CAEB — Chapter 7 Individual

Source: https://www.caeb.uscourts.gov/documents/forms/misc/Ch7IndividualFormsPackage%28Final%29.pdf

FILING AN INDIVIDUAL CHAPTER 7 CASE (INCLUDING JOINT CASES) UNITED STATES BANKRUPTCY COURT, EASTERN DISTRICT OF CALIFORNIA These documents are intended to help debtors filing without an attorney.

Forms and Legal Advice Attached to this document are forms and a list of form requirements for a chapter 7 individual case. You must complete and sign each required document before submitting them to the court. You may need to enter “zero” or “none” in a blank space to fully complete the form. Federal law prohibits the bankruptcy court from giving any type of legal advice or instruction. If you have a question about how to fill out a form, it is recommended that you contact an attorney.

Required Credit Counseling Prior to the submission of your bankruptcy case, a Certificate of Credit Counseling must be completed. Only credit counseling organizations that have been approved by the U.S. Trustee Program may issue this certificate. Find an approved credit counseling agency by going to this website: https://www.justice.gov/ust/credit-counseling-debtor-education-information.

Filing Fee For the current filing fee, see the attached Required Forms for an Individual Chapter 7 Case. Filing fees from individuals filing without an attorney must be paid in person or by mail with money orders or cashier’s checks. All money orders and cashier’s checks must be made payable to: Clerk, U.S. Bankruptcy Court. Debit cards are also accepted in person at our Sacramento and Fresno offices. Debtors may use our Online Installment Payment system to pay court approved filing fee installment payments. No cash accepted. Forms to apply to pay the chapter 7 filing fee in installments or to waive the chapter 7 filing fee are available in the attached forms package. If you are asking the court to waive your fee, you must be an individual filing a chapter 7 bankruptcy who cannot afford to pay the fee in installments and meets the following poverty guidelines, see: https://www.uscourts.gov/sites/default/files/poverty-guidelines.pdf

Revised 6/2025

Where and How to File Your Documents If you reside in this county: Mail or deliver your Electronic Filing Option: documents and Filing Fee to:

Alpine, Amador, Butte, U.S. Bankruptcy Court To save time and the expense of Calaveras, Colusa, El Dorado, 501 I Street, #3-200 traveling to one of our Glenn, Lassen, Modoc, Mono, Sacramento, CA 95814 courthouses, you may submit Nevada, Placer Plumas, 916-930-4400 your documents online using the Sacramento, San Joaquin, Online Debtor Dropbox. If your Shasta, Sierra, Siskiyou, documents are accepted, you Solano, Stanislaus, Sutter, will receive a confirmation email, Tehama, Trinity, Tuolumne, including copies of your Yolo, Yuba documents and instructions on how to pay your filing fee.

Fresno, Inyo, Kings, Kern, U.S. Bankruptcy Court Training Videos: Madera, Mariposa, Merced, 2500 Tulare Street, #2501 Tulare Fresno, CA 93721 • How to Submit a New 559-499-5800 Case • How to Submit documents in an existing case. Please submit original signed documents to the court. If you would like a copy of the documents that you file, please provide a photocopy of each one along with the original. If you are filing by mail, please also submit a self-addressed, stamped envelope with sufficient postage to return your copies to you.

After You File Read everything very closely that is sent to you regarding your bankruptcy case. A Notice of Chapter 7 Bankruptcy Case will be mailed to you and the creditors on the mailing list you prepared. This document will list important information such as the trustee assigned to your case, deadlines and the date, time, and location of a hearing called a “Meeting of Creditors.” You are required to attend this hearing. At the hearing, the trustee appointed in your case will question you about your assets and documents you filed. If you do not file all documents in your case, you will also receive a Notice of Incomplete Filing and Notice of Intent to Dismiss Case, which will include a list of documents that you still need to file and the due dates. You will also receive a Notice of Requirement to File Certification about a Financial Management Course (Official Form 423), along with a form to fill out regarding your instructional course in personal financial management. Failure to take this class and return the form to the court may result in your case being closed without a discharge.

