CACB — Schedule E/F: Creditors Who Have Unsecured Claims

CACB — 106EF.pdf¶

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/106EF.pdf

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Fill in this information to identify your case:

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

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

United States Bankruptcy Court for the: __________Central DistrictDistrictof Californiaof __________ Check if this is an Case number ___________________________________________ (If known) amended filing

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

Do any creditors have priority unsecured claims against you? No. Go to Part 2. Yes.
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 Who incurred the debt? Check one. Disputed 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 ___

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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

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

Is the claim subject to offset?

No Yes

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

Exceptions & meaning →

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

Part 2: List All of Your NONPRIORITY Unsecured Claims

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
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
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
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 ___

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page

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

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

No Yes

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

No Yes

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

No Yes

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

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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

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 ___

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

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

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.
$_________________________

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

Exceptions & meaning →