ % $_______ _____________________________________________________________________ % $_______

Official Form 106A/B Schedule A/B: Property page 5

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

20. Government and corporate bonds and other negotiable and non-negotiable instruments Negotiable instruments include personal checks, cashiers’ checks, promissory notes, and money orders. Non-negotiable instruments are those you cannot transfer to someone by signing or delivering them.

No Yes. Give specific Issuer name: information about them....................... ______________________________________________________________________________________ $__________________ ______________________________________________________________________________________ $__________________ ______________________________________________________________________________________ $__________________

21. Retirement or pension accounts Examples: Interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sharing plans No Yes. List each account separately. Type of account: Institution name:

    401(k) or similar plan: ___________________________________________________________________ $__________________

    Pension plan: ___________________________________________________________________ $__________________

    IRA: ___________________________________________________________________ $__________________

    Retirement account: ___________________________________________________________________ $__________________

    Keogh: ___________________________________________________________________ $__________________

    Additional account: ___________________________________________________________________ $__________________

    Additional account: ___________________________________________________________________ $__________________

22. Security deposits and prepayments Your share of all unused deposits you have made so that you may continue service or use from a company Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications companies, or others No Yes .......................... Institution name or individual: Electric: ______________________________________________________________________ $___________________ Gas: ______________________________________________________________________ $___________________ Heating oil: ______________________________________________________________________ $___________________ Security deposit on rental unit: _____________________________________________________________ $___________________ Prepaid rent: ______________________________________________________________________ $___________________ Telephone: ______________________________________________________________________ $___________________ Water: ______________________________________________________________________ $___________________ Rented furniture: ______________________________________________________________________ $___________________ Other: ______________________________________________________________________ $___________________

23. Annuities (A contract for a periodic payment of money to you, either for life or for a number of years) No Yes .......................... Issuer name and description: _______________________________________________________________________________________ $__________________ _______________________________________________________________________________________ $__________________ _______________________________________________________________________________________ $__________________

Official Form 106A/B Schedule A/B: Property page 6

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

24. Interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program. 26 U.S.C. §§ 530(b)(1), 529A(b), and 529(b)(1). No Yes .................................... Institution name and description. Separately file the records of any interests.11 U.S.C. § 521(c):

    ____________________________________________________________________________________ $_________________
    ____________________________________________________________________________________ $_________________
    ____________________________________________________________________________________ $_________________

25. Trusts, equitable or future interests in property (other than anything listed in line 1), and rights or powers exercisable for your benefit No Yes. Give specific information about them. ... $__________________

26. Patents, copyrights, trademarks, trade secrets, and other intellectual property Examples: Internet domain names, websites, proceeds from royalties and licensing agreements No Yes. Give specific information about them. ... $__________________

27. Licenses, franchises, and other general intangibles Examples: Building permits, exclusive licenses, cooperative association holdings, liquor licenses, professional licenses No Yes. Give specific information about them. ... $__________________

Money or property owed to you? Current value of the portion you own? Do not deduct secured claims or exemptions.

portion you own? Do not deduct secured claims or exemptions.

28. Tax refunds owed to you No Yes. Give specific information Federal: $_________________ about them, including whether you already filed the returns State: $_________________ and the tax years. ....................... Local: $_________________

29. Family support Examples: Past due or lump sum alimony, spousal support, child support, maintenance, divorce settlement, property settlement No Yes. Give specific information. ............. Alimony: $________________ Maintenance: $________________ Support: $________________ Divorce settlement: $________________ Property settlement: $________________

30. Other amounts someone owes you Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compensation, Social Security benefits; unpaid loans you made to someone else

No Yes. Give specific information. .............. $______________________

Official Form 106A/B Schedule A/B: Property page 7

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

31. Interests in insurance policies Examples: Health, disability, or life insurance; health savings account (HSA); credit, homeowner’s, or renter’s insurance No Yes. Name the insurance company Company name: Beneficiary: Surrender or refund value: of each policy and list its value. ... ___________________________________________ ____________________________ $__________________ ___________________________________________ ____________________________ $__________________ ___________________________________________ ____________________________ $__________________

32. Any interest in property that is due you from someone who has died If you are the beneficiary of a living trust, expect proceeds from a life insurance policy, or are currently entitled to receive property because someone has died. No Yes. Give specific information. ............. $_____________________

33. Claims against third parties, whether or not you have filed a lawsuit or made a demand for payment Examples: Accidents, employment disputes, insurance claims, or rights to sue No Yes. Describe each claim. .................... $______________________

34. Other contingent and unliquidated claims of every nature, including counterclaims of the debtor and rights to set off claims No Yes. Describe each claim. .................... $_____________________

35. Any financial assets you did not already list No Yes. Give specific information. ........... $_____________________

36. Add the dollar value of all of your entries from Part 4, including any entries for pages you have attached for Part 4. Write that number here .................................................................................................................................................... $_____________________

Part 5: Describe Any Business-Related Property You Own or Have an Interest In. List any real estate in Part 1.

37. Do you own or have any legal or equitable interest in any business-related property? No. Go to Part 6. Yes. Go to line 38. Current value of the portion you own? Do not deduct secured claims or exemptions.

38. Accounts receivable or commissions you already earned No Yes. Describe ....... $_____________________

39. Office equipment, furnishings, and supplies Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, electronic devices No Yes. Describe ....... $_____________________

Official Form 106A/B Schedule A/B: Property page 8

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

40. Machinery, fixtures, equipment, supplies you use in business, and tools of your trade No Yes. Describe ....... $_____________________

41. Inventory No Yes. Describe ....... $_____________________

42. Interests in partnerships or joint ventures No Yes. Describe ....... Name of entity: % of ownership: ______________________________________________________________________ % $_____________ ______________________________________________________________________ % $_____________ ______________________________________________________________________ % $_____________

43. Customer lists, mailing lists, or other compilations No Yes. Do your lists include personally identifiable information (as defined in 11 U.S.C. § 101(41A))? No Yes. Describe. ....... $____________________

44. Any business-related property you did not already list No Yes. Give specific ______________________________________________________________________________________ $____________________ information ......... ______________________________________________________________________________________ $____________________ ______________________________________________________________________________________ $____________________ ______________________________________________________________________________________ $____________________ ______________________________________________________________________________________ $____________________ ______________________________________________________________________________________ $____________________

45. Add the dollar value of all of your entries from Part 5, including any entries for pages you have attached $____________________ for Part 5. Write that number here ....................................................................................................................................................

Part 6: Describe Any Farm- and Commercial Fishing-Related Property You Own or Have an Interest In. If you own or have an interest in farmland, list it in Part 1.

46. Do you own or have any legal or equitable interest in any farm- or commercial fishing-related property? No. Go to Part 7. Yes. Go to line 47. Current value of the portion you own? Do not deduct secured claims or exemptions.

47. Farm animals Examples: Livestock, poultry, farm-raised fish No Yes ..........................

    $___________________

Official Form 106A/B Schedule A/B: Property page 9

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

48. Crops—either growing or harvested No Yes. Give specific information. ............ $___________________

49. Farm and fishing equipment, implements, machinery, fixtures, and tools of trade No Yes .......................... $___________________

50. Farm and fishing supplies, chemicals, and feed No Yes .......................... $___________________

51. Any farm- and commercial fishing-related property you did not already list No Yes. Give specific information. ............ $___________________

52. Add the dollar value of all of your entries from Part 6, including any entries for pages you have attached $___________________ for Part 6. Write that number here ....................................................................................................................................................

Part 7: Describe All Property You Own or Have an Interest in That You Did Not List Above

53. Do you have other property of any kind you did not already list? Examples: Season tickets, country club membership No Yes. Give specific $________________ information. ............ $________________ $________________

54. Add the dollar value of all of your entries from Part 7. Write that number here ................................................................. $________________

Part 8: List the Totals of Each Part of this Form

55. Part 1: Total real estate, line 2 .............................................................................................................................................................. $________________

56. Part 2: Total vehicles, line 5 $________________

57. Part 3: Total personal and household items, line 15 $________________

58. Part 4: Total financial assets, line 36 $________________

59. Part 5: Total business-related property, line 45 $________________

60. Part 6: Total farm- and fishing-related property, line 52 $________________

61. Part 7: Total other property not listed, line 54 + $________________

62. Total personal property. Add lines 56 through 61. .................... $________________ Copy personal property total + $_________________

63. Total of all property on Schedule A/B. Add line 55 + line 62. ......................................................................................... $_________________

Official Form 106A/B Schedule A/B: Property page 10 Print Save As... Add Attachment Reset

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: Central__________DistrictDistrictof Californiaof __________ Case number ___________________________________________ Check if this is an (If known) amended filing

Official Form 106C Schedule C: The Property You Claim as Exempt 04/25

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. Using the property you listed on Schedule A/B: Property (Official Form 106A/B) as your source, list the property that you claim as exempt. If more space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On the top of any additional pages, write your name and case number (if known).

For each item of property you claim as exempt, you must specify the amount of the exemption you claim. One way of doing so is to state a specific dollar amount as exempt. Alternatively, you may claim the full fair market value of the property being exempted up to the amount of any applicable statutory limit. Some exemptions—such as those for health aids, rights to receive certain benefits, and tax-exempt retirement funds—may be unlimited in dollar amount. However, if you claim an exemption of 100% of fair market value under a law that limits the exemption to a particular dollar amount and the value of the property is determined to exceed that amount, your exemption would be limited to the applicable statutory amount.

Part 1: Identify the Property You Claim as Exempt

1. Which set of exemptions are you claiming? Check one only, even if your spouse is filing with you. You are claiming state and federal nonbankruptcy exemptions. 11 U.S.C. § 522(b)(3) You are claiming federal exemptions. 11 U.S.C. § 522(b)(2)

2. For any property you list on Schedule A/B that you claim as exempt, fill in the information below.

   Brief description of the property and line on Current value of the Amount of the exemption you claim Specific laws that allow exemption Schedule A/B that lists this property portion you own Copy the value from Check only one box for each exemption. Schedule A/B

Brief ____________________________ description: _________________________ $________________ $ ____________ ____________________________ 100% of fair market value, up to ____________________________ Line from Schedule A/B: ______ any applicable statutory limit ____________________________

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______ any applicable statutory limit ____________________________ Schedule A/B:

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from
Schedule A/B: ______ any applicable statutory limit ____________________________

3. Are you claiming a homestead exemption of more than $214,000? (Subject to adjustment on 4/01/28 and every 3 years after that for cases filed on or after the date of adjustment.) No Yes. Did you acquire the property covered by the exemption within 1,215 days before you filed this case? No Yes

Official Form 106C Schedule C: The Property You Claim as Exempt page 1 of __

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

Part 2: Additional Page

Brief description of the property and line Current value of the Amount of the exemption you claim Specific laws that allow exemption
on Schedule A/B that lists this property portion you own
Copy the value from Check only one box for each exemption
Schedule A/B

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______
Schedule A/B: any applicable statutory limit ____________________________

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from
______ any applicable statutory limit ____________________________ Schedule A/B:

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______ any applicable statutory limit ____________________________ Schedule A/B:

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______
Schedule A/B: any applicable statutory limit ____________________________

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from
______ any applicable statutory limit ____________________________ Schedule A/B:

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______ any applicable statutory limit ____________________________ Schedule A/B:

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______
Schedule A/B: any applicable statutory limit ____________________________

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from
Schedule A/B: ______ any applicable statutory limit ____________________________

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______ any applicable statutory limit ____________________________ Schedule A/B:

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______
Schedule A/B: any applicable statutory limit ____________________________

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from
Schedule A/B: ______ any applicable statutory limit ____________________________

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______ any applicable statutory limit ____________________________ Schedule A/B:

Official Form 106C Schedule C: The Property You Claim as Exempt page ___2 of __ Print Save As... Add Attachment Reset

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: ____________________ DistrictDistrictof __________of __________

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

Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property 12/15 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, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any additional pages, write your name and case number (if known).

1. Do any creditors have claims secured by your property? No. Check this box and submit this form to the court with your other schedules. You have nothing else to report on this form. Yes. Fill in all of the information below.

Part 1: List All Secured Claims

Column A Column B Column C

2. List all secured claims. If a creditor has more than one secured claim, list the creditor separately Amount of claim Value of collateral Unsecured for each claim. If more than one creditor has a particular claim, list the other creditors in Part 2. Do not deduct the that supports this portion As much as possible, list the claims in alphabetical order according to the creditor’s name. value of collateral. claim If any 2.1 Describe the property that secures the claim: $_________________ $________________ $____________ ______________________________________ Creditor’s Name

   ---

   Number Street As of the date you file, the claim is: Check all that apply.

   ---

   Contingent

   ______________________________________ Unliquidated City State ZIP Code Disputed Who owes the debt? Check one. Nature of lien. Check all that apply. Debtor 1 only An agreement you made (such as mortgage or secured Debtor 2 only car loan) Debtor 1 and Debtor 2 only Statutory lien (such as tax lien, mechanic’s lien) At least one of the debtors and another Judgment lien from a lawsuit Other (including a right to offset) ____________________

Check if this claim relates to a community debt Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___ 2.2 Describe the property that secures the claim: $_________________ $________________ $____________ ______________________________________ Creditor’s Name

______________________________________
Number Street
As of the date you file, the claim is: Check all that apply.
______________________________________
Contingent
______________________________________ Unliquidated
City State ZIP Code Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply. Debtor 1 only An agreement you made (such as mortgage or secured Debtor 2 only car loan) Debtor 1 and Debtor 2 only Statutory lien (such as tax lien, mechanic’s lien) At least one of the debtors and another Judgment lien from a lawsuit Other (including a right to offset) ____________________ Check if this claim relates to a community debt Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___ Add the dollar value of your entries in Column A on this page. Write that number here: $________________

Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___

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

Additional Page Column A Column B Column C
of claim Value of collateral UnsecuredPart 1: After listing any entries on this page, number them beginning with 2.3, followed Amount that supports this portion Do not deduct the
by 2.4, and so forth. value of collateral. claim If any

______________________________________ Describe the property that secures the claim: $_________________ $________________ $____________
Creditor’s Name

______________________________________
Number Street

______________________________________ As of the date you file, the claim is: Check all that apply.
Contingent ______________________________________
City State ZIP Code Unliquidated
Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply. Debtor 1 only An agreement you made (such as mortgage or secured Debtor 2 only car loan) Debtor 1 and Debtor 2 only Statutory lien (such as tax lien, mechanic’s lien) At least one of the debtors and another Judgment lien from a lawsuit Other (including a right to offset) ____________________ Check if this claim relates to a community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________ Describe the property that secures the claim: $_________________ $________________ $____________
Creditor’s Name

---

Number Street
As of the date you file, the claim is: Check all that apply.
______________________________________
Contingent
______________________________________ Unliquidated
City State ZIP Code Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply. Debtor 1 only An agreement you made (such as mortgage or secured Debtor 2 only car loan) Debtor 1 and Debtor 2 only Statutory lien (such as tax lien, mechanic’s lien) At least one of the debtors and another Judgment lien from a lawsuit Other (including a right to offset) ____________________ Check if this claim relates to a community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________ Describe the property that secures the claim: $_________________ $________________ $____________
Creditor’s Name

______________________________________
Number Street

______________________________________ As of the date you file, the claim is: Check all that apply.
Contingent ______________________________________
City State ZIP Code Unliquidated
Disputed

Who owes the debt? Check one. Nature of lien. Check all that apply. Debtor 1 only An agreement you made (such as mortgage or secured Debtor 2 only car loan) Debtor 1 and Debtor 2 only Statutory lien (such as tax lien, mechanic’s lien) At least one of the debtors and another Judgment lien from a lawsuit Other (including a right to offset) ____________________ Check if this claim relates to a community debt Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here: $_________________
If this is the last page of your form, add the dollar value totals from all pages.
Write that number here: $_________________

Official Form 106D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___

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

Part 2: List Others to Be Notified for a Debt That You Already Listed

Use this page only if you have others to be notified about your bankruptcy for a debt that you already listed in Part 1. For example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection agency here. Similarly, if you have more than one creditor for any of the debts that you listed in Part 1, list the additional creditors here. If you do not have additional persons to be notified for any debts in Part 1, do not fill out or submit this page.

