CASB — Chapter 11 petition package

Source: https://www.casb.uscourts.gov/sites/casb/files/Ch11IndPetPkg_2024-01-19.pdf

UNITED STATES BANKRUPTCY COURT

SOUTHERN DISTRICT OF CALIFORNIA

CHAPTER 11

PETITION PACKAGE

All Forms for Individuals Filing

a Chapter 11 Bankruptcy Case

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

January 2024 Chapter 11 Individual Petition Package

Preparing and Filing a Chapter 11 Individual Bankruptcy Case [Checklist 1]

To file a chapter 11 individual bankruptcy case in the Southern District of California, debtors must comply with the below requirements.

Pursuant to LBR 1007-5 regarding Payment Advices, the debtor must submit the evidence of payment required by FRBP 1007(b)(1)(E) to the chapter 7,12. Or 13 trustee assigned to the debtor’s case or to the U.S. Trustee in a chapter 11 case, preferably through the EDOC System. A debtor should not file this evidence with the Court.

At a minimum, the following documents must be filed to initiate your Bankruptcy Case:

101 - Voluntary Petition
o If you rent your residence and answered yes to question #11 “Has your
landlord obtained an eviction judgment against you?,” you must
include the 101A-Initial Statement About an Eviction Judgment
Against You with your petition.

104 – List of Creditors Holding 20 Largest Unsecured Claims

121 - Statement of Social Security Numbers

List of Creditors [see page 10]

Full filing fee or

o CSD 1006 – Application to Pay Filing Fees in Installment (File this
document only if you are requesting to pay your filing fee in installments.)

Certificate of Credit Counseling or

o If you checked the third button in Step 15 “I certify that I asked for
credit counseling services from an approved agency, but was unable to
obtain those services during the 7 days after I made my request ..,” file
CSD 1025 – Statement of Exigent Circumstances & Request for
Extension of Time to File Certificate of Credit Counseling
or
o If you checked the fourth button in Step 15 “I am not required to
receive a briefing about credit counseling because of:”, file CSD1027
– Notice of Motion for Exemption and Opportunity of Hearing re: Credit
Counseling

January 2024 Chapter 11 Individual Petition Package

CSD 1013 [11/28/17] UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991

HAVE YOU COMPLETED CREDIT COUNSELING?

Use of a U.S. Trustee Approved Agency required. [11 U.S.C. § 109(h)]

READ THIS BEFORE YOU FILE YOUR CASE

If you have not completed counseling before you file your petition and you do not meet the

requirements for an extension to complete the counseling after filing:

• Your case may be DISMISSED without refund of any filing fee paid; • You WILL NOT receive a DISCHARGE of your debts; and • If you REFILE within ONE YEAR after dismissal, protection under the Bankruptcy Code from your creditors (i.e., the automatic stay) may be limited to thirty days.

Under the bankruptcy laws, the court can allow you to complete the course after filing only if you

meet all of the following conditions. See 11 U.S.C. § 109(h)(3).

1) Prior to filing your petition, you must have requested credit counseling services from a
U.S. Trustee approved agency but were unable to obtain the services during the 5-day
period following your request.
2) There are exigent (emergency) circumstances that make it necessary for you to file
your case immediately. (Important: The court will determine what qualifies as an
emergency circumstance.)
3) You must file a certification stating the facts regarding conditions 1) and 2) above with
your petition. Local Forms CSD 1025 and 1027 are available from the clerk.

The decision to file your petition is up to you but, if you file without taking the course, you are

risking dismissal of your case. The clerk cannot provide legal advice or predict how a judge will decide your motion for an extension of time to complete the credit counseling requirement.

To complete the requirement before filing your petition, obtain a list of United States Trustee

approved pre-bankruptcy credit counseling agencies from the clerk or go to this website: https://www.justice.gov/ust/list-credit-counseling-agencies-approved-pursuant-11-usc-111

You may take the course on the Internet, by telephone, or in person. If you do not have a

computer, your public library may allow you to use their public computers.

NOTE: A waiver of the credit counseling requirement is available in very limited circumstances for persons on military duty in an active combat zone, or persons with a physical or mental impairment preventing participation in credit counseling, in person, by telephone, or on the Internet. A waiver must be granted by the court. 11 U.S.C. § 109(h)(4).

CSD 1013

Table of Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Preparation for Individuals Filing a Chapter 11 Bankruptcy Case. . . . . . . . . . . . . 2

1. Credit Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. Chapter 11 Filing Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3. Mailing Your Chapter 11 Bankruptcy Case/Required Copies. . . . . . . . . 3

4. Required Government-Issued Photo Identification . . . . . . . . . . . . . . . . 3

5. Common Causes for Dismissal of Debtor in a Bankruptcy Case . . . . . 4

6. Requirement of a Copy of Judgment for Possession with 101 Petition
and a Rent Deposit (LBR 4001.8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

7. Notice Required by 11 U.S.C.§342(b) for Individuals Filing for Bankruptcy 6

8. Creating a Creditor Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Introduction

This Chapter 11 Petition Package for individual debtors includes the basic information and forms required to file a voluntary chapter 11 bankruptcy case in the Southern District of California. Since bankruptcy is a complex process, debtors considering filing a chapter 11 bankruptcy case are encouraged to consult with a bankruptcy attorney.

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

This petition package, including all of the forms in this package, are available for free on the Court’s website www.casb.uscourts.gov (click on Court Forms). 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. If you complete the fillable forms on your computer and do not have Adobe Acrobat Writer, you must print the completed forms before closing the document. If you do not do this, the information that you typed will be lost.

January 2024 Chapter 11 Individual Petition Package Page 1

Preparation for Filing a Chapter 11 Individual Bankruptcy Case Before filing a Chapter 11 Individual Bankruptcy Case, read the below requirements and filing tips.

