CACB — Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy (207)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/207.pdf

Fill in this information to identify the case:

Debtor name __________________________________________________________________ United States Bankruptcy Court for the: ______________________Central District of California District of _________ (State) Case number (If known): _________________________

Check if this is an amended filing

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy 04/25

The debtor must answer every question. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write the debtor’s name and case number (if known).

Part 1: Income

1. Gross revenue from business

None

Identify the beginning and ending dates of the debtor’s fiscal year, which Sources of revenue Gross revenue
may be a calendar year Check all that apply (before deductions and
exclusions)
From the beginning of the Operating a business
fiscal year to filing date: From ___________ to Filing date Other _______________________ $________________
MM / DD / YYYY

For prior year: From ___________ to ___________ Operating a business
MM / DD / YYYY MM / DD / YYYY $________________ Other _______________________

For the year before that: From ___________ to ___________ Operating a business
MM / DD / YYYY MM / DD / YYYY Other _______________________ $________________

2. Non-business revenue
Include revenue regardless of whether that revenue is taxable. Non-business income may include interest, dividends, money collected
from lawsuits, and royalties. List each source and the gross revenue for each separately. Do not include revenue listed in line 1.

None

Description of sources of revenue Gross revenue from each
source
(before deductions and
exclusions)

From the beginning of the
___________________________ $________________ fiscal year to filing date: From ___________ to Filing date
MM / DD / YYYY

For prior year: From ___________ to ___________
MM / DD / YYYY MM / DD / YYYY ___________________________ $________________

For the year before that: From ___________ to ___________
MM / DD / YYYY MM / DD / YYYY ___________________________ $________________

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 1

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Part 2: List Certain Transfers Made Before Filing for Bankruptcy

3. Certain payments or transfers to creditors within 90 days before filing this case List payments or transfersincluding expense reimbursementsto any creditor, other than regular employee compensation, within 90 days before filing this case unless the aggregate value of all property transferred to that creditor is less than $8,575. (This amount may be adjusted on 4/01/28 and every 3 years after that with respect to cases filed on or after the date of adjustment.)

None

Creditor’s name and address Dates Total amount or value Reasons for payment or transfer
Check all that apply
3.1.
Secured debt __________________________________________ ________ $_________________
Creditor’s name Unsecured loan repayments
__________________________________________
Street ________ Suppliers or vendors
__________________________________________ Services
__________________________________________ ________ Other _______________________________ City State ZIP Code

3.2.
Secured debt __________________________________________ ________ $_________________
Creditor’s name Unsecured loan repayments
__________________________________________
Street ________ Suppliers or vendors
__________________________________________ Services
__________________________________________ ________ Other _______________________________ City State ZIP Code

4. Payments or other transfers of property made within 1 year before filing this case that benefited any insider
List payments or transfers, including expense reimbursements, made within 1 year before filing this case on debts owed to an insider or
guaranteed or cosigned by an insider unless the aggregate value of all property transferred to or for the benefit of the insider is less than
$8,575. (This amount may be adjusted on 4/01/28 and every 3 years after that with respect to cases filed on or after the date of adjustment.)
Do not include any payments listed in line 3. Insiders include officers, directors, and anyone in control of a corporate debtor and their relatives;
general partners of a partnership debtor and their relatives; affiliates of the debtor and insiders of such affiliates; and any managing agent of
the debtor. 11 U.S.C. § 101(31).

None

Insider’s name and address Dates Total amount or value Reasons for payment or transfer

4.1.

__________________________________________ _________ $__________________ ___________________________________________
Insider’s name
__________________________________________ _________ ___________________________________________
Street
__________________________________________ _________ ___________________________________________
__________________________________________
City State ZIP Code

Relationship to debtor

__________________________________________

4.2.

__________________________________________ _________ $__________________ ___________________________________________
Insider’s name
__________________________________________ _________ ___________________________________________
Street
__________________________________________ _________ ___________________________________________
__________________________________________
City State ZIP Code

Relationship to debtor

__________________________________________

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 2

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

5. Repossessions, foreclosures, and returns List all property of the debtor that was obtained by a creditor within 1 year before filing this case, including property repossessed by a creditor, sold at a foreclosure sale, transferred by a deed in lieu of foreclosure, or returned to the seller. Do not include property listed in line 6.