On which line in Part 1 did you enter the creditor? _____
_____________________________________________________________________
Name Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________
Number Street

_____________________________________________________________________

_____________________________________________________________________
City State ZIP Code

On which line in Part 1 did you enter the creditor? _____
_____________________________________________________________________
Name Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________
Number Street

_____________________________________________________________________

_____________________________________________________________________
City State ZIP Code

On which line in Part 1 did you enter the creditor? _____
_____________________________________________________________________
Name Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________
Number Street

_____________________________________________________________________

_____________________________________________________________________
City State ZIP Code

On which line in Part 1 did you enter the creditor? _____
_____________________________________________________________________
Name Last 4 digits of account number ___ ___ ___ ___

---

Number Street

_____________________________________________________________________

_____________________________________________________________________
City State ZIP Code

On which line in Part 1 did you enter the creditor? _____
_____________________________________________________________________
Name Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________
Number Street

_____________________________________________________________________

_____________________________________________________________________
City State ZIP Code

On which line in Part 1 did you enter the creditor? _____
_____________________________________________________________________
Name Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________
Number Street

_____________________________________________________________________

_____________________________________________________________________
City State ZIP Code
Print Save As... Add Attachment Reset

Official Form 106D Part 2 of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___

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

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims 12/15

Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY claims and Part 2 for creditors with NONPRIORITY claims. List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any creditors with partially secured claims that are listed in Schedule D: Creditors Who Have Claims Secured by Property. If more space is needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of any additional pages, write your name and case number (if known).

Part 1: List All of Your PRIORITY Unsecured Claims

1. Do any creditors have priority unsecured claims against you? No. Go to Part 2. Yes.
2. List all of your priority unsecured claims. If a creditor has more than one priority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. If a claim has both priority and nonpriority amounts, list that claim here and show both priority and nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor’s name. If you have more than two priority unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3. (For an explanation of each type of claim, see the instructions for this form in the instruction booklet.) Total claim Priority Nonpriority amount amount

2.1 ____________________________________________ Last 4 digits of account number ___ ___ ___ ___ $_____________ $___________ $____________ Priority Creditor’s Name ____________________________________________ When was the debt incurred? ____________ Number Street ____________________________________________ As of the date you file, the claim is: Check all that apply. ____________________________________________ Contingent City State ZIP Code Unliquidated Who incurred the debt? Check one. Disputed Debtor 1 only Debtor 2 only Type of PRIORITY unsecured claim: Debtor 1 and Debtor 2 only Domestic support obligations At least one of the debtors and another Taxes and certain other debts you owe the government Check if this claim is for a community debt Claims for death or personal injury while you were Is the claim subject to offset? intoxicated No Other. Specify _________________________________ Yes 2.2 ____________________________________________ Last 4 digits of account number ___ ___ ___ ___ $_____________ $___________ $____________ Priority Creditor’s Name When was the debt incurred? ____________ ____________________________________________ Number Street ____________________________________________ As of the date you file, the claim is: Check all that apply. Contingent ____________________________________________ City State ZIP Code Unliquidated Disputed Who incurred the debt? Check one. Debtor 1 only Type of PRIORITY unsecured claim: Debtor 2 only Domestic support obligations Debtor 1 and Debtor 2 only Taxes and certain other debts you owe the government At least one of the debtors and another Claims for death or personal injury while you were Check if this claim is for a community debt intoxicated Is the claim subject to offset? Other. Specify _________________________________ No Yes

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___

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

Part 1: Your PRIORITY Unsecured Claims ─ Continuation Page

After listing any entries on this page, number them beginning with 2.3, followed by 2.4, and so forth. Total claim Priority Nonpriority amount amount

____________________________________________ Last 4 digits of account number ___ ___ ___ ___ $____________ $__________ $____________
Priority Creditor’s Name
____________________________________________ When was the debt incurred? ____________
Number Street
____________________________________________ As of the date you file, the claim is: Check all that apply.
Contingent ____________________________________________
City State ZIP Code Unliquidated
Disputed
Who incurred the debt? Check one.
Debtor 1 only Type of PRIORITY unsecured claim:
Debtor 2 only Domestic support obligations
Debtor 1 and Debtor 2 only Taxes and certain other debts you owe the government
At least one of the debtors and another Claims for death or personal injury while you were
Check if this claim is for a community debt intoxicated
Other. Specify _________________________________
Is the claim subject to offset?

No Yes

____________________________________________ Last 4 digits of account number ___ ___ ___ ___ $____________ $__________ $____________
Priority Creditor’s Name
____________________________________________ When was the debt incurred? ____________
Number Street
____________________________________________ As of the date you file, the claim is: Check all that apply.
Contingent ____________________________________________
City State ZIP Code Unliquidated
Disputed
Who incurred the debt? Check one.
Debtor 1 only Type of PRIORITY unsecured claim:
Debtor 2 only Domestic support obligations
Debtor 1 and Debtor 2 only Taxes and certain other debts you owe the government
At least one of the debtors and another Claims for death or personal injury while you were
Check if this claim is for a community debt intoxicated
Other. Specify _________________________________
Is the claim subject to offset?

No Yes

____________________________________________ Last 4 digits of account number ___ ___ ___ ___ $____________ $__________ $____________
Priority Creditor’s Name
____________________________________________ When was the debt incurred? ____________
Number Street
____________________________________________ As of the date you file, the claim is: Check all that apply.
Contingent ____________________________________________
City State ZIP Code Unliquidated
Disputed
Who incurred the debt? Check one.
Debtor 1 only Type of PRIORITY unsecured claim:
Debtor 2 only Domestic support obligations
Debtor 1 and Debtor 2 only Taxes and certain other debts you owe the government
At least one of the debtors and another Claims for death or personal injury while you were
Check if this claim is for a community debt intoxicated
Other. Specify _________________________________
Is the claim subject to offset?

No Yes

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

Part 2: List All of Your NONPRIORITY Unsecured Claims

3. Do any creditors have nonpriority unsecured claims against you? No. You have nothing to report in this part. Submit this form to the court with your other schedules. Yes

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured claims fill out the Continuation Page of Part 2.

   Total claim

4.1 _____________________________________________________________ Last 4 digits of account number ___ ___ ___ ___ Nonpriority Creditor’s Name $__________________ When was the debt incurred? ____________ _____________________________________________________________ Number Street

_____________________________________________________________
City State ZIP Code As of the date you file, the claim is: Check all that apply.
Contingent
Who incurred the debt? Check one. Unliquidated
Debtor 1 only Disputed
Debtor 2 only
Debtor 1 and Debtor 2 only Type of NONPRIORITY unsecured claim:
At least one of the debtors and another Student loans
Obligations arising out of a separation agreement or divorce Check if this claim is for a community debt
that you did not report as priority claims
Is the claim subject to offset? Debts to pension or profit-sharing plans, and other similar debts

No Other. Specify ______________________________________ Yes

4.2 Last 4 digits of account number ___ ___ ___ ___ $__________________ _____________________________________________________________ Nonpriority Creditor’s Name When was the debt incurred? ____________

---

Number Street
As of the date you file, the claim is: Check all that apply.
_____________________________________________________________
City State ZIP Code Contingent
Who incurred the debt? Check one. Unliquidated
Disputed Debtor 1 only
Debtor 2 only
Type of NONPRIORITY unsecured claim: Debtor 1 and Debtor 2 only
At least one of the debtors and another Student loans
Obligations arising out of a separation agreement or divorce
Check if this claim is for a community debt that you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts Is the claim subject to offset?
Other. Specify ______________________________________ No
Yes

4.3 _____________________________________________________________ Last 4 digits of account number ___ ___ ___ ___ Nonpriority Creditor’s Name $_________________ When was the debt incurred? ____________ _____________________________________________________________ Number Street _____________________________________________________________ As of the date you file, the claim is: Check all that apply. City State ZIP Code Contingent Who incurred the debt? Check one. Unliquidated Debtor 1 only Disputed Debtor 2 only Debtor 1 and Debtor 2 only Type of NONPRIORITY unsecured claim: At least one of the debtors and another Student loans Check if this claim is for a community debt Obligations arising out of a separation agreement or divorce that you did not report as priority claims Is the claim subject to offset? Debts to pension or profit-sharing plans, and other similar debts No Other. Specify ______________________________________ Yes

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page

After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth. Total claim

Last 4 digits of account number ___ ___ ___ ___ _____________________________________________________________ $____________
Nonpriority Creditor’s Name
When was the debt incurred? ____________
_____________________________________________________________
Number Street
As of the date you file, the claim is: Check all that apply.
_____________________________________________________________
City State ZIP Code Contingent
Unliquidated
Who incurred the debt? Check one. Disputed
Debtor 1 only
Debtor 2 only Type of NONPRIORITY unsecured claim:
Debtor 1 and Debtor 2 only Student loans
At least one of the debtors and another Obligations arising out of a separation agreement or divorce that
Check if this claim is for a community debt you did not report as priority claims Debts to pension or profit-sharing plans, and other similar debts
Is the claim subject to offset? Other. Specify________________________________

No Yes

Last 4 digits of account number ___ ___ ___ ___ $____________
_____________________________________________________________
Nonpriority Creditor’s Name
When was the debt incurred? ____________
_____________________________________________________________
Number Street
As of the date you file, the claim is: Check all that apply.
_____________________________________________________________
City State ZIP Code Contingent
Unliquidated
Who incurred the debt? Check one. Disputed
Debtor 1 only
Debtor 2 only Type of NONPRIORITY unsecured claim:
Debtor 1 and Debtor 2 only Student loans
At least one of the debtors and another Obligations arising out of a separation agreement or divorce that
Check if this claim is for a community debt you did not report as priority claims Debts to pension or profit-sharing plans, and other similar debts
Is the claim subject to offset? Other. Specify________________________________

No Yes

$____________
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________________
Nonpriority Creditor’s Name
When was the debt incurred? ____________
_____________________________________________________________
Number Street
As of the date you file, the claim is: Check all that apply.
_____________________________________________________________
City State ZIP Code Contingent
Unliquidated
Who incurred the debt? Check one. Disputed
Debtor 1 only
Debtor 2 only Type of NONPRIORITY unsecured claim:
Debtor 1 and Debtor 2 only Student loans
At least one of the debtors and another Obligations arising out of a separation agreement or divorce that
Check if this claim is for a community debt you did not report as priority claims Debts to pension or profit-sharing plans, and other similar debts
Is the claim subject to offset? Other. Specify________________________________

No Yes

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

Part 3: List Others to Be Notified About a Debt That You Already Listed

5. Use this page only if you have others to be notified about your bankruptcy, for a debt that you already listed in Parts 1 or 2. For example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or 2, then list the collection agency here. Similarly, if you have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill out or submit this page.

   _____________________________________________________ On which entry in Part 1 or Part 2 did you list the original creditor? Name Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims _____________________________________________________ Number Street Part 2: Creditors with Nonpriority Unsecured Claims

   ---

   Last 4 digits of account number ___ ___ ___ ___

   ---

   City State ZIP Code

   _____________________________________________________ On which entry in Part 1 or Part 2 did you list the original creditor? Name Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims _____________________________________________________ Number Street Part 2: Creditors with Nonpriority Unsecured _____________________________________________________ Claims

   _____________________________________________________ Last 4 digits of account number ___ ___ ___ ___ City State ZIP Code

   _____________________________________________________ On which entry in Part 1 or Part 2 did you list the original creditor? Name Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims _____________________________________________________ Number Street Part 2: Creditors with Nonpriority Unsecured Claims _____________________________________________________

   _____________________________________________________ Last 4 digits of account number ___ ___ ___ ___ City State ZIP Code _____________________________________________________ On which entry in Part 1 or Part 2 did you list the original creditor? Name Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims _____________________________________________________ Number Street Part 2: Creditors with Nonpriority Unsecured Claims _____________________________________________________

   _____________________________________________________ Last 4 digits of account number ___ ___ ___ ___ City State ZIP Code

   _____________________________________________________ On which entry in Part 1 or Part 2 did you list the original creditor? Name Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims _____________________________________________________ Number Street Part 2: Creditors with Nonpriority Unsecured Claims _____________________________________________________

   _____________________________________________________ Last 4 digits of account number ___ ___ ___ ___ City State ZIP Code _____________________________________________________ On which entry in Part 1 or Part 2 did you list the original creditor? Name Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims _____________________________________________________ Number Street Part 2: Creditors with Nonpriority Unsecured Claims _____________________________________________________

   _____________________________________________________ Last 4 digits of account number ___ ___ ___ ___ City State ZIP Code

   _____________________________________________________ On which entry in Part 1 or Part 2 did you list the original creditor? Name

_____________________________________________________ Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims Number Street Part 2: Creditors with Nonpriority Unsecured _____________________________________________________ Claims

_____________________________________________________
City State ZIP Code Last 4 digits of account number ___ ___ ___ ___

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

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

Part 4: Add the Amounts for Each Type of Unsecured Claim

6. Total the amounts of certain types of unsecured claims. This information is for statistical reporting purposes only. 28 U.S.C. § 159. Add the amounts for each type of unsecured claim.

   Total claim

   6a. Domestic support obligations 6a.

Total claims $_________________________ from Part 1 6b. Taxes and certain other debts you owe the government 6b. $_________________________

6c. Claims for death or personal injury while you were
intoxicated 6c. $_________________________

6d. Other. Add all other priority unsecured claims.
Write that amount here. 6d. + $_________________________

6e. Total. Add lines 6a through 6d. 6e.
$_________________________

Total claim

6f. Student loans 6f.Total claims $_________________________

from Part 2 6g. Obligations arising out of a separation agreement or divorce that you did not report as priority claims 6g. $_________________________ 6h. Debts to pension or profit-sharing plans, and other similar debts 6h. $_________________________

6i. Other. Add all other nonpriority unsecured claims.
Write that amount here. 6i. + $_________________________

6j. Total. Add lines 6f through 6i. 6j.
$_________________________

Print Save As... Add Attachment Reset

Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___

Fill in this information to identify your case:

Debtor __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ (Spouse If filing) First Name Middle Name Last Name United States Bankruptcy Court for the: ____________________DistrictDistrictof ________of __________

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

Official Form 106G Schedule G: Executory Contracts and Unexpired Leases 12/15

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, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any additional pages, write your name and case number (if known).