1. Debtors must complete Credit Counseling. If you have not completed counseling before you file your petition, and you do not meet the requirements for an extension to complete the counseling after filing:

   • Your case may be DISMISSED without refund of any filing fee paid;

   • You WILL NOT receive a DISCHARGE of your debts; and

   • If you REFILE within ONE YEAR after dismissal, protection under the
   Bankruptcy Code from your creditors (i.e., the automatic stay) may be limited
   to thirty days.

   Under the bankruptcy laws, the court can allow you to complete the course after filing only if you meet all of the following conditions. See 11 U.S.C. § 109(h)(3).

   1. Prior to filing your petition, you must have requested credit counseling services from a U.S. Trustee approved agency but were unable to obtain the services during the 5-day period following your request.
   2. There are exigent (emergency) circumstances that make it necessary for you to file your case immediately. (Important: The court will determine what qualifies as an emergency circumstance.)
   3. You must file a certification stating the facts regarding conditions 1) and 2) above with your petition. Local Forms CSD 1025 (Statement of Exigent Circumstances & Request for Extension of Time to file Certificate of Credit Counseling) and 1027 (Notice of Motion for Exemption and Opportunity for Hearing re: Credit Counseling) are attached.

   The decision to file your petition is up to you but, if you file without taking the course, you are risking dismissal of your case. The clerk cannot provide legal advice or predict how a judge will decide your motion for an extension of time to complete the credit counseling requirement. To complete the requirement before filing your petition, obtain a list of United States Trustee approved pre-bankruptcy credit counseling agencies from the clerk or go to this website: http://www.justice.gov/ust/eo/bapcpa/ccde/cc_approved.htm You may take the course on the Internet, by telephone, or in person. If you do not have a computer, your public library may allow you to use their public computers.

   NOTE: A waiver of the credit counseling requirement is available in very limited circumstances for persons on military duty in an active combat zone, or persons with a physical or mental impairment preventing participation in credit counseling, in person, by telephone, or on the Internet. A waiver must be granted by the court. 11 U.S.C. § 109(h)(4).

January 2024 Chapter 11 Individual Petition Package Page 2

2. Debtors must pay the chapter 11 filing fee (see page 7) at the time of filing. The court accepts cash (exact change), U.S. Postal Service money orders, or cashier’s checks issued by an acceptable financial institution. Make cashier’s checks or money orders payable to: “Clerk, US Bankruptcy Court.” If you are unable to pay the full filing payment, you have the following option:

   • Pay your filing fee in installments, which requires the form CSD 1006: Application to Pay Filing Fees in Installments, to be filed with your petition.

3. If you mail your documents to be filed, please include a self-addressed envelope with sufficient postage so that we can return a copy to you. Our address is: United States Bankruptcy Court, 325 West F Street, San Diego, CA 92101.You must submit one original set. If you would like a stamped copy, bring or mail a copy along with the original. Be sure that you make an additional copy of each document for your records. Remember to sign all of your documents.

4. Government-issued photo identification is required for persons filing a petition without attorney representation. The Bankruptcy Court for the Southern District of California has implemented a policy requiring all debtors who are not represented by an attorney (“pro se”), to provide a copy of current government issued photo identification. This policy also applies to persons who bring pro se petitions to the intake counter for filing.

   • Filing in person: When a petition is presented at the counter for filing, the person presenting the petition must provide a current government issued photo identification. A copy of the identification will be made for retention, but will not be accessible as part of the public record.

   • Filing by mail: A photocopy of the debtor(s)’ government issued photo identification is required with the petition. If the government issued photocopy is not provided, a deficiency will be noted and the case, if filed, may be subject to dismissal.

   Acceptable Forms of Government Issued Identification (must be current, legible and contain a photograph): 1. State issued Driver’s License 2. U.S. Government Passport 3. State or Federal Issued Identification Card 4. Federal, State or Local Government Issued Employee Identification Card 5. Military Photo Identification Card 6. Or other form of Government Issued Photo Identification

January 2024 Chapter 11 Individual Petition Package Page 3

5. Common Causes for Dismissal Pertaining to Debtor Responsibilities/Deadlines in a Bankruptcy Case

   • FAILURE TO OBTAIN CREDIT COUNSELING – Credit counseling must be completed by each individual consumer debtor within 180 days prior to filing for bankruptcy through an Approved Credit Counseling Agency. The U.S. Trustee’s Office listing of Approved Credit Counseling Agencies for the Southern District of California is available at the following website: http://www.justice.gov/ust/eo/bapcpa/ccde/cc_approved.htm

   • FAILURE TO FILE COMPLETE SCHEDULES, STATEMENTS AND/OR CHAPTER 13 PLAN- Regardless of chapter, certain schedules must be completed and filed with the petition or within 14 days of filing the petition.

   • FAILURE TO PAY FILING FEES – Be prepared to pay the required Filing Fee in full at the time you file the petition. Filing fees can be found at www.casb.uscourts.gov. Fees must be paid in cash (exact change only), cashier’s check or money orders. (Personal checks will not be accepted). It is possible to make payments in installments using Form CSD 1006. If a fee is to be paid in installments, you must be an individual and must submit a signed application for the Court to consider. The signed application must state that you are unable to pay the filing fee, except in installments.

   • FAILURE TO FILE – Chapter 11 individual debtor(s) Form 122B: Chapter 11 Statement of Current Monthly Income. To ensure that this form is filled out correctly, review the Chapter 11 Statement of Your Currently Monthly Income Instructions (see page 13).

   • FAILURE TO FILE STATEMENT OF SOCIAL SECURITY NUMBER (Form 121) – Debtor(s) must provide the Statement of Social Security at the time of filing.