UNITED STATES BANKRUPTCY COURT – EASTERN DISTRICT OF CALIFORNIA REQUIRED FORMS FOR AN INDIVIDUAL CHAPTER 7 CASE (INCLUDING JOINT CASES) The current filing fee for a chapter 7 bankruptcy is $338. Forms Form Number Required for When is this form due? Individual Debtors Voluntary Petition 101 Initial Statement About an Eviction 101A (Only if your landlord has an eviction judgment Judgment against you) Statement About Payment of an 101B (Only if your landlord has an eviction judgment Eviction Judgment Against You against you and you want to stay in your residence for 30 days after you file.) Master Address List with Verification EDC 2-100 For more information regarding creating and submitting Time of Filing your master address list, see attached Guidelines for Preparation of Master Address List. Statement of Social Security 121 Number Attorney’s Disclosure of 2030 (Only required from debtors who are represented by Compensation an attorney). Certificate of Credit Counseling No Form Provided Schedule A/B 106A/B Schedule C 106C Schedule D 106D Schedule E/F 106E/F Schedule G 106G Schedule H 106H Schedule I 106I Schedule J 106J 106J2 (For joint debtors with a separate household) Declaration About Schedules 106Dec Summary of Assets and Liabilities 106Sum Within 14 Days of Filing Statement of Financial Affairs 107 Statement of Intention for 108 Individuals Chapter 7 Statement of Your 122A-1 Monthly Income Statement of Exemption from 122A-1Supp (May not be required for all debtors) Presumption of Abuse Chapter 7 Means Test Calculation 122A-2 (May not be required for all debtors) Notice to Individuals with Primarily 2010 Consumer Debts Bankruptcy Petition Preparer’s 119 (Only required if the forms have been completed by a Notice, Declaration and Signature Bankruptcy Petition Preparer) Disclosure of Compensation of 2800 (Only required if the forms have been completed by Bankruptcy Petition Preparer a Bankruptcy Petition Preparer)

OFFICE OF THE CLERK UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA

GUIDELINES FOR PREPARATION OF MASTER ADDRESS LISTS FOR DEBTORS NOT REPRESENTED BY ATTORNEYS1

The following guidelines have been approved by the Court and are issued pursuant to Local Bankruptcy Rule 1007-1(b).

A Master Address List includes the names, addresses and zip codes of all creditors in a bankruptcy case. This list is used for noticing and must be filed at the time the petition is filed.

The Court’s computer system requires the Master Address List to be prepared for electronic recognition. All Master Address Lists must comply with the following guidelines.

Debtors not represented by an attorney, or whose petitions are prepared by a Bankruptcy Petition Preparer, must prepare the Master Address List using one of the following methods:

• In electronic format when submitting their petition online through the court’s Debtor Drop Box program available at www.debtordropbox.caeb.uscourts.gov. This system will format your address list and electronically produce your required verification. • In hard copy format, using the court’s online application available at www.caeb.uscourts.gov/mal/. This guided process will help you complete the address list in the correct format and generate the required verification. • In hard copy format, following the example and requirements below.

Sample Master Address List

Sears Credit 123 Main Street Sacramento, CA 95222

Wells Fargo Bank

8000 W Major Blvd Chicago, IL 12345

Bank of Denver 123 Any Street PO Box 1234 Denver, CO 80202

(EDC Form 2-191, New 4/2024)

1 Attorneys should refer to EDC Form 2-190, Guidelines for Preparation of Master Address Lists and Master Equity Security Holder Lists

General Format Requirements

• Use only plain, 8.5 x 11 white paper.

• Do not print on both sides of the paper.

• Do not use letterhead or include page numbers, line numbers, headers, or footers.

• No handwriting, stray marks, correction fluid or tape.

• Lists should be typed in a single column on the page and prepared in Courier 10 cpi (same as 12 point on a word processor).

• Limit the name and address to 5 lines per creditor.

• Limit each line to 40 characters or less.

• Names of individuals must be in first/middle/last name order. Do not include titles, i.e., Mr., Mrs.

• Creditors must be listed alphabetically, according to the first letter of the company or first name.

• Do not include punctuation in names and addresses, including periods (.) after abbreviations or initials. One comma between the city and state is permitted.

• Do not use any special characters such as %. Hyphens in nine-digit zip codes are permitted.

• “Care of”, and “attention” designations may be included only on the second line.

• The city, state and zip code must be on the last line. The name of the state must be abbreviated using two upper case letters. Zip codes are mandatory.

• Foreign addresses must include the complete name of the country.

• Leave at least two blank lines between one creditor’s name and address and another’s. Do not leave blank lines within an address, or between a creditor’s name and address.

• Do not duplicate creditors with the same address, even if there is more than one account with that creditor. Do not include account numbers in the list of creditors.

• Do not include the debtor, joint debtor, attorney for the debtor(s), or United States Trustee on the list.

• When the Unites States is a creditor on a debt for other than taxes, it must be listed on Master Address Lists in accordance with Local Bankruptcy Rule 2002-1(a). Other federal and state agencies that have specified particular addresses to which notice of bankruptcy proceeding must be listed on Master Address Lists using the addressed shown on form EDC 2-785, Roster of Governmental Agencies.