1. Do you have any executory contracts or unexpired leases? No. Check this box and file this form with the court with your other schedules. You have nothing else to report on this form. Yes. Fill in all of the information below even if the contracts or leases are listed on Schedule A/B: Property (Official Form 106A/B).

2. List separately each person or company with whom you have the contract or lease. Then state what each contract or lease is for (for example, rent, vehicle lease, cell phone). See the instructions for this form in the instruction booklet for more examples of executory contracts and unexpired leases.

Person or company with whom you have the contract or lease State what the contract or lease is for

2.1 _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2.2 _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2.3 _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2.4 _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

---

City State ZIP Code

2.5 _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___

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

Additional Page if You Have More Contracts or Leases

Person or company with whom you have the contract or lease What the contract or lease is for

2._ _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2._ _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2._ _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2._ _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2._ _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2._ _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2._ _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

_____________________________________________________________________
City State ZIP Code

2._ _____________________________________________________________________ Name

_____________________________________________________________________
Number Street

---

City State ZIP Code
Print Save As... Add Attachment Reset

Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page ___ of ___

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: ____________________DistrictDistrictof ________of __________

Case number ____________________________________________ (If known) Check if this is an amended filing Official Form 106H Schedule H: Your Codebtors 12/15 Codebtors are people or entities who are also liable for any debts you may have. 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, copy the Additional Page, fill it out, and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and case number (if known). Answer every question.

1. Do you have any codebtors? (If you are filing a joint case, do not list either spouse as a codebtor.) No Yes

2. Within the last 8 years, have you lived 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. Go to line 3. Yes. Did your spouse, former spouse, or legal equivalent live with you at the time? No Yes. In which community state or territory did you live? __________________. Fill in the name and current address of that person. ______________________________________________________________________ Name of your spouse, former spouse, or legal equivalent ______________________________________________________________________ Number Street ______________________________________________________________________ City State ZIP Code

3. In Column 1, list all of your codebtors. Do not include your spouse as a codebtor if your spouse is filing with you. List the person shown in line 2 again as a codebtor only if that person is a guarantor or cosigner. Make sure you have listed the creditor on Schedule D (Official Form 106D), Schedule E/F (Official Form 106E/F), or Schedule G (Official Form 106G). Use Schedule D, Schedule E/F, or Schedule G to fill out Column 2.

   Column 1: Your codebtor Column 2: The creditor to whom you owe the debt

Check all schedules that apply: 3.1 ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______ ________________________________________________________________________________ City State ZIP Code 3.2 ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______ ________________________________________________________________________________ City State ZIP Code 3.3 ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______ ________________________________________________________________________________ City State ZIP Code

Official Form 106H Schedule H: Your Codebtors page 1 of ___

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

Additional Page to List More Codebtors

Column 1: Your codebtor Column 2: The creditor to whom you owe the debt

Check all schedules that apply:

3._ ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______

________________________________________________________________________________
City State ZIP Code

3._ ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______

________________________________________________________________________________
City State ZIP Code

3._ ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______

________________________________________________________________________________
City State ZIP Code

3._ ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______

________________________________________________________________________________
City State ZIP Code

3._ ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______

________________________________________________________________________________
City State ZIP Code

3._ ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______

________________________________________________________________________________
City State ZIP Code

3._ ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______

________________________________________________________________________________
City State ZIP Code

3._ ________________________________________________________________________________ Schedule D, line ______ Name Schedule E/F, line ______ ________________________________________________________________________________ Number Street Schedule G, line ______

________________________________________________________________________________
City State ZIP Code

Print Save As... Add Attachment Reset Official Form 106H Schedule H: Your Codebtors page ___ of ___

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: ____________________DistrictDistrictof ___________of __________

Case number ___________________________________________ Check if this is: (If known) An amended filing A supplement showing postpetition chapter 13 income as of the following date: Official Form 106I ________________MM / DD / YYYY Schedule I: Your Income 12/15 Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your spouse. If you are separated and your spouse is not filing with you, do not include information about your spouse. 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: Describe Employment

1. Fill in your employment information. Debtor 1 Debtor 2 or non-filing spouse If you have more than one job, attach a separate page with information about additional Employment status Employed Employed employers. Not employed Not employed Include part-time, seasonal, or self-employed work. Occupation __________________________________ __________________________________

Occupation may include student or homemaker, if it applies. Employer’s name __________________________________ __________________________________

Employer’s address _______________________________________ ________________________________________
Number Street Number Street

_______________________________________ ________________________________________

_______________________________________ ________________________________________

---

City State ZIP Code City State ZIP Code
How long employed there? _______ _______

Part 2: Give Details About Monthly Income

Estimate monthly income as of the date you file this form. If you have nothing to report for any line, write $0 in the space. Include your non-filing spouse unless you are separated. If you or your non-filing spouse have more than one employer, combine the information for all employers for that person on the lines below. If you need more space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or
non-filing spouse

2. List monthly gross wages, salary, and commissions (before all payroll deductions). If not paid monthly, calculate what the monthly wage would be. 2. $___________ $____________

3. Estimate and list monthly overtime pay. 3. + $___________ + $____________

4. Calculate gross income. Add line 2 + line 3. 4. $__________ $____________

Official Form 106I Schedule I: Your Income page 1

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

For Debtor 1 For Debtor 2 or
non-filing spouse

Copy line 4 here ............................................................................................... 4. $___________ $_____________

5. List all payroll deductions:

   5a. Tax, Medicare, and Social Security deductions 5a. $____________ $_____________ 5b. Mandatory contributions for retirement plans 5b. $____________ $_____________ 5c. Voluntary contributions for retirement plans 5c. $____________ $_____________ 5d. Required repayments of retirement fund loans 5d. $____________ $_____________ 5e. Insurance 5e. $____________ $_____________ 5f. Domestic support obligations 5f. $____________ $_____________ 5g. Union dues 5g. $____________ $_____________ 5h. Other deductions. Specify: __________________________________ 5h. + $____________ + $_____________

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h. 6. $____________ $_____________

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $____________ $_____________

8. List all other income regularly received: 8a. Net income from rental property and from operating a business, profession, or farm Attach a statement for each property and business showing gross receipts, ordinary and necessary business expenses, and the total $____________ $_____________ monthly net income. 8a. 8b. Interest and dividends 8b. $____________ $_____________ 8c. Family support payments that you, a non-filing spouse, or a dependent regularly receive Include alimony, spousal support, child support, maintenance, divorce $____________ $_____________ settlement, and property settlement. 8c. 8d. Unemployment compensation 8d. $____________ $_____________ 8e. Social Security 8e. $____________ $_____________ 8f. Other government assistance that you regularly receive Include cash assistance and the value (if known) of any non-cash assistance that you receive, such as food stamps (benefits under the Supplemental Nutrition Assistance Program) or housing subsidies. Specify: ___________________________________________________ 8f. $____________ $_____________

   8g. Pension or retirement income 8g. $____________ $_____________ 8h. Other monthly income. Specify: _______________________________ 8h. + $____________ + $_____________

9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h. 9. $____________ $_____________

10. Calculate monthly income. Add line 7 + line 9. $___________ + $_____________ = $_____________ Add the entries in line 10 for Debtor 1 and Debtor 2 or non-filing spouse. 10.

11. State all other regular contributions to the expenses that you list in Schedule J. Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and other friends or relatives. Do not include any amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J. Specify: _______________________________________________________________________________ 11. + $_____________

12. Add the amount in the last column of line 10 to the amount in line 11. The result is the combined monthly income. Write that amount on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies 12. $_____________ Combined monthly income

13. Do you expect an increase or decrease within the year after you file this form? No. Yes. Explain:

Official Form 106I Schedule I: Your Income page 2 Print Save As... Add Attachment Reset

Fill in this information to identify your case:

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name Check if this is:

Debtor 2 ________________________________________________________________ First Name Middle Name Last Name An amended filing (Spouse, if filing)
A supplement showing postpetition chapter 13
United States Bankruptcy Court for the: ____________________ DistrictDistrictof of __________ expenses as of the following date:
______

Case number ___________________________________________ MM / DD / YYYY (If known)

Official Form 106J Schedule J: Your Expenses 12/15

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 another sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case? No. Go to line 2. Yes. Does Debtor 2 live in a separate household? No Yes. Debtor 2 must file Official Form 106J-2, Expenses for Separate Household of Debtor 2.

2. Do you have dependents? No Dependent’s relationship to Dependent’s Does dependent live Do not list Debtor 1 and Yes. Fill out this information for Debtor 1 or Debtor 2 age with you? Debtor 2. each dependent .......................... No Do not state the dependents’ _________________________ ________ names. Yes No _________________________ ________ Yes No _________________________ ________ Yes No _________________________ ________ Yes No _________________________ ________ Yes

3. Do your expenses include No expenses of people other than yourself and your dependents? Yes

Part 2: Estimate Your Ongoing Monthly Expenses

Estimate your expenses as of your bankruptcy filing date unless you are using this form as a supplement in a Chapter 13 case to report expenses as of a date after the bankruptcy is filed. If this is a supplemental Schedule J, check the box at the top of the form and fill in the applicable date. Include expenses paid for with non-cash government assistance if you know the value of such assistance and have included it on Schedule I: Your Income (Official Form 106I.) Your expenses 4. The rental or home ownership expenses for your residence. Include first mortgage payments and $_____________________ any rent for the ground or lot. 4.

If not included in line 4:
4a. Real estate taxes 4a. $_____________________
4b. Property, homeowner’s, or renter’s insurance 4b. $_____________________
4c. Home maintenance, repair, and upkeep expenses 4c. $_____________________
4d. Homeowner’s association or condominium dues 4d. $_____________________

Official Form 106J Schedule J: Your Expenses page 1

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

Your expenses

$_____________________ 5. Additional mortgage payments for your residence, such as home equity loans 5.

6. Utilities: 6a. Electricity, heat, natural gas 6a. $_____________________ 6b. Water, sewer, garbage collection 6b. $_____________________ 6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $_____________________ 6d. Other. Specify: _______________________________________________ 6d. $_____________________

7. Food and housekeeping supplies 7. $_____________________

8. Childcare and children’s education costs 8. $_____________________

9. Clothing, laundry, and dry cleaning 9. $_____________________

10. Personal care products and services 10. $_____________________

11. Medical and dental expenses 11. $_____________________

12. Transportation. Include gas, maintenance, bus or train fare. $_____________________ Do not include car payments. 12.

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $_____________________

14. Charitable contributions and religious donations 14. $_____________________ 1 15. Insurance.

Do not include insurance deducted from your pay or included in lines 4 or 20.

15a. Life insurance 15a. $_____________________
15b. Health insurance 15b. $_____________________
15c. Vehicle insurance 15c. $_____________________
15d. Other insurance. Specify:_______________________________________ 15d. $_____________________

16. Taxes. Do not include taxes deducted from your pay or included in lines 4 or 20. Specify: ________________________________________________________ 16. $_____________________

17. Installment or lease payments: 17a. Car payments for Vehicle 1 17a. $_____________________ 17b. Car payments for Vehicle 2 17b. $_____________________ 17c. Other. Specify:_______________________________________________ 17c. $_____________________ 17d. Other. Specify:_______________________________________________ 17d. $_____________________

18. Your payments of alimony, maintenance, and support that you did not report as deducted from your pay on line 5, Schedule I, Your Income (Official Form 106I). 18. $_____________________

19. Other payments you make to support others who do not live with you. Specify:_______________________________________________________ 19. $_____________________

20. Other real property expenses not included in lines 4 or 5 of this form or on Schedule I: Your Income. 20a. Mortgages on other property 20a. $_____________________ 20b. Real estate taxes 20b. $_____________________ 20c. Property, homeowner’s, or renter’s insurance 20c. $_____________________ 20d. Maintenance, repair, and upkeep expenses 20d. $_____________________ 20e. Homeowner’s association or condominium dues 20e. $_____________________

Official Form 106J Schedule J: Your Expenses page 2

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

21. Other. Specify: _________________________________________________ 21. +$_____________________

22. Calculate your monthly expenses.

    22a. Add lines 4 through 21. 22a. $_____________________ 22b. Copy line 22 (monthly expenses for Debtor 2), if any, from Official Form 106J-2 22b. $_____________________ 22c. Add line 22a and 22b. The result is your monthly expenses. 22c. $_____________________

23. Calculate your monthly net income. $_____________________ 23a. Copy line 12 (your combined monthly income) from Schedule I. 23a.

23b. Copy your monthly expenses from line 22c above. 23b. – $_____________________

23c. Subtract your monthly expenses from your monthly income. $_____________________ The result is your monthly net income. 23c.

24. Do you expect an increase or decrease in your expenses within the year after you file this form?

    For example, do you expect to finish paying for your car loan within the year or do you expect your mortgage payment to increase or decrease because of a modification to the terms of your mortgage?

No. Yes. Explain here:

Official Form 106J Schedule J: Your Expenses page 3 Print Save As... Add Attachment Reset

Fill in this information to identify your case:

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name Check if this is:

Debtor 2 ________________________________________________________________ First Name Middle Name Last Name An amended filing (Spouse, if filing) A supplement showing postpetition chapter 13 United States Bankruptcy Court for the: ______________________ District of __________ expenses as of the following date: (State) ________________ Case number ___________________________________________ MM / DD / YYYY (If known)

Official Form 106J-2 Schedule J-2: Expenses for Separate Household of Debtor 2 12/15

Use this form for Debtor 2’s separate household expenses ONLY IF Debtor 1 and Debtor 2 maintain separate households. If Debtor 1 and Debtor 2 have one or more dependents in common, list the dependents on both Schedule J and this form. Answer the questions on this form only with respect to expenses for Debtor 2 that are not reported on Schedule J. Be as complete and accurate as possible. If more space is needed, attach another sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Describe Your Household

1. Do you and Debtor 1 maintain separate households? No. Do not complete this form. Yes

2. Do you have dependents? No Dependent’s relationship to Dependent’s Does dependent live Do not list Debtor 1 but list all Yes. Fill out this information for Debtor 2: age with you? other dependents of Debtor 2 each dependent .......................... regardless of whether listed as a No dependent of Debtor 1 on _________________________ ________ Yes Schedule J. No Do not state the dependents’ _________________________ ________ names. Yes No _________________________ ________ Yes No _________________________ ________ Yes No _________________________ ________ Yes

3. Do your expenses include No expenses of people other than Yes yourself, your dependents, and Debtor 1?

Part 2: Estimate Your Ongoing Monthly Expenses

Estimate your expenses as of your bankruptcy filing date unless you are using this form as a supplement in a Chapter 13 case to report expenses as of a date after the bankruptcy is filed.