None

Creditor’s name and address Description of the property Date Value of property

5.1.

__________________________________________ ___________________________________________ ______________ $___________
Creditor’s name
__________________________________________ ___________________________________________
Street
__________________________________________ ___________________________________________
__________________________________________
City State ZIP Code

5.2.

__________________________________________ ___________________________________________ _______________ $___________
Creditor’s name
__________________________________________ ___________________________________________
Street
__________________________________________ ___________________________________________
__________________________________________
City State ZIP Code

6. Setoffs

List any creditor, including a bank or financial institution, that within 90 days before filing this case set off or otherwise took anything from an account of
the debtor without permission or refused to make a payment at the debtor’s direction from an account of the debtor because the debtor owed a debt.

None

Creditor’s name and address Description of the action creditor took Date action was Amount
taken

__________________________________________ ___________________________________________ _______________ $___________
Creditor’s name
__________________________________________ ___________________________________________
Street

__________________________________________
Last 4 digits of account number: XXXX– __ __ __ __ __________________________________________
City State ZIP Code

Part 3: Legal Actions or Assignments

7. Legal actions, administrative proceedings, court actions, executions, attachments, or governmental audits List the legal actions, proceedings, investigations, arbitrations, mediations, and audits by federal or state agencies in which the debtor was involved in any capacity—within 1 year before filing this case.

   None Case title Nature of case Court or agency’s name and address Status of case 7.1. Pending _________________________________ ______________________________ __________________________________________ Name On appeal __________________________________________ Case number Street Concluded __________________________________________ _________________________________ __________________________________________ City State ZIP Code
   Case title Court or agency’s name and address Pending 7.2. _________________________________ ______________________________ __________________________________________ On appeal Name Concluded Case number __________________________________________ Street __________________________________________ _________________________________ __________________________________________ City State ZIP Code

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 3

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

8. Assignments and receivership

   List any property in the hands of an assignee for the benefit of creditors during the 120 days before filing this case and any property in the hands of a receiver, custodian, or other court-appointed officer within 1 year before filing this case.

None

Custodian’s name and address Description of the property Value

__________________________________________ ______________________________________ $_____________
Custodian’s name
Case title Court name and address
__________________________________________
Street
______________________________________ __________________________________________
__________________________________________ Name
__________________________________________ Case number __________________________________________
City State ZIP Code Street

______________________________________ __________________________________________
Date of order or assignment __________________________________________
City State ZIP Code

______________________________________

Part 4: Certain Gifts and Charitable Contributions

9. List all gifts or charitable contributions the debtor gave to a recipient within 2 years before filing this case unless the aggregate value of the gifts to that recipient is less than $1,000

None

Recipient’s name and address Description of the gifts or contributions Dates given Value

9.1. __________________________________________ ___________________________________________ _________________ $__________
Recipient’s name
__________________________________________ ___________________________________________
Street

__________________________________________

__________________________________________
City State ZIP Code

Recipient’s relationship to debtor

__________________________________________

__________________________________________ ___________________________________________ _________________ $__________ 9.2. Recipient’s name __________________________________________ ___________________________________________ Street

__________________________________________

__________________________________________
City State ZIP Code

Recipient’s relationship to debtor

__________________________________________

Part 5: Certain Losses

10. All losses from fire, theft, or other casualty within 1 year before filing this case.

None

Description of the property lost and how the loss Amount of payments received for the loss Date of loss Value of property
occurred If you have received payments to cover the loss, for lost
example, from insurance, government compensation, or
tort liability, list the total received.
List unpaid claims on Official Form 106A/B (Schedule A/B:
Assets – Real and Personal Property).

