CACB — Involuntary Petition Against an Individual (105)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/105.pdf

Fill in this information to identify the case:

United States Bankruptcy Court for the: ____________________ DistrictDistrict ofof ____________________

Case number (If known): _________________________ Chapter _____

Check if this is an amended filing

Official Form 105

12/15Involuntary Petition Against an Individual

Use this form to begin a bankruptcy case against an individual you allege to be a debtor subject to an involuntary case. If you want to begin a case against a non-individual, use the Involuntary Petition Against a Non-individual (Official Form 205). Be as complete and accurate as possible. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write name and case number (if known).

Part 1: Identify the Chapter of the Bankruptcy Code Under Which Petition Is Filed

1. Chapter of the Check one: Bankruptcy Code Chapter 7 Chapter 11

Part 2: Identify the Debtor

2. Debtor’s full name __________________________________________________ First name __________________________________________________ Middle name __________________________________________________ Last name ___________________________ Suffix (Sr., Jr., II, III)

3. Other names you know __________________________________________________ the debtor has used in the last 8 years __________________________________________________ Include any assumed, __________________________________________________ married, maiden, or trade names, or doing business as names.

4. Only the last 4 digits of Unknown debtor’s Social Security Number or federal xxx – xx – ____ ____ ____ ____ OR 9 xx – xx – ____ ____ ____ ____ Individual Taxpayer Identification Number (ITIN)

5. Any Employer Identification Numbers Unknown (EINs) used in the last 8 years ___ ___ – ___ ___ ___ ___ ___ ___ ___ EIN ___ ___ – ___ ___ ___ ___ ___ ___ ___ EIN

Official Form 105 Involuntary Petition Against an Individual page 1

Debtor _______________________________________________________ Case number (if known)_____________________________________

Principal residence Mailing address, if different from residence

6. Debtor’s address

   _________________________________________________ _________________________________________________
   Number Street Number Street

   _________________________________________________ _________________________________________________

   _________________________________________________ _________________________________________________
   City State ZIP Code City State ZIP Code

   _________________________________________________
   County

   Principal place of business

   _________________________________________________
   Number Street

   _________________________________________________

   _________________________________________________
   City State ZIP Code

   _________________________________________________
   County

   Debtor does not operate a business7. Type of business

   Check one if the debtor operates a 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

7. Type of debt Each petitioner believes: Debts are 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.” Debts are primarily business debts. Business debts are debts that were incurred to obtain money for a business or investment or through the operation of the business or investment.

8. Do you know of any No bankruptcy cases pending by or against Yes. Debtor _________________________________________________ Relationship __________________________ any partner, spouse, or affiliate of this debtor? District Date filed _______________ Case number, if known MM / DD / YYYY Debtor _________________________________________________ Relationship ___________________________ District __________________________ Date filed _______________ Case number, if known____________ MM / DD / YYYY

Official Form 105 Involuntary Petition Against an Individual page 2

Debtor _______________________________________________________ Case number (if known)_____________________________________

Part 3: Report About the Case

10. Venue Check one: Reason for filing in this court. Over the last 180 days before the filing of this bankruptcy, the debtor has resided, had the principal place of business, or had principal assets in this district longer than in any other district. A bankruptcy case concerning debtor’s affiliates, general partner, or partnership is pending in this district. Other reason. Explain. (See 28 U.S.C. § 1408.) ___________________________________________________

11. Allegations Each petitioner is eligible to file this petition under 11 U.S.C. § 303(b). The debtor may be the subject of an involuntary case under 11 U.S.C. § 303(a). At least one box must be checked: The debtor is generally not paying such debtor’s debts as they become due, unless they are the subject of a bona fide dispute as to liability or amount. Within 120 days before the filing of this petition, a custodian, other than a trustee, receiver, or agent appointed or authorized to take charge of less than substantially all of the property of the debtor for the purpose of enforcing a lien against such property, was appointed or took possession.

12. Has there been a No transfer of any claim against the debtor by or Yes. Attach all documents that evidence the transfer and any statements required under Bankruptcy Rule to any petitioner? 1003(a).

13. Each petitioner’s claim Amount of the Name of petitioner Nature of petitioner’s claim claim above the value of any lien $ ________________ $ ________________ $ ________________

Total $ ________________

If more than 3 petitioners, attach additional sheets with the statement under penalty

of perjury, each petitioner’s (or representative’s) signature under the statement,

along with the signature of the petitioner’s attorney, and the information on the petitioning creditor, the petitioner’s claim, the petitioner’s representative, and the attorney following the format on this form.

Official Form 105 Involuntary Petition Against an Individual page 3

Debtor _______________________________________________________ Case number (if known)_____________________________________

Part 4: Request for Relief

Petitioners request that an order for relief be entered against the debtor under the chapter specified in Part 1 of this petition. If a petitioning creditor is a corporation, attach the corporate ownership statement required by Bankruptcy Rule 1010(b). If any petitioner is a foreign representative appointed in a foreign proceeding, a certified copy of the order of the court granting recognition is attached.

Petitioners declare under penalty of perjury that the information provided in this petition is true and correct. Petitioners understand that if they make a false statement, they could be fined up to $250,000 or imprisoned for up to 5 years, or both.

18 U.S.C. §§ 152 and 3571. If relief is not ordered, the court may award attorneys’ fees, costs, damages, and punitive damages. 11 U.S.C. § 303(i).

Petitioners or Petitioners’ Representative Attorneys

---

Signature of petitioner or representative, including representative’s title Signature of attorney

______________________________________________________________ ________________________________________________________________
Printed name of petitioner Printed name

________________________________________________________________ Date signed _________________
Firm name, if any MM / DD / YYYY

________________________________________________________________
Number Street

Mailing address of petitioner ________________________________________________________________ ______________________________________________________________ City State ZIP Code Number Street

Date signed _________________
______________________________________________________________ MM / DD / YYYY
City State ZIP Code

Contact phone _________________ Email ____________________________

If petitioner is an individual and is not represented by an
attorney:

Contact phone ____________________________

Email ____________________________

Name and mailing address of petitioner’s representative, if any

---

Name

---

Number Street

______________________________________________________________
City State ZIP Code

Official Form 105 Involuntary Petition Against an Individual page 4

Debtor _______________________________________________________ Case number (if known)_____________________________________

---

Signature of petitioner or representative, including representative’s title Signature of Attorney

______________________________________________________________ ________________________________________________________________
Printed name of petitioner Printed name

________________________________________________________________ Date signed _________________
Firm name, if any MM / DD / YYYY

________________________________________________________________
Number Street

Mailing address of petitioner ________________________________________________________________ ______________________________________________________________ City State ZIP Code Number Street

Date signed _________________
______________________________________________________________ MM / DD / YYYY
City State ZIP Code

Contact phone _________________ Email ____________________________

Name and mailing address of petitioner’s representative, if any

---

Name

---

Number Street

______________________________________________________________
City State ZIP Code

---

Signature of petitioner or representative, including representative’s title Signature of Attorney

______________________________________________________________ ________________________________________________________________
Printed name of petitioner Printed name

Date signed _________________ ________________________________________________________________
Firm name, if any MM / DD / YYYY

---

Number Street

Mailing address of petitioner ________________________________________________________________ ______________________________________________________________ City State ZIP Code Number Street

Date signed _________________
______________________________________________________________ MM / DD / YYYY
City State ZIP Code

Contact phone _________________ Email ____________________________

Name and mailing address of petitioner’s representative, if any

---

Name

---

Number Street

_____________________________________________________________
City State ZIP Code

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