Include expenses paid for with non-cash government assistance if you know the value of such assistance and have included it on Schedule I: Your Income (Official Form 106I.) Your expenses 4. The rental or home ownership expenses for your residence. Include first mortgage payments and $_____________________ any rent for the ground or lot. 4.

If not included in line 4:
4a. Real estate taxes 4a. $_____________________

4b. Property, homeowner’s, or renter’s insurance 4b. $_____________________

4c. Home maintenance, repair, and upkeep expenses 4c. $_____________________

4d. Homeowner’s association or condominium dues 4d. $_____________________

Official Form 106J-2 Schedule J-2: Expenses for Separate Household of Debtor 2 page 1

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

Your expenses

$_____________________

5. Additional mortgage payments for your residence, such as home equity loans 5.

6. Utilities: 6a. Electricity, heat, natural gas 6a. $_____________________

   6b. Water, sewer, garbage collection 6b. $_____________________

   6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $_____________________

   6d. Other. Specify: _______________________________________________ 6d. $_____________________

7. Food and housekeeping supplies 7. $_____________________

8. Childcare and children’s education costs 8. $_____________________

9. Clothing, laundry, and dry cleaning 9. $_____________________

10. Personal care products and services 10. $_____________________

11. Medical and dental expenses 11. $_____________________

12. Transportation. Include gas, maintenance, bus or train fare. $_____________________ Do not include car payments. 12.

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $_____________________

14. Charitable contributions and religious donations 14. $_____________________

    1 15. Insurance.

Do not include insurance deducted from your pay or included in lines 4 or 20.

15a. Life insurance 15a. $_____________________

15b. Health insurance 15b. $_____________________

15c. Vehicle insurance 15c. $_____________________

15d. Other insurance. Specify:_______________________________________ 15d. $_____________________

16. Taxes. Do not include taxes deducted from your pay or included in lines 4 or 20. Specify: ________________________________________________________ 16. $_____________________

17. Installment or lease payments: 17a. Car payments for Vehicle 1 17a. $_____________________

    17b. Car payments for Vehicle 2 17b. $_____________________

    17c. Other. Specify:_______________________________________________ 17c. $_____________________

    17d. Other. Specify:_______________________________________________ 17d. $_____________________

18. Your payments of alimony, maintenance, and support that you did not report as deducted from your pay on line 5, Schedule I, Your Income (Official Form 106I). 18. $_____________________

19. Other payments you make to support others who do not live with you.

Specify:_______________________________________________________ 19. $_____________________

20. Other real property expenses not included in lines 4 or 5 of this form or on Schedule I: Your Income.

    20a. Mortgages on other property 20a. $_____________________

    20b. Real estate taxes 20b. $_____________________

    20c. Property, homeowner’s, or renter’s insurance 20c. $_____________________

    20d. Maintenance, repair, and upkeep expenses 20d. $_____________________

    20e. Homeowner’s association or condominium dues 20e. $_____________________

Official Form 106J-2 Schedule J-2: Expenses for Separate Household of Debtor 2 page 2

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

21. Other. Specify: _________________________________________________ 21. +$_____________________

22. Your monthly expenses. Add lines 5 through 21. The result is the monthly expenses of Debtor 2. Copy the result to line 22b of Schedule J to calculate the total expenses for Debtor 1 and Debtor 2. 22. $_____________________

23. Line not used on this form.

24. Do you expect an increase or decrease in your expenses within the year after you file this form?

    For example, do you expect to finish paying for your car loan within the year or do you expect your mortgage payment to increase or decrease because of a modification to the terms of your mortgage?

No. Yes. Explain here:

Official Form 106J-2 Schedule J-2: Expenses for Separate Household of Debtor 2 page 3

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: ____________________ DistrictDistrictof __________of __________

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

Official Form 106Dec Declaration About an Individual Debtor’s Schedules 12/15

If two married people are filing together, both are equally responsible for supplying correct information.

You must file this form whenever you file bankruptcy schedules or amended schedules. 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.

Sign Below

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 Bankruptcy Petition Preparer’s Notice, Declaration, and Signature (Official Form 119).

Under penalty of perjury, I declare that I have read the summary and schedules filed with this declaration and that they are true and correct.

---

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY

Official Form 106Dec Declaration About an Individual Debtor’s Schedules

Print Save As... Add Attachment Reset

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

1. What is your current marital status?

Married Not married

2. 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

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

4. 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

5. 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

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

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

6. 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

____________________________________ _________ $_________________ $__________________ 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

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

7. 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

8. 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

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

Part 4: Identify Legal Actions, Repossessions, and Foreclosures 9. 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

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

Case number ________________________ ________________________________________
City State ZIP Code

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

Case number ________________________ ________________________________________
City State ZIP Code

10. 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

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

11. 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–___ ___ ___ ___

12. 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

13. 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

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

14. 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

15. 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

16. 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

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

17. 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

18. 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

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

19. 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

20. 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

21. 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 ____________________________________ _______________________________________ Yes Name of Financial Institution Name

    ---

    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

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

22. 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

23. 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.

24. 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

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

25. 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

26. 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 27. 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

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

28. 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

Print Save As... Add Attachment Reset

B2800 (Form 2800) (12/15)

United States Bankruptcy Court _________________________ District of District__________Of ________________

In re _______________________________________________ Case No. ____________ Debtor Chapter _____________

DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREPARER

[Must be filed with the petition if a bankruptcy petition preparer prepares the petition. 11 U.S.C. § 110(h)(2).]

1. Under 11 U.S.C. § 110(h), I declare under penalty of perjury that I am not an attorney or employee of an attorney, that I prepared or caused to be prepared one or more documents for filing by the above-named debtor(s) in connection with this bankruptcy case, and that compensation paid to me within one year before the filing of the bankruptcy petition, or agreed to be paid to me, for services rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows:

For document preparation services I have agreed to accept............................... $______________

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

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

2. I have prepared or caused to be prepared the following documents (itemize):

and provided the following services (itemize):

3. The source of the compensation paid to me was:
   Debtor Other (specify)

4. The source of compensation to be paid to me is:
   Debtor Other (specify)

5. The foregoing is a complete statement of any agreement or arrangement for payment to me for preparation of the petition filed by the debtor(s) in this bankruptcy case.

6. To my knowledge no other person has prepared for compensation a document for filing in connection with this bankruptcy case except as listed below:

NAME SOCIAL SECURITY NUMBER

---

Signature Social Security number of bankruptcy Date
petition preparer*

---

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

• 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).

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.

Fill in this information to identify the 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 ___________________________________________ Chapter ____________ (If known)

Official Form 119 Bankruptcy Petition Preparer’s Notice, Declaration, and Signature 12/15

Bankruptcy petition preparers as defined in 11 U.S.C. § 110 must fill out this form every time they help prepare documents that are filed in the case. If more than one bankruptcy petition preparer helps with the documents, each must sign in Part 2. A bankruptcy petition preparer who does not comply with the provisions of title 11 of the United States Code and the Federal Rules of Bankruptcy Procedure may be fined, imprisoned, or both. 11 U.S.C. § 110; 18 U.S.C. § 156.

Part 1: Notice to Debtor

Bankruptcy petition preparers must give the debtor a copy of this form and have the debtor sign it before they prepare any documents for filing or accept any compensation. A signed copy of this form must be filed with any document prepared.

Bankruptcy petition preparers are not attorneys and may not practice law or give you legal advice, including the following:

whether to file a petition under the Bankruptcy Code (11 U.S.C. § 101 et seq.);

whether filing a case under chapter 7, 11, 12, or 13 is appropriate; whether your debts will be eliminated or discharged in a case under the Bankruptcy Code; whether you will be able to keep your home, car, or other property after filing a case under the Bankruptcy Code;

what tax consequences may arise because a case is filed under the Bankruptcy Code; whether any tax claims may be discharged; whether you may or should promise to repay debts to a creditor or enter into a reaffirmation agreement;

how to characterize the nature of your interests in property or your debts; or what procedures and rights apply in a bankruptcy case.

The bankruptcy petition preparer ________________________________________________________________ has notified me of Name any maximum allowable fee before preparing any document for filing or accepting any fee.

8 ___________________________________________________________________________________ Date _________________ Signature of Debtor 1 acknowledging receipt of this notice MM / DD / YYYY

8 ___________________________________________________________________________________ Date _________________ Signature of Debtor 2 acknowledging receipt of this notice MM / DD / YYYY

Official Form 119 Bankruptcy Petition Preparer’s Notice, Declaration, and Signature page 1

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

Part 2: Declaration and Signature of the Bankruptcy Petition Preparer

Under penalty of perjury, I declare that: I am a bankruptcy petition preparer or the officer, principal, responsible person, or partner of a bankruptcy petition preparer; I or my firm prepared the documents listed below and gave the debtor a copy of them and the Notice to Debtor by Bankruptcy Petition Preparer as required by 11 U.S.C. §§ 110(b), 110(h), and 342(b); and

if rules or guidelines are established according to 11 U.S.C. § 110(h) setting a maximum fee for services that bankruptcy petition preparers may charge, I or my firm notified the debtor of the maximum amount before preparing any document for filing or before accepting any fee from the debtor.

________________________________ ______________________ _______________________________________________________
Printed name Title, if any Firm name, if it applies

______________________________________________________
Number Street

____________________________________ __________ ______________ ______________________________
City State ZIP Code Contact phone

I or my firm prepared the documents checked below and the completed declaration is made a part of each document that I check: (Check all that apply.) Voluntary Petition (Form 101) Schedule I (Form 106I) Chapter 11 Statement of Your Current Monthly Statement About Your Social Security Numbers Schedule J (Form 106J) Income (Form 122B) (Form 121) Chapter 13 Statement of Your Current Monthly Declaration About an Individual Debtor’s Income and Calculation of Commitment Period Summary of Your Assets and Liabilities and Schedules (Form 106Dec) (Form 122C-1) Certain Statistical Information (Form 106Sum) Statement of Financial Affairs (Form 107) Chapter 13 Calculation of Your Disposable Schedule A/B (Form 106A/B) Income (Form 122C-2) Statement of Intention for Individuals Filing Schedule C (Form 106C) Under Chapter 7 (Form 108) Application to Pay Filing Fee in Installments Schedule D (Form 106D) Chapter 7 Statement of Your Current (Form 103A) Monthly Income (Form 122A-1) Application to Have Chapter 7 Filing Fee Schedule E/F (Form 106E/F) Statement of Exemption from Presumption Waived (Form 103B) Schedule G (Form 106G) of Abuse Under § 707(b)(2) A list of names and addresses of all creditors Schedule H (Form 106H) (Form 122A-1Supp) (creditor or mailing matrix) Chapter 7 Means Test Calculation Other _____________________________ (Form 122A-2)

Bankruptcy petition preparers must sign and give their Social Security numbers. If more than one bankruptcy petition preparer prepared the documents to which this declaration applies, the signature and Social Security number of each preparer must be provided. 11 U.S.C. § 110.

8 _______________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ___ Date _________________ Signature of bankruptcy petition preparer or officer, principal, responsible Social Security number of person who signed MM / DD / YYYY person, or partner

---

Printed name

8 _______________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ___ Date _________________ Signature of bankruptcy petition preparer or officer, principal, responsible Social Security number of person who signed MM / DD / YYYY person, or partner

---

Printed name

Official Form 119 Bankruptcy Petition Preparer’s Notice, Declaration, and Signature page 2 Print Save As... Add Attachment Reset

B2030 (Form 2030) (12/25)

United States Bankruptcy Court _______________Central DistrictDistrictof CaliforniaOf _______________

In re

Case No. ___________________

Debtor Chapter ____________________

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

1. Pursuant to 11 U.S.C. § 329(a) and Fed. Bankr. P. 2016(b), I certify that I am the attorney for the above named debtor(s) and that compensation paid to me within one year before the filing of the petition in bankruptcy, or agreed to be paid to me, for services rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows:

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

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

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

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

   Debtor Other (specify)

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

   Debtor Other (specify)

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

   members and associates of my law firm.

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

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

5. Subject to any applicable local rule or court order, in return for the above-disclosed fee, I have agreed to render legal service for the following aspects of the bankruptcy case, except as excluded in Section 6:

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

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

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

B2030 (Form 2030) (12/25)

d. Representation of the debtor in adversary proceedings and other contested bankruptcy matters;

e. [List other services that counsel has agreed to provide]

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

   CERTIFICATION

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

   me for representation of the debtor(s) in this bankruptcy proceeding.

   ______________________
   Date Signature of Attorney

   Name of law firm

Attorney or Party Name, Address, Telephone & FAX FOR COURT USE ONLY Nos., State Bar No. & Email Address

Debtor(s) appearing without an attorney Attorney for Debtor(s)

UNITED STATES BANKRUPTCY COURT

CENTRAL DISTRICT OF CALIFORNIA - SELECT DIVISION DIVISION

In re: CASE NO.: CHAPTER:

DECLARATION BY DEBTOR(S)
AS TO WHETHER INCOME WAS RECEIVED
FROM AN EMPLOYER WITHIN 60 DAYS OF
THE PETITION DATE
[11 U.S.C. § 521(a)(1)(B)(iv)]

[No hearing required] Debtor(s).

Debtor(s) provides the following declaration(s) as to whether income was received from an employer within 60 days of the Debtor(s) filing this bankruptcy case (Petition Date), as required by 11 U.S.C. § 521(a)(1)(B)(iv):

Declaration of Debtor 1

1. I am Debtor 1 in this case, and I declare under penalty of perjury that the following information is true and correct:

   During the 60-day period before the Petition Date (Check only ONE box below): I was paid by an employer. Attached are copies of all statements of earnings, pay stubs, or other proof of employment income I received from my employer during this 60-day period. (If the Debtor’s social security number or bank account is on a pay stub or other proof of income, the Debtor must cross out (redact) the number(s) before filing this declaration.)

   I was not paid by an employer because I was either self-employed only, or not employed.

Date: __________________________________ _____________________________________ Printed name of Debtor 1 Signature of Debtor 1

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

December 2015 Page 1 F 1002-1.EMP.INCOME.DEC

Declaration of Debtor 2 (Joint Debtor) (if applicable)

2. I am Debtor 2 in this case, and I declare under penalty of perjury that the following information is true and correct:

   During the 60-day period before the Petition Date (Check only ONE box below): I was paid by an employer. Attached are copies of all statements of earnings, pay stubs, or other proof of employment income I received from my employer during this 60 day period. (If the Debtor’s social security number or bank account is on a pay stub or other proof of income, the Debtor must cross out (redact) the number(s) before filing this declaration.)

   I was not paid by an employer because I was either self-employed only, or not employed.