   • FAILURE TO ATTEND THE MEETING OF CREDITORS – The debtor is required to be in attendance at the Meeting of Creditors (‘341 meeting’) to give the trustee and/or creditors an opportunity to examine the debtor under oath concerning property and financial affairs.

January 2024 Chapter 11 Individual Petition Package Page 4

6. Requirement of a Copy of Judgment for Possession with 101 Petition and a Rent Deposit (Local Bankruptcy Rule 4001.8) a) Any rent Any rent deposited with the Clerk pursuant to 11 U.S.C. § 362(l)(1)(B) must be in the form of a certified or cashier’s check or money order payable to the lessor or landlord in the full amount of any rent that would become due during the 30-day period following the filing of the Petition. b) The debtor must deposit rent with the Clerk on the Petition Date. A copy of the judgment for possession must accompany the rent deposit and the Petition. The Clerk is directed to refuse any rent check not accompanied by a copy of the judgment for possession. c) The debtor should use the Court-approved form CSD 1033, to meet the certification, filing, and service requirements of 11 U.S.C. § 362(l)(2). d) Pursuant to 11 U.S.C. § 362(l)(5)(D), the Clerk will transmit the payment to the lessor at the address listed in the section on page 2 of the Petition entitled "Statement by a Debtor Who Resides as a Tenant of Residential Property." e) 11 U.S.C. § 362(l)(1) and (2) are inapplicable to post-foreclosure judgments for possession, and the Clerk will not accept deposits tendered in connection with post-foreclosure judgments for possession.

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

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January 2024 Chapter 11 Petition Package for Individuals Page 7

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8. Creating a Creditor Matrix (List of Creditors)

When you file a voluntary petition under any bankruptcy chapter, you the debtor (or your attorney, if you use one) must prepare and submit to the Court a mailing list called the creditor matrix, which is a list of creditors to whom you owe money. This mailing list contains all of your creditors’ and/or equity security holders’ name(s) and addresses.

This list must be submitted in an electronic format, using a computer and word- processing software. If you are unable to bring your creditor matrix on electronic media (such as a CD, DVD, or flash/thumb drive), you will be instructed to prepare your creditor matrix using the Court’s computers located in the file review area.

Do not include the debtor, joint debtor, U.S. Trustee, Internal Revenue Service, or Franchise Tax Board on the creditor matrix.

1. The creditor matrix list must be in a single column. Do not list names and address entries in multiple columns.

2. Each name and address entry may contain a maximum of four lines. Do not use all uppercase letters. Do not use bold or italic fonts. Do not use special characters ie: #,&,@.

3. Each line can be no more than 35 characters in length including spaces. The second line of each entry must be either a street address or a P.O. Box. The word P.O. must include periods. Do not include account numbers.

4. States must be two-letter abbreviations. Examples: CA for California, NY for New York.

5. ZIP codes must appear on the last line, following the city and state. Nine digit ZIP codes must contain a dash between the first five digits and the remaining four digits, not a space.

6. Each name and address entry must be separated by at least one blank line.

7. Certain federal and state agencies specify particular addresses to which notice of bankruptcy proceedings should be directed. The Court maintains CSD 1271- roster of State and Federal Agencies, which is available to the public on the Court Forms page of the Court’s Web site.

8. When listing a debt to the United States for other than taxes, the debtor shall include both the United States Attorney and the federal agency through which the debtor became indebted. The name and address of the United States Attorney must include the name of the federal agency in parentheses.

January 2024 Chapter 11 Individual Petition Package Page 10

Example: U.S. Attorney for the Southern District of CA (For Department of Education) 940 Front Street, Room 5152 San Diego, CA 92101-8800

When completed, save your creditor matrix in a text-format file with a .txt file extension. (This ensures that the creditor matrix can be uploaded to the Court’s CM/ECF system.)To save the file as a text file with a .txt file extension when using word-processing software:

1. Click on the File menu option, then select Save As.

2. A drop-down menu appears in your word-processing software. Name the file with your name (as debtor).

3. From the drop-down list, select the Plain Text (.txt) file type.

4. Click on the Save button to save the document to your computer.

5. Copy the .txt file to any electronic media.

   Example of Creditor Matrix Format

   Acme Auto Repair 1234 S Street San Diego, CA 92101

   Acme Hair Repair Attn Herman 1234 S Ave San Diego, CA 92101

January 2024 Chapter 11 Individual Petition Package Page 11

CSD 1006 [01/01/2023]

Name, Address, Telephone No. & I.D. No.

UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991

In Re

BANKRUPTCY NO.

Debtor.

APPLICATION FOR INDIVIDUALS TO PAY FILING FEES IN INSTALLMENTS

In accordance with FRBP 1006 and Local Rule 1006-4, application is made for permission to pay half the filing fee

at the time of filing with the balance of the fee in one final installment due within 30 days of petition file date (complete Part A by checking one of the four options). If you are unable to pay the first installment payment at time of filing, please complete Part B.

Part A:
Chapter 7 (payment of $169.00) Chapter 13 (payment of $156.50)
Chapter 11 (payment of $869.00) Chapter 12 (payment of $139.00)
Part B:
I propose to pay $0.00 with the petition, and pay the first installment (see fees above) 7 days from petition filing
date.
I will make my final payment of $ on or before 30 days from petition filing date.

I certify that I am unable to pay the filing fee except in installments and I understand the following:

I must pay my entire fee before I make any more payments or transfer any more property to an attorney, bankruptcy

petition preparer, or anyone else for services in connection with my bankruptcy case. I must pay the entire fee no later than 30 days after I first file for bankruptcy, unless the court later extends my deadline. My debts will not be discharged until my entire fee is paid. If I do not make my payment when it is due, my bankruptcy case may be dismissed, and my rights in other bankruptcy proceedings may be affected.