___________________________________________ ___________________________________________ _________________ $__________

___________________________________________

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 4

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Part 6: Certain Payments or Transfers

11. Payments related to bankruptcy List any payments of money or other transfers of property made by the debtor or person acting on behalf of the debtor within 1 year before the filing of this case to another person or entity, including attorneys, that the debtor consulted about debt consolidation or restructuring, seeking bankruptcy relief, or filing a bankruptcy case.

None

Who was paid or who received the transfer? If not money, describe any property transferred Dates Total amount or
value

__________________________________________
11.1. ___________________________________________
______________ $_________
Address
___________________________________________

__________________________________________
Street

__________________________________________

__________________________________________
City State ZIP Code

Email or website address

_________________________________

Who made the payment, if not debtor?

__________________________________________

Who was paid or who received the transfer? If not money, describe any property transferred Dates Total amount or
value

11.2. __________________________________________ ___________________________________________ ______________ $_________

Address ___________________________________________
__________________________________________
Street

__________________________________________

__________________________________________
City State ZIP Code

Email or website address

__________________________________________

Who made the payment, if not debtor?

__________________________________________

12. Self-settled trusts of which the debtor is a beneficiary

List any payments or transfers of property made by the debtor or a person acting on behalf of the debtor within 10 years before the filing of this case to a self-settled trust or similar device. Do not include transfers already listed on this statement. None

Name of trust or device Describe any property transferred Dates transfers Total amount or
were made value

__________________________________________ ___________________________________________ ______________ $_________

Trustee ___________________________________________

__________________________________________

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 5

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

13. Transfers not already listed on this statement List any transfers of money or other propertyby sale, trade, or any other meansmade by the debtor or a person acting on behalf of the debtor within 2 years before the filing of this case to another person, other than property transferred in the ordinary course of business or financial affairs. Include both outright transfers and transfers made as security. Do not include gifts or transfers previously listed on this statement.

None

Who received transfer? Description of property transferred or payments received Date transfer Total amount or
or debts paid in exchange was made value

13.1. __________________________________________ ___________________________________________ ________________ $_________

___________________________________________
Address

__________________________________________
Street

__________________________________________

__________________________________________
City State ZIP Code

Relationship to debtor

__________________________________________

Who received transfer?
___________________________________________ ________________ $_________

13.2. __________________________________________ ___________________________________________

Address

__________________________________________
Street

__________________________________________

__________________________________________
City State ZIP Code

Relationship to debtor

__________________________________________

Part 7: Previous Locations

14. Previous addresses List all previous addresses used by the debtor within 3 years before filing this case and the dates the addresses were used.

Does not apply

Address Dates of occupancy

14.1. _______________________________________________________________________ From ____________ To ____________
Street

_______________________________________________________________________

_______________________________________________________________________
City State ZIP Code

14.2. _______________________________________________________________________ From ____________ To ____________
Street

---

_______________________________________________________________________
City State ZIP Code

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 6

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Part 8: Health Care Bankruptcies

15. Health Care bankruptcies Is the debtor primarily engaged in offering services and facilities for: diagnosing or treating injury, deformity, or disease, or providing any surgical, psychiatric, drug treatment, or obstetric care?

No. Go to Part 9. Yes. Fill in the information below.

Facility name and address Nature of the business operation, including type of services the If debtor provides meals
debtor provides and housing, number of
patients in debtor’s care

15.1. ________________________________________ ___________________________________________________________ ____________________
Facility name
____________________________________________________________

________________________________________
Street Location where patient records are maintained (if different from facility How are records kept?
address). If electronic, identify any service provider.
________________________________________
Check all that apply:
____________________________________________________________
________________________________________ Electronically City State ZIP Code ____________________________________________________________
Paper

Facility name and address Nature of the business operation, including type of services the If debtor provides meals
debtor provides and housing, number of
patients in debtor’s care

15.2. ________________________________________ ___________________________________________________________ ____________________
Facility name
___________________________________________________________

---

Street Location where patient records are maintained (if different from facility How are records kept?
address). If electronic, identify any service provider.
________________________________________
Check all that apply:
____________________________________________________________
________________________________________ Electronically City State ZIP Code ____________________________________________________________
Paper

Part 9: Personally Identifiable Information

16. Does the debtor collect and retain personally identifiable information of customers?

No. Yes. State the nature of the information collected and retained. ___________________________________________________________________ Does the debtor have a privacy policy about that information? No Yes

17. Within 6 years before filing this case, have any employees of the debtor been participants in any ERISA, 401(k), 403(b), or other pension or profit-sharing plan made available by the debtor as an employee benefit?