Date: __________________________________ _____________________________________ Printed name of Debtor 2 Signature of Debtor 2

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

December 2015 Page 2 F 1002-1.EMP.INCOME.DEC

Fill in this information to identify your case: Check as directed in lines 17 and 21: According to the calculations required by Debtor 1 __________________________________________________________________ this Statement: First Name Middle Name Last Name Debtor 2 ________________________________________________________________ 1. Disposable income is not determined (Spouse, if filing) First Name Middle Name Last Name under 11 U.S.C. § 1325(b)(3). 2. Disposable income is determined United States Bankruptcy Court for the: ______________________Central District of California District of __________ (State) under 11 U.S.C. § 1325(b)(3). Case number ___________________________________________ (If known) 3. The commitment period is 3 years. 4. The commitment period is 5 years.

Check if this is an amended filing

Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period 04/20 Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any additional pages, write your name and case number (if known).

Part 1: Calculate Your Average Monthly Income

1. What is your marital and filing status? Check one only. Not married. Fill out Column A, lines 2-11. Married. Fill out both Columns A and B, lines 2-11.

   Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this bankruptcy case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through August 31. If the amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6. Fill in the result. Do not include any income amount more than once. For example, if both spouses own the same rental property, put the income from that property in one column only. If you have nothing to report for any line, write $0 in the space.

   Column A Column B
   Debtor 1 Debtor 2 or
   non-filing spouse

2. Your gross wages, salary, tips, bonuses, overtime, and commissions (before all payroll deductions). $__________ $__________

3. Alimony and maintenance payments. Do not include payments from a spouse. $__________ $__________

4. All amounts from any source which are regularly paid for household expenses of you or your dependents, including child support. Include regular contributions from an unmarried partner, members of your household, your dependents, parents, and roommates. Do not include payments from a spouse. Do not include payments you listed on line 3. $_________ $__________

5. Net income from operating a business, profession, or Debtor 1 Debtor 2 farm $______ $______ Gross receipts (before all deductions) Ordinary and necessary operating expenses – $______ – $______ Copy Net monthly income from a business, profession, or farm $______ $______ here $_________ $__________

6. Net income from rental and other real property Debtor 1 Debtor 2 Gross receipts (before all deductions) $______ $______ Ordinary and necessary operating expenses – $______ – $______ Copy Net monthly income from rental or other real property $______ $______ here $_________ $__________

Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 1

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

Column A Column B
Debtor 1 Debtor 2 or
non-filing spouse

7. Interest, dividends, and royalties $____________ $__________

8. Unemployment compensation $____________ $__________ Do not enter the amount if you contend that the amount received was a benefit under the Social Security Act. Instead, list it here: ........................................

   For you ..................................................................................... $_____________ For your spouse ..................................................................... $_____________

9. Pension or retirement income. Do not include any amount received that was a benefit under the Social Security Act. Also, except as stated in the next sentence, do not include any compensation, pension, pay, annuity, or allowance paid by the United States Government in connection with a disability, combat-related injury or disability, or death of a member of the uniformed services. If you received any retired pay paid under chapter 61 of title 10, then include that pay only to the extent that it does not exceed the amount of retired pay to which you would otherwise be entitled if retired under any provision of title 10 other than chapter 61 of that title. $____________ $__________

10. Income from all other sources not listed above. Specify the source and amount. Do not include any benefits received under the Social Security Act; payments made under the Federal law relating to the national emergency declared by the President under the National Emergencies Act (50 U.S.C. 1601 et seq.) with respect to the coronavirus disease 2019 (COVID-19); payments received as a victim of a war crime, a crime against humanity, or international or domestic terrorism; or compensation, pension, pay, annuity, or allowance paid by the United States Government in connection with a disability, combat-related injury or disability, or death of a member of the uniformed services. If necessary, list other sources on a separate page and put the total below. $____________ $___________ __________________________________________________________________ $____________ $___________ __________________________________________________________________ Total amounts from separate pages, if any. + $____________ + $__________

    Add lines 2 through 10 for each11. Calculate your total average monthly income. $____________ + $___________ = $________ column. Then add the total for Column A to the total for Column B.

    Total average
    monthly income

Part 2: Determine How to Measure Your Deductions from Income

12. Copy your total average monthly income from line 11. .......................................................................................................................... $_____________
13. Calculate the marital adjustment. Check one: You are not married. Fill in 0 below. You are married and your spouse is filing with you. Fill in 0 below. You are married and your spouse is not filing with you. Fill in the amount of the income listed in line 11, Column B, that was NOT regularly paid for the household expenses of you or your dependents, such as payment of the spouse’s tax liability or the spouse’s support of someone other than you or your dependents. Below, specify the basis for excluding this income and the amount of income devoted to each purpose. If necessary, list additional adjustments on a separate page. If this adjustment does not apply, enter 0 below. __________________________________________________________________________ $___________ __________________________________________________________________________ $___________ __________________________________________________________________________ + $___________ Total ................................................................................................................................................ $___________ Copy here ─____________

Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 2

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

14. Your current monthly income. Subtract the total in line 13 from line 12. $ __________

15. Calculate your current monthly income for the year. Follow these steps: $ ____________ 15a. Copy line 14 here ........................................................................................................................................................................................... Multiply line 15a by 12 (the number of months in a year). x 12

    15b. The result is your current monthly income for the year for this part of the form. .................................................................................... $___________

16. Calculate the median family income that applies to you. Follow these steps: 16a. Fill in the state in which you live. _________

    16b. Fill in the number of people in your household. _________

    16c. Fill in the median family income for your state and size of household. ................................................................................................ $___________ To find a list of applicable median income amounts, go online using the link specified in the separate instructions for this form. This list may also be available at the bankruptcy clerk’s office.

17. How do the lines compare? 17a. Line 15b is less than or equal to line 16c. On the top of page 1 of this form, check box 1, Disposable income is not determined under 11 U.S.C. § 1325(b)(3). Go to Part 3. Do NOT fill out Calculation of Your Disposable Income (Official Form 122C–2). 17b. Line 15b is more than line 16c. On the top of page 1 of this form, check box 2, Disposable income is determined under 11 U.S.C. § 1325(b)(3). Go to Part 3 and fill out Calculation of Your Disposable Income (Official Form 122C–2). On line 39 of that form, copy your current monthly income from line 14 above.

Part 3: Calculate Your Commitment Period Under 11 U.S.C. § 1325(b)(4)

18. Copy your total average monthly income from line 11. ............................................................................................................................ $__________

19. Deduct the marital adjustment if it applies. If you are married, your spouse is not filing with you, and you contend that calculating the commitment period under 11 U.S.C. § 1325(b)(4) allows you to deduct part of your spouse’s income, copy the amount from line 13. 19a. If the marital adjustment does not apply, fill in 0 on line 19a. ............................................................................................. ─ $__________

    19b. Subtract line 19a from line 18. $__________

20. Calculate your current monthly income for the year. Follow these steps:

    20a. Copy line 19b.. ............................................................................................................................................................................................... $___________ Multiply by 12 (the number of months in a year). x 12

    20b. The result is your current monthly income for the year for this part of the form. $___________

    20c. Copy the median family income for your state and size of household from line 16c....................................................................... $___________

21. How do the lines compare?

Line 20b is less than line 20c. Unless otherwise ordered by the court, on the top of page 1 of this form, check box 3, The commitment period is 3 years. Go to Part 4.

Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 3

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

Line 20b is more than or equal to line 20c. Unless otherwise ordered by the court, on the top of page 1 of this form, check box 4, The commitment period is 5 years. Go to Part 4.

Part 4: Sign Below

By signing here, under penalty of perjury I declare that the information on this statement and in any attachments is true and correct.
___________________________________________________ ____________________________________
Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY

If you checked 17a, do NOT fill out or file Form 122C–2.
If you checked 17b, fill out Form 122C–2 and file it with this form. On line 39 of that form, copy your current monthly income from line 14 above.

Print Save As... Add Attachment Reset

Official Form 122C–1 Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period page 4

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: __________Central DistrictDistrictof Californiaof _________

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

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income 04/25

To fill out this form, you will need your completed copy of Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period (Official Form 122C–1). Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any additional pages, write your name and case number (if known).

Part 1: Calculate Your Deductions from Your Income

The Internal Revenue Service (IRS) issues National and Local Standards for certain expense amounts. Use these amounts to answer the questions in lines 6-15. To find the IRS standards, go online using the link specified in the separate instructions for this form. This information may also be available at the bankruptcy clerk’s office.

Deduct the expense amounts set out in lines 6-15 regardless of your actual expense. In later parts of the form, you will use some of your actual expenses if they are higher than the standards. Do not include any operating expenses that you subtracted from income in lines 5 and 6 of Form 122C–1, and do not deduct any amounts that you subtracted from your spouse’s income in line 13 of Form 122C–1.

If your expenses differ from month to month, enter the average expense.

Note: Line numbers 1-4 are not used in this form. These numbers apply to information required by a similar form used in chapter 7 cases.

5. The number of people used in determining your deductions from income
Fill in the number of people who could be claimed as exemptions on your federal income tax
return, plus the number of any additional dependents whom you support. This number may
be different from the number of people in your household.

National
You must use the IRS National Standards to answer the questions in lines 6-7.
Standards

6. Food, clothing, and other items: Using the number of people you entered in line 5 and the IRS National
Standards, fill in the dollar amount for food, clothing, and other items. $________

7. Out-of-pocket health care allowance: Using the number of people you entered in line 5 and the IRS National Standards, fill in the dollar amount for out-of-pocket health care. The number of people is split into two categories─people who are under 65 and people who are 65 or older─because older people have a higher IRS allowance for health care costs. If your actual expenses are higher than this IRS amount, you may deduct the additional amount on line 22.

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 1

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

People who are under 65 years of age

7a. Out-of-pocket health care allowance per person $______________

7b. Number of people who are under 65 X ______

Copy
7c. Subtotal. Multiply line 7a by line 7b. $______________ here $___________

People who are 65 years of age or older

7d. Out-of-pocket health care allowance per person $______________

7e. Number of people who are 65 or older X ______

Copy
7f. Subtotal. Multiply line 7d by line 7e. $______________ $__________ here+

7g. Total. Add lines 7c and 7f. ...................................................................................................... $___________ Copy here ....... $________

Local
You must use the IRS Local Standards to answer the questions in lines 8-15.
Standards

Based on information from the IRS, the U.S. Trustee Program has divided the IRS Local Standard for housing for bankruptcy purposes into two parts:

Housing and utilities – Insurance and operating expenses Housing and utilities – Mortgage or rent expenses

To answer the questions in lines 8-9, use the U.S. Trustee Program chart. To find the chart, go online using the link specified in the separate instructions for this form. This chart may also be available at the bankruptcy clerk’s office.

8. Housing and utilities – Insurance and operating expenses: Using the number of people you entered in line 5, fill
$________ in the dollar amount listed for your county for insurance and operating expenses.

9. Housing and utilities – Mortgage or rent expenses:

9a. Using the number of people you entered in line 5, fill in the dollar amount
$____________ listed for your county for mortgage or rent expenses.

9b. Total average monthly payment for all mortgages and other debts secured by
your home.
To calculate the total average monthly payment, add all amounts that are
contractually due to each secured creditor in the 60 months after you file
for bankruptcy. Next divide by 60.

Name of the creditor Average monthly
payment

_________________________________ $__________

_________________________________ $__________ _________________________________ + $__________ Copy this amount 9b. Total average monthly payment $__________ here─ $____________Repeaton line 33a.

9c. Net mortgage or rent expense.
Subtract line 9b (total average monthly payment) from line 9a (mortgage or $____________ Copy here ....... $________
rent expense). If this number is less than $0, enter $0.

10. If you claim that the U.S. Trustee Program’s division of the IRS Local Standard for housing is incorrect and affects $________
the calculation of your monthly expenses, fill in any additional amount you claim.
Explain _______________________________________________________________ why:
_______________________________________________________________

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 2

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

11. Local transportation expenses: Check the number of vehicles for which you claim an ownership or operating expense.
0. Go to line 14.
1. Go to line 12.
2 or more. Go to line 12.

12. Vehicle operation expense: Using the IRS Local Standards and the number of vehicles for which you claim the operating
expenses, fill in the Operating Costs that apply for your Census region or metropolitan statistical area. $_______

13. Vehicle ownership or lease expense: Using the IRS Local Standards, calculate the net ownership or lease expense for
each vehicle below. You may not claim the expense if you do not make any loan or lease payments on the vehicle. In
addition, you may not claim the expense for more than two vehicles.

Vehicle 1 Describe Vehicle 1: _________________________________________________________________

_________________________________________________________________

13a. Ownership or leasing costs using IRS Local Standard ....................................... $____________

13b. Average monthly payment for all debts secured by Vehicle 1.
Do not include costs for leased vehicles.

To calculate the average monthly payment here and on line 13e,
add all amounts that are contractually due to each secured
creditor in the 60 months after you file for bankruptcy. Then divide
by 60.

Name of each creditor for Vehicle 1 Average monthly
payment
_________________________________ $__________
_________________________________ + $__________
Copy Repeat this amount
Total average monthly payment ─ $___________ on line 33b. $__________ here

13c. Net Vehicle 1 ownership or lease expense Copy net Vehicle
Subtract line 13b from line 13a. If this number is less than $0, enter $0. ............ $___________ 1 expense here $_______

Vehicle 2 Describe Vehicle 2: _________________________________________________________________

_________________________________________________________________

13d. Ownership or leasing costs using IRS Local Standard ................................... $___________

13e. Average monthly payment for all debts secured by Vehicle 2.
Do not include costs for leased vehicles.

Name of each creditor for Vehicle 2 Average monthly payment _________________________________ $__________ _________________________________ + $__________ Copy Repeat this amount Total average monthly payment ─ $___________ on line 33c. $__________ here

13f. Net Vehicle 2 ownership or lease expense Copy net Vehicle
$__________ 2 expense here $_______
Subtract line 13e from 13d. If this number is less than $0, enter $0. ...................

14. Public transportation expense: If you claimed 0 vehicles in line 11, using the IRS Local Standards, fill in the Public
Transportation expense allowance regardless of whether you use public transportation. $_______

15. Additional public transportation expense: If you claimed 1 or more vehicles in line 11 and if you claim that you may also
deduct a public transportation expense, you may fill in what you believe is the appropriate expense, but you may not claim
more than the IRS Local Standard for Public Transportation. $_______

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 3

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

Other Necessary In addition to the expense deductions listed above, you are allowed your monthly expenses for the
Expenses following IRS categories.

16. Taxes: The total monthly amount that you actually pay for federal, state and local taxes, such as income taxes,
self-employment taxes, social security taxes, and Medicare taxes. You may include the monthly amount withheld
from your pay for these taxes. However, if you expect to receive a tax refund, you must divide the expected $_______
refund by 12 and subtract that number from the total monthly amount that is withheld to pay for taxes.
Do not include real estate, sales, or use taxes.