---

Signature of Debtor 1 Signature of Debtor 2 Signature of Attorney Dated: Dated: Dated:

If this document is prepared by a Non-Attorney Bankruptcy Petition Preparer,

Official Form 119, Bankruptcy Petition Preparer’s Notice, Declaration, and Signature, must be completed and submitted with this Application.

Form of payment: Cash, pay.gov, money orders, or certified checks only; please do not mail cash. Personal checks of the debtor will not be accepted.

CSD 1025 [12/01/15] Name, Address, Telephone No. & I.D. No.

UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991

In Re

BANKRUPTCY NO.

Debtor.

STATEMENT OF EXIGENT CIRCUMSTANCES AND REQUEST FOR EXTENSION OF TIME TO FILE CERTIFICATE OF CREDIT COUNSELING PURSUANT TO 11 U.S.C. § 109(h)(3)

The debtor(s) declare under penalty of perjury that the following exigent circumstances exist which have prevented

me from obtaining budget and credit counseling within the 180-day period prior to the filing of my bankruptcy petition.

Those circumstances include (provide a detailed explanation in the space provided below)

I further declare that I requested credit counseling services from:

an approved nonprofit budget and credit counseling agency,

on , but was unable to obtain the services during the 7-day period following my request. (date)

I understand that this initial counseling does not replace or waive the necessity to complete a course concerning

personal financial management. I understand that I must file a Certification About a Financial Management Course (Official Form 423) no later than 45 days from (1) the first date set for the first meeting of creditors under § 341 in order to receive a chapter 7 discharge or (2) if a chapter 13 debtor, no later than the last payment made as required by my chapter 13 plan or the filing of a motion for entry of a discharge under § 1328(b) in my chapter 13 case.

I request that I be granted an extension of 30 days from the date of the filing of my petition within which to

complete the credit counseling, obtain and file a Certificate of Credit Counseling issued by a United States Trustee approved nonprofit budget and credit counseling agency.

DATED:

Debtor Joint Debtor

CSD 1025

CSD 1027 [12/01/23] Name, Address, Telephone No. & I.D. No

UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991

In Re

BANKRUPTCY NO.

Debtor(s)

NOTICE OF MOTION FOR EXEMPTION AND

OPPORTUNITY FOR HEARING RE: CREDIT COUNSELING

I (we), the debtor(s), certify that no credit counseling is required and request exemption from the requirement

because:

I am incapacitated or disabled, as defined in 11 U.S.C. § 109(h)(4); or I am on active military duty in a military combat zone.

If you object to this Motion,

1. You are required to obtain a hearing date and time from the appropriate Courtroom Deputy for the judge assigned to this bankruptcy case. Determine which deputy to call by looking at the Bankruptcy Case No. in the above caption of this notice. If the case number is followed by the letters:

   - MM - call (619) 557-7407 - DEPARTMENT ONE (Room 218)
   - LT - call (619) 557-6018 - DEPARTMENT THREE (Room 129)
   - CL - call (619) 557-6019 - DEPARTMENT FIVE (Room 318)

2. Within 141 days from the date of service of this notice, you are further required to serve a copy of your
   Declaration in Opposition and separate Request and Notice of Hearing [Local Form CSD 1184] upon the
   debtor, counsel for the debtor (if any), and the trustee, together with any opposing papers. The opposing declaration
   must be signed and verified in the manner prescribed by FRBP 9011, and the declaration must:
   a. identify the interest of the opposing party; and
   b. state, with particularity, the grounds for the opposition.

3. You must file the original Declaration and Request and Notice of Hearing with proof of service with the Clerk of the U.S. Bankruptcy Court at 325 West F Street, San Diego, California 92101-6991, no later than the next business day following the date of service. If you fail to serve your “Declaration in Opposition” and “Request and Notice for Hearing” within the 14-day1 period, no hearing will take place, you will lose your opportunity for a hearing and an order may be entered.

DATED: Debtor Joint Debtor

1Depending on how you were served, you may have additional time for response. See FRBP 9006.

CSD 1027 [12/01/23]

CERTIFICATE OF SERVICE

I, the undersigned whose address appears below, certify:

That I am, and at all relevant times was, more than 18 years of age;

That on day of , 20 , I served a true copy of this NOTICE OF MOTION FOR

EXEMPTION AND OPPORTUNITY FOR HEARING RE: CREDIT COUNSELING, together with the following pleadings [describe any other papers] by the mode of service shown below: Pleadings:

1. To Be Served by the Court via Notice of Electronic Filing (“NEF”):

   Under controlling Local Bankruptcy Rules(s) (“LBR”), the document(s) listed above will be served by the court via NEF and hyperlink to the document. On , I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the following person(s) are on the Electronic Mail Notice List to receive NEF transmission at the e-mail address(es) indicated and/or as checked below:

   Chapter 7 Trustee:

   For Chapter 7, 11, & 12 cases: For Chapter 13 cases:
   UNITED STATES TRUSTEE MICHAEL KOCH, TRUSTEE
   ustp.region15@usdoj.gov mkoch@ch13.sdcoxmail.com

2. Served by United States Mail:

On , I served the following person(s) and/or entity(ies) at the last known

address(es) in this bankruptcy case or adversary proceeding by placing accurate copies in a sealed envelope in the United States Mail via 1) first class, postage prepaid or 2) certified mail with receipt number, addressed as follows:

CSD 1027 [12/01/23]

3. Served by Personal Delivery, Facsimile Transmission, Overnight Delivery, or Electronic Mail:

   Under FRCP 5 and controlling LBR, on , I served the following person(s) and/or entity(ies) by personal delivery, or (for those who consented in writing to such service method), by facsimile transmission, by overnight delivery and/or electronic mail as follows:

   I declare under penalty of perjury under the laws of the United States of America that the statements made

   in this proof of service are true and correct.