No. Go to Part 10. q Yes. Does the debtor serve as plan administrator? No. Go to Part 10. Yes. Fill in below: Name of plan Employer identification number of the plan

_______________________________________________________________________ EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Has the plan been terminated?
No
Yes

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 7

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Part 10: Certain Financial Accounts, Safe Deposit Boxes, and Storage Units

18. Closed financial accounts Within 1 year before filing this case, were any financial accounts or instruments held in the debtor’s name, or for the debtor’s benefit, closed, sold, moved, or transferred? Include checking, savings, money market, or other financial accounts; certificates of deposit; and shares in banks, credit unions, brokerage houses, cooperatives, associations, and other financial institutions.

None

Financial institution name and address Last 4 digits of account Type of account Date account was Last balance
number closed, sold, moved, before closing or
or transferred transfer
18.1. ______________________________________ XXXX–___ ___ ___ ___ Checking ___________________ $__________
Name Savings
______________________________________
Street Money market
______________________________________ Brokerage
______________________________________
City State ZIP Code Other______________

18.2. ______________________________________ XXXX–___ ___ ___ ___ Checking ___________________ $__________
Name Savings
______________________________________
Street Money market
______________________________________ Brokerage
______________________________________
City State ZIP Code Other______________

19. Safe deposit boxes
List any safe deposit box or other depository for securities, cash, or other valuables the debtor now has or did have within 1 year before filing this case.

None

Depository institution name and address Names of anyone with access to it Description of the contents Does debtor still have it? ______________________________________ __________________________________ __________________________________ No Name Yes __________________________________ __________________________________ ______________________________________ Street __________________________________ __________________________________
______________________________________ ______________________________________ Address
City State ZIP Code ____________________________________

---

20. Off-premises storage List any property kept in storage units or warehouses within 1 year before filing this case. Do not include facilities that are in a part of a building in which the debtor does business.

None

Facility name and address Names of anyone with access to it Description of the contents Does debtor
still have it?
No
______________________________________ __________________________________ __________________________________ Yes Name
__________________________________ __________________________________ ______________________________________
Street __________________________________ __________________________________
______________________________________
______________________________________ Address
City State ZIP Code
________________________________

_________________________________

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 8

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Part 11: Property the Debtor Holds or Controls That the Debtor Does Not Own

21. Property held for another List any property that the debtor holds or controls that another entity owns. Include any property borrowed from, being stored for, or held in trust. Do not list leased or rented property.

None

Owner’s name and address Location of the property Description of the property Value

$_______
______________________________________ __________________________________ __________________________________
Name
__________________________________ __________________________________
______________________________________
Street __________________________________ __________________________________
______________________________________

______________________________________
City State ZIP Code

Part 12: Details About Environmental Information

For the purpose of Part 12, the following definitions apply:

Environmental law means any statute or governmental regulation that concerns pollution, contamination, or hazardous material, regardless of the medium affected (air, land, water, or any other medium).

Site means any location, facility, or property, including disposal sites, that the debtor now owns, operates, or utilizes or that the debtor formerly owned, operated, or utilized.

Hazardous material means anything that an environmental law defines as hazardous or toxic, or describes as a pollutant, contaminant, or a similarly harmful substance.

Report all notices, releases, and proceedings known, regardless of when they occurred.

22. Has the debtor been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders.

No Yes. Provide details below.

Case title Court or agency name and address Nature of the case Status of case

_________________________________ _____________________________________ __________________________________ Pending Case number Name On appeal __________________________________ _____________________________________ Concluded _________________________________ Street __________________________________ _____________________________________
_____________________________________ City State ZIP Code

23. Has any governmental unit otherwise notified the debtor that the debtor may be liable or potentially liable under or in violation of an environmental law?