17. Involuntary deductions: The total monthly payroll deductions that your job requires, such as retirement contributions,
union dues, and uniform costs.
Do not include amounts that are not required by your job, such as voluntary 401(k) contributions or payroll savings. $_______

18. Life insurance: The total monthly premiums that you pay for your own term life insurance. If two married people are filing
together, include payments that you make for your spouse’s term life insurance.
Do not include premiums for life insurance on your dependents, for a non-filing spouse’s life insurance, or for any form of
life insurance other than term. $_______

19. Court-ordered payments: The total monthly amount that you pay as required by the order of a court or administrative
agency, such as spousal or child support payments. $_______
Do not include payments on past due obligations for spousal or child support. You will list these obligations in line 35.

20. Education: The total monthly amount that you pay for education that is either required:
as a condition for your job, or $_______
for your physically or mentally challenged dependent child if no public education is available for similar services.

21. Childcare: The total monthly amount that you pay for childcare, such as babysitting, daycare, nursery, and preschool.
Do not include payments for any elementary or secondary school education. $_______

22. Additional health care expenses, excluding insurance costs: The monthly amount that you pay for health care that is required for the health and welfare of you or your dependents and that is not reimbursed by insurance or paid by a health savings account. Include only the amount that is more than the total entered in line 7. $_______ Payments for health insurance or health savings accounts should be listed only in line 25.

    23. Optional telephones and telephone services: The total monthly amount that you pay for telecommunication services for you and your dependents, such as pagers, call waiting, caller identification, special long distance, or business cell phone service, to the extent necessary for your health and welfare or that of your dependents or for the production of income, if it is not reimbursed by your employer. + $________ Do not include payments for basic home telephone, internet or cell phone service. Do not include self-employment expenses, such as those reported on line 5 of Form 122C-1, or any amount you previously deducted.

    24. Add all of the expenses allowed under the IRS expense allowances. $________ Add lines 6 through 23.

    Additional Expense These are additional deductions allowed by the Means Test. Deductions Note: Do not include any expense allowances listed in lines 6-24.

    25. Health insurance, disability insurance, and health savings account expenses. The monthly expenses for health insurance, disability insurance, and health savings accounts that are reasonably necessary for yourself, your spouse, or your dependents.

    Health insurance $__________

    Disability insurance $__________

    Health savings account + $__________ Total $__________ Copy total here ...................................................................... $________

    Do you actually spend this total amount? No. How much do you actually spend? $__________ Yes

    26. Continuing contributions to the care of household or family members. The actual monthly expenses that you will continue to pay for the reasonable and necessary care and support of an elderly, chronically ill, or disabled member of your household or member of your immediate family who is unable to pay for such expenses. These expenses may $_______ include contributions to an account of a qualified ABLE program. 26 U.S.C. § 529A(b).

    27. Protection against family violence. The reasonably necessary monthly expenses that you incur to maintain the safety of you and your family under the Family Violence Prevention and Services Act or other federal laws that apply. $_______

    By law, the court must keep the nature of these expenses confidential.

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 4

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

28. Additional home energy costs. Your home energy costs are included in your insurance and operating expenses on line 8.
If you believe that you have home energy costs that are more than the home energy costs included in expenses on line 8,
then fill in the excess amount of home energy costs. $_______
You must give your case trustee documentation of your actual expenses, and you must show that the additional amount
claimed is reasonable and necessary.

29. Education expenses for dependent children who are younger than 18. The monthly expenses (not more
$_______
than $214.58* per child) that you pay for your dependent children who are younger than 18 years old to attend a
private or public elementary or secondary school.
You must give your case trustee documentation of your actual expenses, and you must explain why the amount
claimed is reasonable and necessary and not already accounted for in lines 6-23.
* Subject to adjustment on 4/01/28, and every 3 years after that for cases begun on or after the date of adjustment.

30. Additional food and clothing expense. The monthly amount by which your actual food and clothing expenses are higher $_______
than the combined food and clothing allowances in the IRS National Standards. That amount cannot be more
than 5% of the food and clothing allowances in the IRS National Standards.
To find a chart showing the maximum additional allowance, go online using the link specified in the separate
instructions for this form. This chart may also be available at the bankruptcy clerk’s office.
You must show that the additional amount claimed is reasonable and necessary.

31. Continuing charitable contributions. The amount that you will continue to contribute in the form of cash or financial
instruments to a religious or charitable organization. 11 U.S.C. § 548(d)(3) and (4). + $________
Do not include any amount more than 15% of your gross monthly income.

32. Add all of the additional expense deductions. $_________
Add lines 25 through 31.

Deductions for Debt Payment

33. For debts that are secured by an interest in property that you own, including home mortgages, vehicle
loans, and other secured debt, fill in lines 33a through 33e.

To calculate the total average monthly payment, add all amounts that are contractually due
to each secured creditor in the 60 months after you file for bankruptcy. Then divide by 60.

Average monthly payment Mortgages on your home

33a. Copy line 9b here ................................................................................................... $___________

Loans on your first two vehicles
33b. Copy line 13b here. ............................................................................................... $___________

33c. Copy line 13e here. ............................................................................................... $___________

33d. List other secured debts:

Name of each creditor for other Identify property that Does
secured debt secures the debt payment
include taxes
or insurance?

No
$___________
___________________________________ ________________________ Yes
No
$___________
___________________________________ ________________________ Yes
No
$___________ ___________________________________ ________________________ Yes+

Copy total
33e. Total average monthly payment. Add lines 33a through 33d. .......................................... $___________ here $_______

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 5

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

34. Are any debts that you listed in line 33 secured by your primary residence, a vehicle, or other property necessary
for your support or the support of your dependents?

No. Go to line 35.
Yes. State any amount that you must pay to a creditor, in addition to the payments listed in line 33, to keep
possession of your property (called the cure amount). Next, divide by 60 and fill in the information below.

Name of the creditor Identify property that Total cure Monthly cure amount
secures the debt amount

_________________________ __________________ $__________ ÷ 60 = $___________

_________________________ __________________ $__________ ÷ 60 = $___________

_________________________ __________________ $__________ ÷ 60 = + $___________

Copy
Total $___________ total $_______
here

35. Do you owe any priority claimssuch as a priority tax, child support, or alimony that are past due as of
the filing date of your bankruptcy case? 11 U.S.C. § 507.
No. Go to line 36.
Yes. Fill in the total amount of all of these priority claims. Do not include current or
ongoing priority claims, such as those you listed in line 19.
Total amount of all past-due priority claims. .................................................................... $______________ ÷ 60 $_______

36. Projected monthly Chapter 13 plan payment $______________

Current multiplier for your district as stated on the list issued by the Administrative
Office of the United States Courts (for districts in Alabama and North Carolina) or by
the Executive Office for United States Trustees (for all other districts).
x ______
To find a list of district multipliers that includes your district, go online using the link
specified in the separate instructions for this form. This list may also be available at the
bankruptcy clerk’s office.
Copy
Average monthly administrative expense $______________ total $_______
here

37. Add all of the deductions for debt payment. Add lines 33e through 36. $_______

Total Deductions from Income

38. Add all of the allowed deductions.

Copy line 24, All of the expenses allowed under IRS expense allowances ................................... $______________

Copy line 32, All of the additional expense deductions ...................................................................... $______________

Copy line 37, All of the deductions for debt payment .........................................................................+ $______________

Copy
Total deductions ........................................................................................................................................ $______________ total $_______
here

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 6

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

Part 2: Determine Your Disposable Income Under 11 U.S.C. § 1325(b)(2)

39. Copy your total current monthly income from line 14 of Form 122C-1, Chapter 13 $_______ Statement of Your Current Monthly Income and Calculation of Commitment Period. ...................................................................

40. Fill in any reasonably necessary income you receive for support for dependent children. The monthly average of any child support payments, foster care payments, or disability payments for a dependent child, reported in Part I of Form 122C-1, that you $____________ received in accordance with applicable nonbankruptcy law to the extent reasonably necessary to be expended for such child.

41. Fill in all qualified retirement deductions. The monthly total of all amounts that your employer withheld from wages as contributions for qualified retirement plans, as $____________ specified in 11 U.S.C. § 541(b)(7) plus all required repayments of loans from retirement plans, as specified in 11 U.S.C. § 362(b)(19).

42. Total of all deductions allowed under 11 U.S.C. § 707(b)(2)(A). Copy line 38 here ............ $____________

43. Deduction for special circumstances. If special circumstances justify additional expenses and you have no reasonable alternative, describe the special circumstances and their expenses. You must give your case trustee a detailed explanation of the special circumstances and documentation for the expenses.

    Describe the special circumstances Amount of expense

    ______________________________________________________ $___________

    ______________________________________________________ $___________ ______________________________________________________ + $___________

    Copy here
    Total $___________ + $_____________

    $____________

44. Total adjustments. Add lines 40 through 43. .................................................................................... Copy here – $______

45. Calculate your monthly disposable income under § 1325(b)(2). Subtract line 44 from line 39. $_______

Part 3: Change in Income or Expenses

46. Change in income or expenses. If the income in Form 122C-1 or the expenses you reported in this form have changed or are virtually certain to change after the date you filed your bankruptcy petition and during the time your case will be open, fill in the information below. For example, if the wages reported increased after you filed your petition, check 122C-1 in the first column, enter line 2 in the second column, explain why the wages increased, fill in when the increase occurred, and fill in the amount of the increase.

    Form Line Reason for change Date of change Increase or Amount of change decrease?

122C─1 Increase ____ _______________________________ ____________ $____________ 122C─2 Decrease

122C─1 Increase ____ _______________________________ ____________ $____________ 122C─2 Decrease

122C─1 Increase ____ _______________________________ ____________ $____________ 122C─2 Decrease

122C─1 Increase ____ _______________________________ ____________ $____________ 122C─2 Decrease

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 7

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

Part 4: Sign Below

By signing here, under penalty of perjury you declare that the information on this statement and in any attachments is true and correct.

---

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________ MM / DD / YYYY MM / DD / YYYY

Print Save As... Add Attachment Reset

Official Form 122C-2 Chapter 13 Calculation of Your Disposable Income page 8

Attorney or Party Name, Address, Telephone & FAX FOR COURT USE ONLY Nos., State Bar No. & Email Address

Debtor(s) appearing without attorney Attorney for Debtor

UNITED STATES BANKRUPTCY COURT

CENTRAL DISTRICT OF CALIFORNIA -NameSELECTof DIVISIONDIVISION

In re: CASE NO.: CHAPTER: Select Chapter

VERIFICATION OF MASTER MAILING LIST OF CREDITORS [LBR 1007-1(a)]

Debtor(s).

Pursuant to LBR 1007-1(a), the Debtor, or the Debtor’s attorney if applicable, certifies under penalty of perjury that the master mailing list of creditors filed in this bankruptcy case, consisting of ___ sheet(s) is complete, correct, and consistent with the Debtor’s schedules and I/we assume all responsibility for errors and omissions.

Date: ___________________ _______________________________________ Signature of Debtor 1

Date: ___________________ _______________________________________ Signature of Debtor 2 (joint debtor) (if applicable)

Date: ___________________ _______________________________________ Signature of Attorney for Debtor (if applicable)

This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California

December 2015 F 1007-1.MAILING.LIST.VERIFICATION

Attorney or Party Name, Address, Telephone & FAX FOR COURT USE ONLY Numbers, State Bar Number & Email Address

Debtor appearing without attorney
Attorney for Debtor

UNITED STATES BANKRUPTCY COURT
CENTRAL DISTRICT OF CALIFORNIA - SELECT DIVISION DIVISION

List all names (including trade names) used by Debtor CASE NUMBER: within the last 8 years. CHAPTER 13 In re: CHAPTER 13 PLAN Original 1st Amended* 2nd Amended* ___ Amended* *list below which sections have been changed:

[FRBP 3015(b); LBR 3015-1]

11 U.S.C. SECTION 341(a) CREDITORS’ MEETING: Date: Time: Address:

PLAN CONFIRMATION HEARING: [LBR 3015-1(d)] Date: Time: Address:

Debtor(s).

“Bankruptcy Code” and “11 U.S.C.” refer to the United States Bankruptcy Code, Title 11 of the United States Code.

“FRBP” refers to the Federal Rules of Bankruptcy Procedure. “LBR” and “LBRs” refer to the Local Bankruptcy Rule(s) of this court.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 1 F 3015-1.01.CHAPTER13.PLAN

Part 1: PRELIMINARY INFORMATION TO DEBTOR (the term "Debtor" includes and refers to both spouses as Debtors in a joint bankruptcy case): This Chapter 13 Plan (Plan) sets out options that may be appropriate in some cases, but the presence of an option in this Plan does not indicate that the option is appropriate, or permissible, in your situation. A Plan that does not comply with local rules and judicial rulings may not be confirmable. You should read this Plan carefully and discuss it with your attorney if you have one. If you do not have an attorney, you may wish to consult one.

TO ALL CREDITORS: This Plan is proposed by Debtor and your rights may be affected by this Plan. Your claim may be reduced, modified, or eliminated. You should read this Plan carefully and discuss it with your attorney if you have one. If you do not have an attorney, you may wish to consult one.

PLEASE NOTE THAT THE PROVISIONS OF THIS PLAN MAY BE MODIFIED BY ORDER OF THE COURT.

If you oppose this Plan’s treatment of your claim or any provision of this Plan, you or your attorney must file a written objection to confirmation of the Plan at least 14 days before the date set for the hearing on confirmation. However, the amounts listed on a proof of claim for an allowed secured or priority claim control over any contrary amounts listed in the Plan. The Bankruptcy Court may confirm this plan without further notice if no objection to confirmation is filed. See FRBP 3015. In addition, you must file a timely proof of claim in order to be paid under any plan. See LBR 3015-1 and FRBP 3002(a). Defaults will be cured using the interest rate set forth below in the Plan.

The following matters may be of particular importance to you:

Debtor must check one box on each line to state whether or not this Plan includes each of the following items. If an item is checked as “Not included,” if both boxes are checked, or neither box is checked, the item will be ineffective if set out later as a provision in this Plan.

1.1 Valuation of property and avoidance of a lien on property of the bankruptcy estate, set out in Class 3B and/or Section IV (11 U.S.C. § 506(a) and (d)): Included Not included

1.2 Avoidance of a judicial lien or nonpossessory, nonpurchase-money security interest, set out in Section IV (11 U.S.C. § 522(f)): Included Not included

1.3 Less than full payment of a domestic support obligation that has been assigned to a governmental unit, pursuant to 11 U.S.C. §1322(a)(4). This provision requires that payments in Part 2 Section I.A. be for a term of 60 months: Included Not included

1.4 Other Nonstandard Plan provisions, set out in Section IV: Included Not included

ALL CREDITORS ARE REQUIRED TO FILE A PROOF OF CLAIM IN ORDER TO HAVE AN ALLOWED CLAIM, EXCEPT AS PROVIDED IN FRBP 3002(a). A Debtor whose Plan is confirmed may be eligible thereafter to receive a discharge of debts to the extent specified in 11 U.S.C. § 1328.