   Executed on (Typed Name and Signature) (Address) (City, State, ZIP Code)

Fill in this information to identify your case:

United States Bankruptcy Court for the: District 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 ofDistrict__________of ________

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

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy 04/20

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 government-issued picture __________________________________________________ __________________________________________________ identification (for example, First name First name your driver’s license or __________________________________________________ __________________________________________________ passport). Middle name Middle name Bring your picture __________________________________________________ __________________________________________________ identification to your meeting Last name Last name 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 __________________________________________________ __________________________________________________ Include your married or Middle name Middle name maiden names. __________________________________________________ __________________________________________________ Last name Last name __________________________________________________ __________________________________________________ First name First name __________________________________________________ __________________________________________________ Middle name Middle name __________________________________________________ __________________________________________________ Last name Last name

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. Any business names and Employer I have not used any business names or EINs. I have not used any business names or EINs. Identification Numbers (EIN) you have used in _________________________________________________ _________________________________________________ the last 8 years Business name Business name Include trade names and _________________________________________________ _________________________________________________ doing business as names Business name Business name

   ___ ___ – ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___ ___ ___ ___
   EIN EIN

   ___ ___ – ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ ___ ___ ___ ___ ___
   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 last 8 years? Yes. District __________________________ When _______________ Case number ___________________________ 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 filed by a spouse who is Yes. Debtor _________________________________________________ Relationship to you _____________________ 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 _______________________________________________________________________________________ individual, and is not a Name of business, if any 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 or a debtor Chapter 11 of the choosing to proceed under Subchapter V so that it can set appropriate deadlines. If you indicate that you Bankruptcy Code and are a small business debtor or you are choosing to proceed under Subchapter V, you must attach your most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or are you a small business if any of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B).

debtor or a debtor as defined by 11 U.S.C. § No. I am not filing under Chapter 11. 1182(1)? No. I am filing under Chapter 11, but I am NOT a small business debtor according to the definition in For a definition of small the Bankruptcy Code. business debtor, see Yes. I am filing under Chapter 11, I am a small business debtor according to the definition in the Bankruptcy 11 U.S.C. § 101(51D). Code, and I do not choose to proceed under Subchapter V of Chapter 11. Yes. I am filing under Chapter 11, I am a debtor according to the definition in §1182(1) of the Bankruptcy Code, and I choose to proceed under Subchapter V of Chapter 11. 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 alleged to pose a threat Yes. What is the hazard? ________________________________________________________________________ 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 4

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

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 5

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 Chapter 7? No. I am not filing under Chapter 7. Go to line 18. 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 are paid that funds will be Yes 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 6

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 7

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 8 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: __________________ District 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 (www.uscourts.gov/rulesandpolicies/rules.aspx) and the local court’s website (to find your court’s website, go to www.uscourts.gov/Court_Locator.aspx) 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

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: ______________________ District of ________ (State) 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

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: ______________________ District of __________ (State) Case number ___________________________________________ (If known) Check if this is an amended filing

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims Against You and Are Not Insiders 12/15

If you are an individual filing for bankruptcy under Chapter 11, you must fill out this form. If you are filing under Chapter 7, Chapter 12, or Chapter 13, do not fill out this form. Do not include claims by anyone who is 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 percent 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. Also, do not include claims by secured creditors unless the unsecured claim resulting from inadequate collateral value places the creditor among the holders of the 20 largest unsecured claims. Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information.

Part 1: List the 20 Unsecured Claims in Order from Largest to Smallest. Do Not Include Claims by Insiders.

Unsecured claim

1 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. Contingent __________________________________________ Number Street Unliquidated Disputed __________________________________________ None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ ____________________________________ Value of security: - $_____________________ Contact phone Unsecured claim $_____________________

2 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. Contingent __________________________________________ Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 1

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

Unsecured claim

3 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name __________________________________________ As of the date you file, the claim is: Check all that apply. Number Street Contingent __________________________________________ Unliquidated Disputed __________________________________________ None of the above apply City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ ____________________________________ Value of security: - $_____________________ Contact phone Unsecured claim $_____________________

$____________________________ 4 __________________________________________ What is the nature of the claim? ____________________________
Creditor’s Name As of the date you file, the claim is: Check all that apply.
__________________________________________ Contingent
Number Street Unliquidated
__________________________________________ Disputed
None of the above apply
__________________________________________
City State ZIP Code Does the creditor have a lien on your property?
No
__________________________________________ Yes. Total claim (secured and unsecured): $_____________________
Contact Value of security: - $_____________________
____________________________________ Contact phone Unsecured claim $_____________________

5 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 6 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ f Contact phone Unsecured claim $ 7 What is the nature of the claim? ____________________________ $_____________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Contingent Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 2

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

Unsecured claim

8 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 9 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

$10 __________________________________________ What is the nature of the claim? ____________________________
Creditor’s Name As of the date you file, the claim is: Check all that apply.
______________ Contingent
Number Street Unliquidated
__________________________________________ Disputed
None of the above apply
__________________________________________
City State ZIP Code Does the creditor have a lien on your property?
No
__________________________________________ Yes. Total claim (secured and unsecured): $_____________________
Contact Value of security: - $_____________________
____________________________________ Contact phone Unsecured claim $_____________________

11 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 12 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. Contingent __________________________________________ Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ Does the creditor have a lien on your property? City State ZIP Code No Yes. Total claim (secured and unsecured): $_____________________ __________________________________________ Contact Value of security: - $_____________________ Unsecured claim $_____________________