No Yes. Provide details below.

Site name and address Governmental unit name and address Environmental law, if known Date of notice

__________________________________ _____________________________________ __________________________________ __________
Name Name
__________________________________
__________________________________ _____________________________________
Street Street __________________________________
__________________________________ _____________________________________

__________________________________ _____________________________________
City State ZIP Code City State ZIP Code

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 9

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

24. Has the debtor notified any governmental unit of any release of hazardous material?

No Yes. Provide details below.

Site name and address Governmental unit name and address Environmental law, if known Date of notice

__________________________________ ______________________________________ __________________________________ __________
Name Name
__________________________________
__________________________________ ______________________________________
Street Street __________________________________
__________________________________ ______________________________________

__________________________________ ______________________________________
City State ZIP Code City State ZIP Code

Part 13: Details About the Debtor’s Business or Connections to Any Business

25. Other businesses in which the debtor has or has had an interest List any business for which the debtor was an owner, partner, member, or otherwise a person in control within 6 years before filing this case. Include this information even if already listed in the Schedules.

None

Business name and address Describe the nature of the business Employer Identification number
Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
25.1. __________________________________ _____________________________________________
Name Dates business existed
_____________________________________________
__________________________________
Street _____________________________________________
__________________________________ From _______ To _______
__________________________________
City State ZIP Code

Business name and address Describe the nature of the business Employer Identification number
25.2. Do not include Social Security number or ITIN.

__________________________________ _____________________________________________ EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___ Name Dates business existed _____________________________________________ __________________________________ Street _____________________________________________ __________________________________ From _______ To _______ __________________________________ City State ZIP Code

Business name and address Describe the nature of the business Employer Identification number
Do not include Social Security number or ITIN.

25.3. __________________________________ _____________________________________________ EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
Name
_____________________________________________ Dates business existed
__________________________________
Street _____________________________________________
__________________________________
From _______ To _______ __________________________________
City State ZIP Code

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 10

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

26. Books, records, and financial statements
26a. List all accountants and bookkeepers who maintained the debtor’s books and records within 2 years before filing this case.
None

Name and address Dates of service

From _______ To _______
26a.1. __________________________________________________________________________________
Name

__________________________________________________________________________________
Street

__________________________________________________________________________________

__________________________________________________________________________________
City State ZIP Code

Name and address Dates of service

From _______ To _______
26a.2. __________________________________________________________________________________
Name

__________________________________________________________________________________
Street

__________________________________________________________________________________

__________________________________________________________________________________
City State ZIP Code

26b. List all firms or individuals who have audited, compiled, or reviewed debtor’s books of account and records or prepared a financial
statement within 2 years before filing this case.
None

Name and address Dates of service

From _______ To _______
26b.1. ______________________________________________________________________________
Name

______________________________________________________________________________
Street

______________________________________________________________________________

______________________________________________________________________________
City State ZIP Code

Name and address Dates of service

From _______ To _______ 26b.2. ______________________________________________________________________________ Name

______________________________________________________________________________
Street

______________________________________________________________________________

______________________________________________________________________________
City State ZIP Code

26c. List all firms or individuals who were in possession of the debtor’s books of account and records when this case is filed.
None
If any books of account and records are Name and address
unavailable, explain why

26c.1. ______________________________________________________________________________ _________________________________________
Name
_________________________________________
______________________________________________________________________________
Street _________________________________________
______________________________________________________________________________

______________________________________________________________________________
City State ZIP Code

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 11

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

If any books of account and records are Name and address
unavailable, explain why

26c.2. ______________________________________________________________________________ _________________________________________
Name
_________________________________________
______________________________________________________________________________
Street _________________________________________
______________________________________________________________________________

______________________________________________________________________________
City State ZIP Code

26d. List all financial institutions, creditors, and other parties, including mercantile and trade agencies, to whom the debtor issued a financial statement
within 2 years before filing this case.