Regardless of whether this Plan treats a claim as secured or unsecured, any lien securing such claim is not avoided other than as provided by law or order of the court.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 2 F 3015-1.01.CHAPTER13.PLAN

Part 2: PLAN TERMS Debtor proposes the following Plan terms and makes the following declarations: Section I. PLAN PAYMENT AND LENGTH OF PLAN A. Monthly Plan Payments will begin 30 days from the date the bankruptcy petition was filed. If the payment due date falls on the 29th, 30th, or 31st day of the month, payment is due on the 1st day of the following month (LBR 3015-1(k)(1)(A)). Payments by Debtor of: $_______________ per month for months 1 through ____ totaling $. $ per month for months ____ through ____ totaling $. $ per month for months ____ through ____ totaling $. $ per month for months ____ through ____ totaling $. For a total plan length of ____ months totaling $. B. Nonpriority unsecured claims. The total amount of estimated non-priority unsecured claims is $__________________. 1. Unless otherwise ordered by the court, after Class 1 through Class 4 creditors are paid, allowed nonpriority unsecured claims that are not separately classified (Class 5) will be paid pro rata per the option checked below. If both options below are checked, the option providing the largest payment will be effective.

a. “Percentage” plan: % of the total amount of these claims, for an estimated total payment
of $.
b. “Residual” plan: The remaining funds, after disbursements have been made to all other
creditors provided for in this Plan, estimated to pay a total of $ _____________ and % to
claims in Class 5. The amount distributed to Class 5 claims may be less than the amount
specified here depending on the amount of secured and priority claims allowed.
2. Minimum Plan payments. Regardless of the options checked above, payments on allowed nonpriority
unsecured claims will be made in at least the greater of the following amounts:
a. the sum of $, representing the liquidation value of the estate in a hypothetical
Chapter 7 case under 11 U.S.C. § 1325(a)(4), or
b. if Debtor has above-median income and otherwise subject to 11 U.S.C. § 1325(b), the sum of
$_______________, representing all disposable income payable for 60 months under the means test.

C. Income tax refunds. Debtor will provide the Chapter 13 Trustee with a copy of each income tax return filed during the Plan term within 14 days of filing the return and, unless the Plan provides 100% payment to nonpriority unsecured creditors (Class 5), will turn over to the Chapter 13 Trustee all federal and state income tax refunds received for the term of the plan. The Debtor may retain a total of $500 of the sum of the federal and state tax refunds for each tax year. Income tax refunds received by the debtor and turned over to the Chapter 13 Trustee or directly turned over to the Chapter 13 Trustee by the taxing authorities do not decrease the total amount of payments stated in Section I.A., above. The refunds are pledged to the plan in addition to the amounts stated in Section I.A. and can be used by the Chapter 13 Trustee to increase the percentage paid to general unsecured creditors without further order of the Bankruptcy Court. D. In the event that secured creditor(s) file a Notice of Postpetition Fees and Costs pursuant to FRBP 3002.1(c), the Chapter 13 Trustee is authorized, but not required, to commence paying those charges 90 days after that notice is filed, unless within that time the Debtor contests those charges by filing a motion to determine payment under FRBP 3002.1(e) or agrees to pay those charges by filing a motion to modify this Plan.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 3 F 3015-1.01.CHAPTER13.PLAN

E. Debtor must make preconfirmation adequate protection payments for any creditor that holds an allowed claim secured by personal property where such security interest is attributable to the purchase of such property and preconfirmation payments on leases of personal property whose allowed claim is impaired by the terms proposed in this Plan. Debtor must make preconfirmation adequate protection payments and preconfirmation lease payments to the Chapter 13 Trustee for the following creditor(s) in the following amounts:

Last 4 Digits Creditor/Lessor Name Collateral Description Amount of Account #

Each adequate protection payment or preconfirmation lease payment will accrue beginning the 30th day from the date of filing of the case. The Chapter 13 Trustee must deduct the foregoing adequate protection payment(s) and/or preconfirmation lease payment from Debtor's Plan Payment and disburse the adequate protection payment or preconfirmation lease payment to the secured creditor(s) at the next disbursement or as soon as practicable after the payment is received and posted to the Chapter 13 Trustee’s account. The Chapter 13 Trustee will collect his or her statutory fee on all receipts made for preconfirmation adequate protection payments or preconfirmation lease payments. F. Debtor must not incur debt greater than $1,000 without prior court approval unless the debt is incurred in the ordinary course of business pursuant to 11 U.S.C. §1304(b) or for medical emergencies. G. The Chapter 13 Trustee is authorized to disburse funds after the date Plan confirmation is announced in open court. H. Debtor must file timely all postpetition tax returns and pay timely all postconfirmation tax liabilities directly to the appropriate taxing authorities. I. Debtor must pay all amounts required to be paid under a Domestic Support Obligation that first became payable after the date of the filing of the bankruptcy petition. J. If the Plan proposes to avoid a lien of a creditor, the Chapter 13 Trustee must not disburse any payments to that creditor on that lien until the Plan confirmation order is entered. K. Debtor must pay all required ongoing property taxes and insurance premiums for all real and personal property that secures claims paid under the Plan. Section II. ORDER OF PAYMENT OF CLAIMS; CLASSIFICATION AND TREATMENT OF CLAIMS: Except as otherwise provided in this Plan, the Chapter 13 Trustee must disburse all available funds for the payment of claims as follows: A. ORDER OF PAYMENT OF CLAIMS: 1st If there are Domestic Support Obligations, the order of priority will be: (a) Domestic Support Obligations and the Chapter 13 Trustee’s fee not exceeding the amount accrued on Plan Payments made to date; (b) Administrative expenses (Class 1(a)) until paid in full; If there are no Domestic Support Obligations, the order of priority will be: (a) The Chapter 13 Trustee’s fee not exceeding the amount accrued on Plan Payments made to date; (b) Administrative expenses (Class 1(a)) until paid in full. 2nd Subject to the 1st paragraph, pro rata to all secured claims and all priority unsecured claims until paid in full except as otherwise provided in this Plan. 3rd Non-priority unsecured creditors will be paid pro rata except as otherwise provided in this Plan. No payment will be made on nonpriority unsecured claims until all the above administrative, secured and priority claims have been paid in full unless otherwise provided in this Plan.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 4 F 3015-1.01.CHAPTER13.PLAN

B. CLASSIFICATION AND TREATMENT OF CLAIMS:

CLASS 1

ALLOWED UNSECURED CLAIMS ENTITLED TO PRIORITY UNDER 11 U.S.C. §507

Class 1 claims will be paid in full pro rata. Any treatment that proposes to pay claims in Class 1(a) or 1(b) less than in full must be agreed to in writing by the holder of each such claim and specifically addressed in Section IV.D.

Unless otherwise ordered by the court, the claim amount stated on a proof of claim, and the dollar amount of any allowed administrative expense, controls over any contrary amount listed below.

AMOUNT OF INTEREST TOTAL CATEGORY PRIORITY CLAIM RATE, if any PAYMENT

a. Administrative Expenses

(1) Chapter 13 Trustee’s Fee – estimated at 11% of all payments to be made to all classes through this Plan.

(2) Attorney’s Fees

(3) Chapter 7 Trustee's Fees

(4) Other

(5) Other

b. Other Priority Claims

(1) Internal Revenue Service 0.00%

(2) Franchise Tax Board 0.00%

(3) Domestic Support Obligation 0.00%

(4) Other 0.00%

c. Domestic Support Obligations that have been assigned to a governmental unit and are not to be paid in full in the Plan pursuant to 11 U.S.C. §1322(a)(4) (this provision requires that payments in Part 2 Section I.A. be for a term of 60 months) (specify creditor name):

0.00% 0.00%

0.00% 0.00%

See attachment for additional claims in Class 1.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 5 F 3015-1.01.CHAPTER13.PLAN

CLASS 2

CLAIMS SECURED SOLELY BY PROPERTY THAT IS DEBTOR’S PRINCIPAL RESIDENCE ON WHICH OBLIGATION MATURES AFTER THE FINAL PLAN PAYMENT IS DUE

Check one.

None. If “None” is checked, the rest of this form for Class 2 need not be completed.

Debtor will maintain and make the current contractual installment payments on the secured claims listed below, with
any changes required by the applicable contract and noticed in conformity with any applicable rules. Unless otherwise
ordered by the court, these payments will be disbursed either by the Chapter 13 Trustee or directly by Debtor, as
specified below. Debtor will cure the prepetition arrearages, if any, on a listed claim through disbursements by the
Chapter 13 Trustee, with interest, if any, at the rate stated.

The arrearage amount stated on a proof of claim controls over any contrary amount listed below.

ESTIMATED POST- LAST 4 AMOUNT OF MONTHLY ESTIMATED PETITION DIGITS OF INTEREST NAME OF CREDITOR ARREARAGE, PAYMENT TOTAL PAYMENT ACCOUNT RATE IF ANY ON PAYMENTS DISBURSING NUMBER ARREARAGE AGENT
Trustee
0.00% Debtor
Trustee
0.00% Debtor
Trustee
0.00%
Debtor

See attachment for additional claims in Class 2.

CLASS 3A

UNIMPAIRED CLAIMS TO BE PAID DIRECTLY BY DEBTOR

Check one.

None. If “None” is checked, the rest of this form for Class 3A need not be completed.

Debtor will make regular payments, including any preconfirmation payments, directly to the following creditors

in accordance with the terms of the applicable contract (Include Creditor Name and Last 4 Digits of Account Number):

---

---

_____________________________________________________________________________________________ . The claims of these creditors are unimpaired under the plan.

See attachment for additional claims in Class 3A.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 6 F 3015-1.01.CHAPTER13.PLAN

CLASS 3B

CLAIMS SECURED BY REAL OR PERSONAL PROPERTY WHICH ARE TO BE BIFURCATED AND PAID IN FULL DURING THE TERM OF THIS PLAN.

Check one.

None. If “None” is checked, the rest of this form for Class 3B need not be completed.

Debtor proposes:

Bifurcation of Claims - Dollar amounts/lien avoidance. Except as provided below regarding bifurcation of
claims into a secured part and an unsecured part, the claim amounts listed on a proof of claim control this
Plan over any contrary amounts listed below.

(a) Bifurcated claims - secured parts: Debtor proposes that, for the purposes of distributions under this
Plan, the dollar amount of secured claims in this Class 3B should be as set forth in the column
headed “Secured Claim Amount.” For that dollar amount to be binding on the affected parties, either

(i) Debtor must obtain a court order granting a motion fixing the dollar amount of the secured claim
and/or avoiding the lien, or

(ii) Debtor must complete and comply with Part 2 Section IV.C., so that the Plan itself serves as such
a motion; the "Included" boxes must be checked in Part 1 Paragraphs 1.1 and/or 1.2 (indicating
that this Plan includes valuation and lien avoidance, and/or avoidance of a judicial lien or
nonpossessory, nonpurchase-money lien in Section IV.C.); and this Plan must be confirmed - if
any one of those conditions is not satisfied, then the claim will not be bifurcated into a secured
part and an unsecured part pursuant to this sub-paragraph.

(b) Bifurcated claims - unsecured parts: Any allowed claim that exceeds the amount of the secured claim
will be treated as a nonpriority unsecured claim in Class 5 below.

LAST 4 SECURED ESTIMATED ESTIMATED DIGITS OF CLAIM INTEREST NAME OF CREDITOR CLAIM MONTHLY TOTAL ACCOUNT TOTAL RATE AMOUNT PAYMENT PAYMENTS NUMBER

0.00%

0.00%

See attachment for additional claims in Class 3B.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 7 F 3015-1.01.CHAPTER13.PLAN

CLASS 3C

CLAIMS SECURED BY REAL OR PERSONAL PROPERTY WHICH ARE TO BE PAID IN FULL DURING THE TERM OF THIS PLAN (WITHOUT BIFURCATION), INCLUDING CURE OF ARREARS, IF APPLICABLE.

Check all that apply.

None. If “None” is checked, the rest of this form for Class 3C need not be completed.

Debtor proposes to treat the claims listed below as fully secured claims on the terms set forth below. These
claims will not be bifurcated. The claim amounts listed on a proof of claim control this Plan over any contrary
amounts listed below.

IMPAIRED CLAIMS PAID THROUGH THE PLAN BY THE TRUSTEE
LAST 4 ESTIMATED ESTIMATED DIGITS OF INTEREST NAME OF CREDITOR CLAIM TOTAL MONTHLY TOTAL ACCOUNT RATE PAYMENT PAYMENTS NUMBER

0.00%

CURE AND MAINTAIN CLAIMS

Debtor will maintain and make the current contractual installment payments (Ongoing Payments) on the secured
claims listed below pursuant to the terms of the applicable contract, except as stated otherwise in this Plan.
These payments will be disbursed either by the Chapter 13 Trustee or directly by Debtor, as specified below.
Debtor will cure and pay the prepetition arrearages, if any, on a claim listed below through disbursements by the
Chapter 13 Trustee, with interest, if any, at the rate stated. The dollar amount of arrearage stated on a proof of
claim controls over any contrary amount listed below.
Cure of Default
LAST 4
DIGITS OF ESTIMATED ONGOING NAME OF CREDITOR AMOUNT OF ESTIMATED ACCOUNT INTEREST MONTHLY PAYMENT ARREARAGE, TOTAL NUMBER RATE PAYMENT ON DISBURSING IF ANY PAYMENTS ARREARAGE AGENT

Trustee 0.00%
Debtor

See attachment for additional claims in Class 3C.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 8 F 3015-1.01.CHAPTER13.PLAN

CLASS 3D

SECURED CLAIMS EXCLUDED FROM 11 U.S.C. §506

Check one.

None. If “None” is checked, the rest of this form for Class 3D need not be completed.

The claims listed below were either:

1. Incurred within 910 days before the petition date and secured by a purchase money security interest in a motor vehicle acquired for the personal use of Debtor, or

2. Incurred within 1 year of the petition date and secured by a purchase money security interest in any other thing of value. These claims will be paid in full under this Plan with interest at the rate stated below. The claim amount stated on a proof of claim controls over any contrary amount listed below.

   LAST 4 ESTIMATED ESTIMATED DIGITS OF INTEREST NAME OF CREDITOR CLAIM TOTAL MONTHLY TOTAL ACCOUNT RATE PAYMENT PAYMENTS NUMBER

   0.00%

   0.00%

   0.00%

See attachment for additional claims in Class 3D.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 9 F 3015-1.01.CHAPTER13.PLAN

CLASS 4

OTHER CLAIMS ON WHICH THE LAST PAYMENT ON A CLAIM IS DUE AFTER THE DATE ON WHICH THE FINAL PLAN PAYMENT IS DUE, WHICH ARE PROVIDED FOR UNDER 11 U.S.C. §1322(b)(5)

Check one.

None. If “None” is checked, the rest of this form for Class 4 need not be completed.