---

Contact phone

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 3

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

Unsecured claim

13 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 14 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

$15 __________________________________________ What is the nature of the claim? ____________________________
Creditor’s Name As of the date you file, the claim is: Check all that apply.
______________ Contingent
Number Street Unliquidated
__________________________________________ Disputed
None of the above apply
__________________________________________
City State ZIP Code Does the creditor have a lien on your property?
No
__________________________________________ Yes. Total claim (secured and unsecured): $_____________________
Contact Value of security: - $_____________________
____________________________________ Contact phone Unsecured claim $_____________________

16 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 17 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Contingent Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 4

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

Unsecured claim

18 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Contingent Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

19 What is the nature of the claim? ____________________________ __________________________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ ____________________________________ Value of security: - $_____________________ Contact phone Unsecured claim $_____________________

20 What is the nature of the claim? ____________________________ $____________________________ As of the date you file, the claim is: Check all that apply. Contingent __________________________________________ Creditor’s Name Unliquidated Disputed __________________________________________ Number Street None of the above apply __________________________________________ Does the creditor have a lien on your property? __________________________________________ No City State ZIP Code Yes. Total claim (secured and unsecured): $_____________________ Value of security: - $_____________________ __________________________________________ Contact Unsecured claim $_____________________

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Contact phone

Part 2: Sign Below

Under penalty of perjury, I declare that the information 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 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 5

Checklist 2

The following documents 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.

CSD 1099 - Balance of Schedules, Statements, and/or Chapter 13 Plan (This form must accompany the below forms if they are filed within 14 days after filing the Voluntary Petition. If the below forms are filed with the Voluntary Petition, do not file this form.)

106 Sum - Summary of Your Assets and Liabilities and Certain Statistical Information

106A/B - Schedule A/B / Property

106C - Schedule C / Property Claimed as Exempt

106D - Schedule D / Creditors Holding Secured Claims

106E/F - Schedule E/F / Creditors Holding Unsecured Claims

106G - Schedule G / Executory Contracts & Unexpired Leases

106H - Schedule H / Codebtors

106I - Schedule I / Your Income

106J - Schedule J / Your Expenses

106J-2 - Schedule J-2 / Expenses for Separate Household of Debtor 2

106 Dec - Declaration Concerning Debtor's Schedules

107 - Statement of Financial Affairs for Individuals Filing for Bankruptcy

Instructions for completing 122B

122B - Chapter 11 Statement of Current Monthly Income

2020 Chapter 11 Individual Petition Package

CSD 1099 [12/01/23]

Name, Address, Telephone No. & I.D. No.

UNITED STATES BANKRUPTCY COURT
SOUTHERN DISTRICT OF CALIFORNIA
325 West F Street, San Diego, California 92101-6991

In Re Bankruptcy No.

Debtor(s)

BALANCE OF SCHEDULES, STATEMENTS, AND/OR CHAPTER 13 PLAN
Presented are the originals required by CSD 1800 Administrative Procedures [Check one or more boxes as

appropriate]:

Schedules A/B – J (Forms 106A/B - J & 206A/B-G) Statement of Financial Affairs for Individuals Filing for Bankruptcy (Form 107 & 207) Summary of Your Assets and Liabilities and Certain Statistical Information Schedules (Form 106Sum & 206Sum) Chapter 7 Statement of Your Current Monthly Income (Form 122A-1) Chapter 7 Statement of Exemption from Presumption of Abuse Under § 707(b)(2) (Form 122A-1Supp) Chapter 7 Means Test Calculation (Form 122A-2) Chapter 11 Statement of Your Current Monthly Income (Form 122B) Chapter 13 Statement of Your Current Monthly Income and Calculation of Commitment Period (Form 122C-1) Chapter 13 Calculation of Your Disposable Income (Form 122C-2) Chapter 13 Plan (CSD1300) Schedule A/B: Property (Form 106A/B & 206A/B) Schedule C: The Property You Claim as Exempt (Form 106C) Creditors Who Have Claims Secured by Property (Form 106D & 206D) Creditors Who Have Unsecured Claims (Form 106E/F & 206E/F) Executory Contracts & Unexpired Leases (Form 106G &206G) Your Co-Debtors (Form 106H) Schedule I: Your Income (Form 106I) Your Expenses (Form 106J) Expenses for Separate Household of Debtor 2 (Form 106J-2)

If additional creditors are added at this time, the following are required:

1. Electronic media required, see CSD 1007, containing only the added names and addresses (when the Balance of Schedules are filed on paper).

2. Local Form CSD 1101, Notice to Creditors of This Debtor Added by Amendment or Balance of Schedules. See instructions on reverse side.

Dated: Signed: Attorney for Debtor I[We] and , the debtor(s), hereby declare under penalty of perjury that the information set forth in the balance of schedules and/or chapter 13 plan attached hereto, consisting of pages, and on the creditor matrix, if any, is true and correct. Dated:

*Debtor *Joint Debtor
*If filed electronically, pursuant to LBR 5005-4(C), the original debtor signature(s) in a scanned format is required.

CSD 1099 [12/01/23] INSTRUCTIONS

1. Local Form CSD 1101, Notice to Creditors of The Above-Named Debtor Added by Amendment or Balance of Schedules, may be used to notify any added entity. When applicable, copies of the following notices must accompany the notice: Order for and Notice of Section 341(a) Meeting, Discharge of Debtor, Notice of Order Confirming Plan, and Proof of Claim.

2. If not filed previously and this is an ECF case, the Declaration Re: Electronic Filing of Petition, Schedules &

   Statements (Local Form CSD 1801) must be filed in accordance with LBR 5005-4(c).