None

Name and address

26d.1. ______________________________________________________________________________
Name

______________________________________________________________________________
Street

______________________________________________________________________________

______________________________________________________________________________
City State ZIP Code

Name and address

26d.2. ______________________________________________________________________________
Name

______________________________________________________________________________
Street

______________________________________________________________________________

______________________________________________________________________________
City State ZIP Code

27. Inventories

Have any inventories of the debtor’s property been taken within 2 years before filing this case?

No Yes. Give the details about the two most recent inventories.

Name of the person who supervised the taking of the inventory Date of The dollar amount and basis (cost, market, or inventory other basis) of each inventory

______________________________________________________________________ _______ $___________________

Name and address of the person who has possession of inventory records

27.1. ______________________________________________________________________
Name

______________________________________________________________________
Street

______________________________________________________________________

______________________________________________________________________
City State ZIP Code

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 12

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Name of the person who supervised the taking of the inventory Date of The dollar amount and basis (cost, market, or
inventory other basis) of each inventory

______________________________________________________________________ _______ $___________________

Name and address of the person who has possession of inventory records

27.2. ______________________________________________________________________
Name

______________________________________________________________________
Street

______________________________________________________________________

______________________________________________________________________
City State ZIP Code

28. List the debtor’s officers, directors, managing members, general partners, members in control, controlling shareholders, or other
people in control of the debtor at the time of the filing of this case.

Name Address Position and nature of any % of interest, if any
interest

____________________________ _____________________________________________ ____________________________ _______________

____________________________ _____________________________________________ ____________________________ _______________

____________________________ _____________________________________________ ____________________________ _______________

____________________________ _____________________________________________ ____________________________ _______________

____________________________ _____________________________________________ ____________________________ _______________

29. Within 1 year before the filing of this case, did the debtor have officers, directors, managing members, general partners, members in control
of the debtor, or shareholders in control of the debtor who no longer hold these positions?

No Yes. Identify below.

Name Address Position and nature of Period during which
any interest position or interest was
held
____________________________ _____________________________________________ ______________________ From _____ To _____

____________________________ _____________________________________________ ______________________ From _____ To _____

____________________________ _____________________________________________ ______________________ From _____ To _____

____________________________ _____________________________________________ ______________________ From _____ To _____

30. Payments, distributions, or withdrawals credited or given to insiders

Within 1 year before filing this case, did the debtor provide an insider with value in any form, including salary, other compensation, draws,
bonuses, loans, credits on loans, stock redemptions, and options exercised?

No Yes. Identify below.

Name and address of recipient Amount of money or Dates Reason for
description and value of providing the value
property

30.1. ______________________________________________________________ _________________________ _____________ ____________
Name

______________________________________________________________
Street _____________

______________________________________________________________
______________________________________________________________ _____________
City State ZIP Code

Relationship to debtor _____________

______________________________________________________________ _____________

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 13

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Name and address of recipient
__________________________ _____________ ______________

30.2 ______________________________________________________________
Name _____________

______________________________________________________________
Street _____________

______________________________________________________________
______________________________________________________________ _____________
City State ZIP Code

Relationship to debtor _____________

______________________________________________________________

31. Within 6 years before filing this case, has the debtor been a member of any consolidated group for tax purposes?

No Yes. Identify below.

Name of the parent corporation Employer Identification number of the parent
corporation

______________________________________________________________ EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

32. Within 6 years before filing this case, has the debtor as an employer been responsible for contributing to a pension fund?

No Yes. Identify below.

Name of the pension fund Employer Identification number of the pension fund

______________________________________________________________ EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Part 14: Signature and Declaration

WARNING -- Bankruptcy fraud is a serious crime. 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 $500,000 or imprisonment for up to 20 years, or both.
18 U.S.C. §§ 152, 1341, 1519, and 3571.

I have examined the information in this Statement of Financial Affairs and any attachments and have a reasonable belief that the information
is true and correct.

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

Executed on _________________
MM / DD / YYYY

Printed name _________________________________________________ ___________________________________________________________ Signature of individual signing on behalf of the debtor

Position or relationship to debtor ____________________________________

Are additional pages to Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy (Official Form 207) attached? No Yes

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy page 14