Debtor will maintain and make the current contractual installment payments (Ongoing Payments) on the secured
claims listed below pursuant to the terms of the applicable contract, except as stated otherwise in this Plan. These
payments will be disbursed either by the Chapter 13 Trustee or directly by Debtor, as specified below. Debtor will
cure and pay the prepetition arrearages, if any, on a claim listed below through disbursements by the Chapter 13
Trustee, with interest, if any, at the rate stated. The dollar amount of arrearage stated on a proof of claim controls
over any contrary amount listed below.

Cure of Default
LAST 4
DIGITS OF ESTIMATED ONGOING NAME OF CREDITOR AMOUNT OF ESTIMATED ACCOUNT INTEREST MONTHLY PAYMENT ARREARAGE, TOTAL NUMBER RATE PAYMENT ON DISBURSING IF ANY PAYMENTS ARREARAGE AGENT

Trustee
0.00% Debtor

Trustee 0.00%
Debtor

Trustee 0.00%
Debtor

See attachment for additional claims in Class 4.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 10 F 3015-1.01.CHAPTER13.PLAN

CLASS 5A

NON-PRIORITY UNSECURED CLAIMS NOT SEPARATELY CLASSIFIED

Allowed nonpriority unsecured claims not separately classified must be paid pursuant to Section I.B. above.

SEPARATE CLASSIFICATION:

Check all that apply if Debtor proposes any separate classification of nonpriority unsecured claims. None. If “None” is checked, the rest of this form for Class 5 need not be completed.

CLASS 5B

Maintenance of payments. Debtor will maintain and make the contractual installment payments on the unsecured
claims listed below on which the last payment is due after the final Plan payment. The contractual installment
payments will be disbursed by Debtor.
LAST 4 ESTIMATED ESTIMATED DIGITS OF INTEREST NAME OF CREDITOR MONTHLY TOTAL ACCOUNT RATE PAYMENT PAYMENTS NUMBER

0.00%

0.00%

CLASS 5C

Other separately classified nonpriority unsecured claims.
LAST 4 AMOUNT TO BE INTEREST ESTIMATED DIGITS OF NAME OF CREDITOR PAID ON THE RATE TOTAL AMOUNT ACCOUNT CLAIM OF PAYMENTS NUMBER
0.00%

0.00%

See attachment for additional claims in Class 5.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 11 F 3015-1.01.CHAPTER13.PLAN

CLASS 6

SURRENDER OF COLLATERAL

Check one. None. If “None” is checked, the rest of this form for Class 6 need not be completed. Debtor elects to surrender to each creditor listed below the collateral that secures the creditor’s claim. Debtor requests that upon confirmation of the Plan the stay under 11 U.S.C. § 362(a) be terminated as to the collateral only and that the stay under 11 U.S.C. §1301 be terminated in all respects. Any allowed unsecured claim resulting from the disposition of the collateral will be treated in Class 5 above. Creditor Name: Description:

See attachment for additional claims in Class 6.

CLASS 7

EXECUTORY CONTRACTS AND UNEXPIRED LEASES

Any executory contracts or unexpired leases not listed below are deemed rejected.

Check one.

None. If “None” is checked, the rest of this form for Class 7 need not be completed.

The executory contracts and unexpired leases listed below are treated as specified (identify the contract or
lease at issue and the other party(ies) to the contract or lease):

Creditor Name:

Description:
Rejected Assumed; cure amount (if any): $________________,
to be paid over _________ months

Creditor Name:

Description:
Rejected Assumed; cure amount (if any): $________________,
to be paid over _________ months

Payments to be cured within _____ months of filing of the bankruptcy petition. All cure payments will be
made through disbursements by the Chapter 13 Trustee.

See attachment for additional claims in Class 7.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 12 F 3015-1.01.CHAPTER13.PLAN

Section III. PLAN SUMMARY

CLASS 1a CLASS 1b CLASS 1c CLASS 2 CLASS 3B CLASS 3C CLASS 3D CLASS 4 CLASS 5A CLASS 5C CLASS 7 SUB-TOTAL CHAPTER 13 TRUSTEE'S FEE (Estimated 11% unless advised otherwise) TOTAL PAYMENT

Section IV. NON-STANDARD PLAN PROVISIONS None. If “None” is checked, the rest of Section IV need not be completed. Pursuant to FRBP 3015(c), Debtor must set forth all nonstandard Plan provisions in this Plan in this separate Section IV of this Plan and must check off the “Included” box or boxes in Paragraphs 1.1, 1.2, 1.3 and/or 1.4 of Part 1 of this Plan. Any nonstandard Plan provision that does not comply with these requirements is ineffective. A nonstandard Plan provision means any Plan provision not otherwise included in this mandatory Chapter 13 Plan form, or any Plan provision deviating from this form. The nonstandard Plan provisions seeking modification of liens and security interests address only those liens and security interests known to Debtor, and known to be subject to avoidance, and all rights are reserved as to any matters not currently known to Debtor. A. Debtor’s Intent to File Separate Motion to Value Property Subject to Creditor’s Lien or Avoid Creditor’s Lien [11 U.S.C. § 506(a) and (d)]. Debtor will file motion(s) to value real or personal property of the bankruptcy estate and/or to avoid a lien pursuant to 11 U.S.C § 506(a) and (d), as specified in Attachment A. B. Debtor’s Intent to File Separate Motion to Avoid Creditor’s Judicial Lien or Nonpossessory, Nonpurchase Security Interest [11 U.S.C. § 522(f)]. Debtor will file a Motion to avoid a judicial lien or nonpossessory, nonpurchase-money security interest, on real or personal property of the bankruptcy estate listed below pursuant to 11 U.S.C § 522(f). If the court enters an order avoiding a lien under 11 U.S.C. § 522(f), the Chapter 13 Trustee will not pay any claim filed based on that lien as a secured claim. Name of Creditor Lienholder/Servicer: Description of lien and collateral (e.g., 2nd lien on 123 Main St.):

Name of Creditor Lienholder/Servicer: Description of lien and collateral (e.g., 2nd lien on 123 Main St.):

See attachment for any additional liens and security interests to be avoided by separate 11 U.S.C. § 522(f) motion.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 13 F 3015-1.01.CHAPTER13.PLAN

C. Debtor’s Request in this Plan to Modify Creditor’s Secured Claim and Lien. Debtor proposes to modify the following secured claims and liens in this Plan without a separate motion or adversary proceeding - this Plan will serve as the motion to value the collateral and/or avoid the liens as proposed below. To use this option, Debtor must serve this Plan, LBR Form F 3015-1.02.NOTICE.341.LIEN.CONFRM and all related exhibits as instructed in that form. Note: Not all Judges will grant motions to value and/or avoid liens through this Plan. Please consult the specific Judge’s Instructions/Procedures on the court’s website for more information.

DEBTOR’S REQUEST TO MODIFY CREDITOR’S SECURED CLAIM AND LIEN

TO CREDITOR LIENHOLDER/SERVICER __________________________________________________

---

Real property collateral (street address and/or legal description or document recording number, including county of recording):

---

(attach page with legal description of property or document recording number as appropriate).

Other collateral (add description such as judgment date, date and place of lien recording, book

and page number):

---

11 U.S.C. § 522(f) – Debtor seeks avoidance of your lien(s) on the above described collateral effective immediately upon issuance of the order confirming this Plan.

11 U.S.C. § 506(a) and (d) – Debtor seeks avoidance of your lien(s) on the above described collateral that will be effective upon the earliest to occur of either payment of the underlying debt determined under nonbankruptcy law or one of the following: (check all that apply and see LBR Form F 4003-2.4.ORDER.AFTERDISCH): (1) discharge under 11 U.S.C. § 1328, or

(2) Upon completion of all Plan payments.

Value of collateral: ........................................................................................................ $_______________ Liens reducing equity (to which subject lien can attach): $_______________ + $_______________ + $_______________ = $) Exemption (only applicable for lien avoidance under 11 U.S.C. § 522(f)): …………….($) Wherefore, Debtor requests that this court issue an order granting the foregoing property valuation and/or lien avoidance of the above-listed creditor on the above-described collateral in the form Attachment B, C and/or D to this Plan, as applicable. (Debtor must use and attach a separate Attachment B, C and/or D which are also mandatory court forms for modification of each secured claim and lien.) Amount of remaining secured claim (negative results should be listed as $-0-): .......... $_______________ Note: See other parts of this Plan for the proposed treatment of any remaining secured claim (generally Class 3).

See attachment(s) for additional request(s) to modify secured claims and liens by this Plan.

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 14 F 3015-1.01.CHAPTER13.PLAN

D. Other Non-Standard Plan Provisions (use attachment, if necessary):

V. REVESTING OF PROPERTY

Property of the bankruptcy estate will not revest in Debtor until a discharge is granted or the case is dismissed or closed without discharge. Revesting will be subject to all liens and encumbrances in existence when the case was filed, except those liens avoided by court order or extinguished by operation of law. In the event the case is converted to a case under Chapter 7, 11, or 12 of the Bankruptcy Code, the property of the estate will vest in accordance with applicable law. After confirmation of this Plan, the Chapter 13 Trustee will not have any further authority or fiduciary duty regarding use, sale, or refinance of property of the estate except to respond to any motion for proposed use, sale, or refinance as required by the LBRs. Prior to any discharge or dismissal, Debtor must seek approval of the court to purchase, sell, or refinance real property.

By filing this document, the Attorney for Debtor, or Debtor if not represented by an attorney, also certify(ies) that the wording and order of the provisions in this Plan are identical to those contained in the Central District of California Chapter 13 Plan other than any nonstandard Plan provisions included in Section IV.

Date: _______________ Attorney for Debtor

Debtor 1

Debtor 2

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 15 F 3015-1.01.CHAPTER13.PLAN

ATTACHMENT A to Chapter 13 Plan/Confirmation Order (11 U.S.C. §§ 506: valuation/lien avoidance by separate motion(s))

None. If “None” is checked, the rest of this Attachment A need not be completed.

1. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 2nd Lien on 123 Main St.): ___________________________________________ ________________________________________________________________________________.

2. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 3rd Lien on 123 Main St.): ___________________________________________ ________________________________________________________________________________.

3. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 4th Lien on 123 Main St.): ___________________________________________ ________________________________________________________________________________.

4. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 2nd Lien on 456 Broadway): __________________________________________ ________________________________________________________________________________.

5. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 3rd Lien on 456 Broadway): __________________________________________ ________________________________________________________________________________.

6. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 4th Lien on 456 Broadway): __________________________________________ ________________________________________________________________________________.

7. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 2nd Lien on 789 Crest Ave.): __________________________________________ ________________________________________________________________________________.

8. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 3rd Lien on 789 Crest Ave.): __________________________________________ ________________________________________________________________________________.

9. Creditor Lienholder/Servicer: ___________________________________________________________. Subject Lien (e.g., 4th Lien on 789 Crest Ave.): __________________________________________ ________________________________________________________________________________.

(Attach additional pages for more liens/provisions.)

CERTIFICATION: I have prepared this attachment (including any additional pages) for use by the Chapter 13 Trustee. I certify under penalty of perjury under the laws of the United States of America that the information provided in this attachment is accurate to the best of my knowledge after reasonable inquiry, and I acknowledge that the Chapter 13 Trustee has no duty to verify the accuracy of that information.

Executed on (date) ________________

Printed Name ___________________________________ Signature: _______________________________________ Attorney for Debtor or Debtor appearing without attorney

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

April 2019 Page 16 F 3015-1.01.CHAPTER13.PLAN

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: ____________________DistrictDistrictof __________of __________

Case number ___________________________________________ (If known)

Official Form 101B Statement About Payment of an Eviction Judgment Against You 12/15

Fill out this form only if: you filed Initial Statement About an Eviction Judgment Against You (Official Form 101A); and you served a copy of Form 101A on your landlord; and you want to stay in your rented residence for more than 30 days after you file your Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101).

File this form within 30 days after you file your Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101). Also serve a copy on your landlord within that same time period.

Certification About Applicable Law and Payment of Eviction Judgment

I certify under penalty of perjury that (Check all that apply):

Under the state or other nonbankruptcy law that applies to the judgment for possession (eviction
judgment), I have the right to stay in my residence by paying my landlord the entire delinquent amount.

Within 30 days after I filed my Voluntary Petition for Individuals Filing for Bankruptcy (Official
Form 101), I have paid my landlord the entire amount I owe as stated in the judgment for possession
(eviction judgment).

____________________________________________ ____________________________________________
Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY

You must serve your landlord with a copy of this form.

Check the Bankruptcy Rules (www.uscourts.gov/rulesandpolicies/rules.aspx) and the court’s local website (go to http://www.uscourts.gov/Court_Locator.aspx to find your court’s website) for any specific requirements that you might have to meet to serve this statement.

Official Form 101B Statement About Payment of an Eviction Judgment Against You Print Save As... Reset

UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA

In re: CASE NUMBER:

DEBTOR’S REQUEST TO ACTIVATE ELECTRONIC NOTICING (DeBN) Debtor(s).

Debtor Electronic Bankruptcy Noticing (DeBN) is a voluntary program that enables a debtor to receive by email the orders and court-generated notices normally sent by U.S. mail to a mailing address. A debtor must complete and file this form with the court to activate a DeBN account. Joint debtors must each complete and file a separate form.

ACTIVATION REQUEST

Pursuant to Federal Rule of Bankruptcy Procedure 9036, I request that the court deliver orders and court-generated notices to my email address rather than by U.S. mail to my mailing address.

DEBTOR’S NAME AND EMAIL ADDRESS

My name is: My email address is: (CAPITAL letters only) Confirm email address: (CAPITAL letters only) Select one: I am the Debtor in this bankruptcy case. The Debtor in this bankruptcy case is a corporation, partnership, or other legal entity, and I am the authorized representative.

DEBTOR’S SIGNATURE

1. I understand that my request is limited to the email delivery of only orders and court-generated notices that are filed

by the U.S. Bankruptcy Court. Documents filed by a bankruptcy trustee, creditors, and other parties that require service upon me must continue to be served by U.S. mail or in person as required by court rules. 2. I understand that by requesting email notification, the court may establish my DeBN account and deliver to me, by email, documents filed by the court in any current or future case from any bankruptcy court in which I am listed with the same name and mailing address, including cases in which I am a creditor, plaintiff or defendant. 3. I understand that I will be assigned a DeBN account number and my DeBN account will be activated after I complete, sign, and file this “Debtor’s Request to Activate Electronic Noticing (DeBN)” form. 4. I understand that emails sent by the court's noticing center may arrive in my email spam folder and I should regularly check it for electronic delivery of my orders and court-generated notices. I understand further that my DeBN account will be deactivated by the court if an email is returned undelivered or “bounces back,” and the court will instead serve orders and court-generated notices delivered by U.S. mail to my mailing address. I have read and understand the requirements set forth above and I agree to the terms and conditions of the Debtor Electronic Bankruptcy Noticing (DeBN) program. I request delivery of orders and court-generated notices to my email address indicated above rather than to my mailing address.

Date: Signature:

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

June 2018 F 9036-1.1.DeBN.ACTIVATE