3. If this is a Chapter 11 case, each member of any committee appointed must be served this Balance of Schedules.

   PROOF OF SERVICE

   I, whose address appears below, certify:

   That I am, and at all relevant times was, more than 18 years of age;

   I served a true copy of this Balance of Schedules and/or Chapter 13 Plan on the following persons listed below

   via the following method(s):

   1. To Be Served by the Court via Notice of Electronic Filing (“NEF”):

   Under controlling Local Bankruptcy Rules(s) (“LBR”), the document(s) listed above will be served by the court

   via NEF and hyperlink to the document. On , I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the following person(s) are on the Electronic Mail Notice List to receive NEF transmission at the e-mail address(es) indicated and/or as checked below:

   Chapter 7 Trustee:

   For Chapter 7, 11, & 12 cases: For Chapter 13 cases:

   UNITED STATES TRUSTEE MICHAEL KOCH, TRUSTEE
   ustp.region15@usdoj.gov mkoch@ch13.sdcoxmail.com

   2. Served by United States Mail:

   On , I served the following person(s) and/or entity(ies) at the last known in this bankruptcy case or adversary proceeding by placing accurate copies in a sealed envelope in the United States Mail via 1) first class, postage prepaid or 2) certified mail with receipt number, addressed as follows:

CSD 1099 [12/01/23] 3. Served by Personal Delivery, Facsimile Transmission, Overnight Delivery, or Electronic Mail:

Under Fed.R.Civ.P.5 and controlling LBR, on , I served the following person(s)

and/or entity(ies) by personal delivery, or (for those who consented in writing to such service method), by facsimile transmission, by overnight delivery, and/or electronic mail as follows:

I declare under penalty of perjury under the laws of the United States of America that the statements made in this
proof of service are true and correct.

Executed on
(Date) (Typed Name and Signature)

(Address)

(City, State, ZIP Code)

CSD 1101 [12/01/23] Name, Address, Telephone No. & I.D. No.

UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991

In Re

BANKRUPTCY NO.

Debtor(s)

NOTICE TO CREDITORS OF THE ABOVED-NAMED DEBTOR ADDED BY AMENDMENT OR BALANCE OF SCHEDULES

You are hereby notified that the debtor is filing in this case a schedule or an amendment to the debtor's list of debts to

include you as a creditor of this estate. If you have questions concerning the legal effect of this filing upon you as a creditor, please consult your own legal counsel. Neither the Court nor I may advise you on legal matters.

You are further notified that on , the debtor filed a petition for relief under Chapter , of the

United States Bankruptcy Code. [If applicable: The case was subsequently converted to a case under Chapter of the Code on: .]

As a result of the filing of the petition, you are notified that certain acts and proceedings against the debtor and

his estate are stated as provided in 11 U.S.C. § 362(a).

Copies of notices indicated below are pertinent to this case and are enclosed with this notice.

Order for and Notice of Section 341(a) Meeting and/or Notice of Hearing on Objection to Confirmation of Chapter 13 Plan

Meeting and/or Hearing pending

Meeting and/or Hearing concluded

Meeting and/or Hearing continued to , at .m.

Discharge of the Debtor

Order Fixing Last Date for Filing Claims and Proof of Claim (Form 410)

Order Confirming Plan

Other (specify)

Dated: Signed: Debtor Attorney for Debtor

CSD 1101 [12/01/23]

INSTRUCTIONS

1. Determine which of the notices or orders listed on the reverse side have been mailed to creditors prior to preparation of the amendment or balance of schedules being filed with this notice. Copies of those notices must be mailed to the added creditors and copies attached to this notice. Failure to do so may cause the amendment, schedules and/or notice to be returned for correction.

2. Compliance with LBR 1007-4 and 1009 are required.

   PROOF OF SERVICE

   I, whose address appears below, certify:

   That I am, and at all relevant times was, more than 18 years of age;

   I served a true copy of this Notice to Creditors of the Above-Named Debtor Added by Amendment on the

following persons listed below by mode of service shown below:

1. To Be Served by the Court via Notice of Electronic Filing (“NEF”):

   Under controlling Local Bankruptcy Rules(s) (“LBR”), the document(s) listed above will be served by the court via NEF and hyperlink to the document. On , I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the following person(s) are on the Electronic Mail Notice List to receive NEF transmission at the e-mail address(es) indicated and/or as checked below:

   Chapter 7 Trustee:

   For Chapter 7, 11, & 12 cases: For EVEN numbered Chapter 13 cases:
   UNITED STATES TRUSTEE MICHAEL KOCH, TRUSTEE
   ustp.region15@usdoj.gov mkoch@ch13.sdcoxmail.com

2. Served by United States Mail:

On , I served the following person(s) and/or entity(ies) at the last known

address(es) in this bankruptcy case or adversary proceeding by placing accurate copies in a sealed envelope in the United States Mail via 1) first class, postage prepaid or 2) certified mail with receipt number, addressed as follows:

CSD 1101 [12/01/23]

3. Served by Personal Delivery, Facsimile Transmission, Overnight Delivery, or Electronic Mail:

   Under Fed.R.Civ.P.5 and controlling LBR, on , I served the following person(s) and/or entity(ies) by personal delivery, or (for those who consented in writing to such service method) by facsimile transmission, by overnight delivery, and/or electronic mail as follows:

   I declare under penalty of perjury under the laws of the United States of America that the statements made in this

   proof of service are true and correct.

   Executed on (Date) (Typed Name and Signature) (Address) (City, State, ZIP Code)

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: ______________________ District of __________ (State) 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

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: ______________________ District of __________ (State) 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 Check if this is community property Debtor 1 and Debtor 2 only (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 the amount of any secured claims on Schedule D: Model: ______________ Creditors Who Have Claims Secured by Property. 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 the amount of any secured claims on Schedule D: Model: ______________ Creditors Who Have Claims Secured by Property.
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 the amount of any secured claims on Schedule D: Model: ______________ Creditors Who Have Claims Secured by Property.
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 the amount of any secured claims on Schedule D: Model: ______________ Creditors Who Have Claims Secured by Property.
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 the amount of any secured claims on Schedule D: Model: ____________________ Creditors Who Have Claims Secured by Property. 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 the amount of any secured claims on Schedule D: Model: ____________________ Creditors Who Have Claims Secured by Property.
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.

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

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: ______________________ District of __________ (State) Case number ___________________________________________ Check if this is an (If known) amended filing

Official Form 106C Schedule C: The Property You Claim as Exempt 04/19

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 $170,350? (Subject to adjustment on 4/01/22 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 ______ 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 ______ 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
______ 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 ______ 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 ______ 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
______ 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:

Official Form 106C Schedule C: The Property You Claim as Exempt 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: ______________________ District of __________ (State) 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

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: ______________________ District of __________ (State) 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 4.5, followed by 4.6, 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.
$_________________________

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:______________________ District of ________ (State) Case (If known) number ___________________________________________ 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

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:_______________________ District of ________ (State) 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 ______ ________________________________________________________________________________zz 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

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: ______________________ District of ___________ (State) 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

Fill in this information to identify your case:

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

Debtor 2 ________________________________________________________________ Name Middle Name Last Name An amended filing (Spouse, if filing) First 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 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’ _________________________ ________ Yes names. 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

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’ _________________________ ________ Yes names. No _________________________ ________ Yes No _________________________ ________ Yes No _________________________ ________ Yes

3. Do your expenses include No expenses of people other than yourself, your dependents, and Yes 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: ______________________ District of __________ (State) 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

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: ____________________ DistrictDistrict ofof________________________

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

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy 04/19

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 $6,825* or more?

   No. Go to line 7. Yes. List below each creditor to whom you paid a total of $6,825* 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 4/01/22 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

Chapter 11 Statement of Your Current Monthly Income (Official Form 122B)

You must file the Chapter 11 Statement of Your
If you are filing under chapter 7, Current Monthly Income (Official Form 122B)
12, or 13, do not fill out this form. if you are an individual filing for bankruptcy
under chapter 11.

Information for completing the forms

If you have nothing to report for a line, write
$0.

If you are a servicemember, veteran, or the
family member of a veteran, and are looking for
a list of the types of benefits that the United
States Department of Justice confirms need not
be reported on lines 9 or 10 of Form 122B on
account of the veteran’s death or disability
under the “Helping American Veterans in
Extreme Need Act of 2019” (HAVEN Act), go
to:

https://www.justice.gov/ust/means-testing

Chapter 11 Statement of Your Current Monthly Income (Official Form 122B) page 35

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: _____________________ DistrictDistrict ofof____________________

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

Official Form 122B Chapter 11 Statement of Your Current Monthly Income 04/20

You must file this form if you are an individual and are filing for bankruptcy under Chapter 11. 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 Current Monthly Income

1. What is your marital and filing status? Check one only.

Not married. Fill out Column A, lines 2-11.
Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11.
Married and your spouse is NOT filing with you. Fill out Column A, 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

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 if Column B is filled in. $____________ $__________

   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. Include regular contributions from a spouse only if Column B is not filled in. $____________ $__________ Do not include payments you listed on line 3.

   5. Net income from operating a business, profession, or farm Debtor 1 Debtor 2 Gross receipts (before all deductions) $______ $______ Ordinary and necessary operating expenses – $______ – $______ Net monthly income from a business, profession, or farm $______ $______ Copy 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 122B Chapter 11 Statement of Your Current Monthly Income page 1

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

Column A Column B
Debtor 1 Debtor 2

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. + $____________ + $__________

11. Calculate your total current monthly income. Add lines 2 through 10 for each column. + = Then add the total for Column A to the total for Column B. $____________ $_________ $_______

    Total current

    monthly income

Part 2: 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

Official Form 122B Chapter 11 Statement of Your Current Monthly Income page 2

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: _____________________ District of _________ (State)

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.

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

___________________________________________________________________________________ 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.

_______________________________________________________________ ___ ___ ___ -- ___ ___ -- ___ ___ ___ ___ 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

_______________________________________________________________ ___ ___ ___ -- ___ ___ -- ___ ___ ___ ___ 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

CSD 2800 [12/1/15] Name, Address, Telephone No. & I.D. No.

UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991

In Re

BANKRUPTCY NO.

Debtor.

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)

CSD 2800 [Continued on Page 2]

CSD 2800 (Page 2)[12/1/15]

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

X Signature Social Security Number Date of bankruptcy petition preparer (If the bankruptcy petition preparer is not an individual, state thePrinted name and title, if any, of Bankruptcy Petition Social Security number of thePreparer officer, principal, responsible person or partner of the bankruptcy petition preparer.) (Required by 11 U.S.C. § 110.)Address

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.

CSD 2800

CSD 2030 [12/01/15]Name, Address, Telephone No. & I.D. No.

UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA

325 West F Street, San Diego, California 92101-6991

In Re

BANKRUPTCY NO.

Debtor.

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

1. Pursuant to 11 U.S.C. § 329(a) and Federal Rule of Bankruptcy Procedure 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 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. In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy case, including:

   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, statement 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;

CSD [Continued on Page 2] 2030

CSD (Page 2) [12/01/15] 2030

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

e. [Other provisions as needed]

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.

DATED:

(Typed Name and Signature)

(Name of Law Firm)

CSD 2030