• Every Master Address List must be accompanied by a Verification of Master Address List, form EDC 2- 100.

Fill in this information to identify your case:

United States Bankruptcy Court for the:

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

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

The bankruptcy forms use you and Debtor 1 to refer to a debtor filing alone. A married couple may file a bankruptcy case together—called a joint case—and in joint cases, these forms use you to ask for information from both debtors. For example, if a form asks, “Do you own a car,” the answer would be yes if either debtor owns a car. When information is needed about the spouses separately, the form uses Debtor 1 and Debtor 2 to distinguish between them. In joint cases, one of the spouses must report information as Debtor 1 and the other as Debtor 2. The same person must be Debtor 1 in all of the forms. Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Identify Yourself

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

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

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

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

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

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

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

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

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

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

   _________________________________________________ _________________________________________________
   Number Street Number Street

   _________________________________________________ _________________________________________________

   _________________________________________________ _________________________________________________
   City State ZIP Code City State ZIP Code

   _________________________________________________ _________________________________________________
   County County

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

   _________________________________________________ _________________________________________________
   Number Street Number Street

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

City State ZIP Code City State ZIP Code

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

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

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

Part 2: Tell the Court About Your Bankruptcy Case

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

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

9. Have you filed for No bankruptcy within the 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 _______________________________________________________________________________________ Name of business, if any individual, and is not a

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

Check the appropriate box to describe your business:

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

None of the above

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

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

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

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

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

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

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

________________________________________________________________________

________________________________________ _______ ____________________
City State ZIP Code

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

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

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

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

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

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

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

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

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

Part 6: Answer These Questions for Reporting Purposes

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

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

17. Are you filing under 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 7

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

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

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

_________________________________________________________________________________________________
Printed name

_________________________________________________________________________________________________
Firm name

_________________________________________________________________________________________________
Number Street

_________________________________________________________________________________________________

______________________________________________________ ____________ ______________________________
City State ZIP Code

Contact phone _____________________________________ Email address ______________________________

______________________________________________________ ____________
Bar number State

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

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

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

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

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

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

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

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

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

_______________________________________________ ______________________________
Signature of Debtor 1 Signature of Debtor 2

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

Contact phone ______________________________________ Contact phone ________________________________

Cell phone ______________________________________ Cell phone ________________________________

Email address ______________________________________ Email address ________________________________

Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 9

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

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

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

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

Part 1: Identify the Property You Claim as Exempt

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

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

   Brief description of the property and line on Current value of the Amount of the exemption you claim Specific laws that allow exemption Schedule A/B that lists this property portion you own

   Copy the value from Check only one box for each exemption.
   Schedule A/B

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

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

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

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

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

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

Part 2: Additional Page

Brief description of the property and line Current value of the Amount of the exemption you claim Specific laws that allow exemption
on Schedule A/B that lists this property portion you own

Copy the value from Check only one box for each exemption
Schedule A/B

Brief ____________________________
description: _________________________ $________________ $ ____________ ____________________________
100% of fair market value, up to ____________________________ Line from ______
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 __

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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: __________ District of ______________

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

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy 04/25

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Give Details About Your Marital Status and Where You Lived Before

1. What is your current marital status?

Married Not married

2. During the last 3 years, have you lived anywhere other than where you live now?

No Yes. List all of the places you lived in the last 3 years. Do not include where you live now.

Debtor 1: Dates Debtor 1 Debtor 2: Dates Debtor 2
lived there lived there

Same as Debtor 1 Same as Debtor 1

__________________________________________ From ________ ___________________________________________ From ________
Number Street Number Street
To ________ To ________
__________________________________________ ___________________________________________

__________________________________________ ___________________________________________
City State ZIP Code City State ZIP Code

Same as Debtor 1 Same as Debtor 1

__________________________________________ From ________ ___________________________________________ From ________ Number Street Number Street To ________ To ________ __________________________________________ ___________________________________________

__________________________________________ ___________________________________________
City State ZIP Code City State ZIP Code

3. Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory? (Community property
states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)
No
Yes. Make sure you fill out Schedule H: Your Codebtors (Official Form 106H).

Part 2: Explain the Sources of Your Income

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 1

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

4. Did you have any income from employment or from operating a business during this year or the two previous calendar years? Fill in the total amount of income you received from all jobs and all businesses, including part-time activities. If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.

No Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income Gross income Sources of income Gross income
Check all that apply. (before deductions and Check all that apply. (before deductions and
exclusions) exclusions)

Wages, commissions, Wages, commissions, From January 1 of current year until bonuses, tips $________________ bonuses, tips $________________
the date you filed for bankruptcy:
Operating a business Operating a business

Wages, commissions, Wages, commissions, For last calendar year:
bonuses, tips $________________ bonuses, tips $________________
(January 1 to December 31, _________) Operating a business Operating a business
YYYY

Wages, commissions, Wages, commissions, For the calendar year before that:
bonuses, tips bonuses, tips
$________________ $________________
(January 1 to December 31, _________) Operating a business Operating a business
YYYY

5. Did you receive any other income during this year or the two previous calendar years? Include income regardless of whether that income is taxable. Examples of other income are alimony; child support; Social Security, unemployment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and gambling and lottery winnings. If you are filing a joint case and you have income that you received together, list it only once under Debtor 1.

   List each source and the gross income from each source separately. Do not include income that you listed in line 4.

No Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income Gross income from Sources of income Gross income from
Describe below. each source Describe below. each source
(before deductions and (before deductions and
exclusions) exclusions)

__________________ $_________________ _____________________ $_________________ From January 1 of current year until
the date you filed for bankruptcy: __________________ $_________________ _____________________ $_________________
__________________ $_________________ _____________________ $_________________

For last calendar year: __________________ $_________________ _____________________ $_________________
(January 1 to December 31, ) __________________ $___________ _____________________ $_________________
YYYY
__________________ $_________________ _____________________ $_________________

For the calendar year before that: __________________ $_________________ _____________________ $_________________
(January 1 to December 31, ) __________________ $___________ _____________________ $_________________
YYYY
__________________ $_________________ _____________________ $_________________

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 2

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

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

6. Are either Debtor 1’s or Debtor 2’s debts primarily consumer debts?

No. Neither Debtor 1 nor Debtor 2 has primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8) as “incurred by an individual primarily for a personal, family, or household purpose.” During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $8,575* or more?

No. Go to line 7. Yes. List below each creditor to whom you paid a total of $8,575* or more in one or more payments and the total amount you paid that creditor. Do not include payments for domestic support obligations, such as child support and alimony. Also, do not include payments to an attorney for this bankruptcy case. * Subject to adjustment on 4/01/28 and every 3 years after that for cases filed on or after the date of adjustment.

Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts. During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more?

No. Go to line 7.
Yes. List below each creditor to whom you paid a total of $600 or more and the total amount you paid that
creditor. Do not include payments for domestic support obligations, such as child support and
alimony. Also, do not include payments to an attorney for this bankruptcy case.

Dates of Total amount paid Amount you still owe Was this payment for…
payment

____________________________________ _________ $_________________ $__________________ Mortgage
Creditor’s Name
Car
____________________________________ _________
Number Street Credit card
Loan repayment
____________________________________ _________
Suppliers or vendors
____________________________________ City State ZIP Code Other ____________

____________________________________ _________ $_________________ $__________________ Mortgage
Creditor’s Name
Car
____________________________________ _________ Number Street Credit card
Loan repayment
____________________________________ _________
Suppliers or vendors
____________________________________ Other ____________
City State ZIP Code

____________________________________ _________ $_________________ $__________________ Mortgage
Creditor’s Name
Car
____________________________________ _________ Number Street Credit card
Loan repayment
____________________________________ _________
Suppliers or vendors
____________________________________ Other ____________
City State ZIP Code

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 3

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

7. Within 1 year before you filed for bankruptcy, did you make a payment on a debt you owed anyone who was an insider? Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations, such as child support and alimony.

No Yes. List all payments to an insider.

Dates of Total amount Amount you still Reason for this payment
payment paid owe

____________________________________________ _________ $____________ $____________
Insider’s Name

____________________________________________ _________
Number Street

____________________________________________ _________

____________________________________________
City State ZIP Code

$____________ $____________ ____________________________________________ _________
Insider’s Name

____________________________________________ _________
Number Street

____________________________________________ _________

____________________________________________
City State ZIP Code

8. Within 1 year before you filed for bankruptcy, did you make any payments or transfer any property on account of a debt that benefited an insider? Include payments on debts guaranteed or cosigned by an insider.

No Yes. List all payments that benefited an insider.

Dates of Total amount Amount you still Reason for this payment
payment paid owe Include creditor’s name

____________________________________________ _________ $____________ $____________
Insider’s Name

____________________________________________ _________
Number Street

____________________________________________ _________

____________________________________________
City State ZIP Code

$____________ $____________ ____________________________________________ _________ Insider’s Name

____________________________________________ _________
Number Street

____________________________________________ _________

____________________________________________
City State ZIP Code

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 4

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

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

9. Within 1 year before you filed for bankruptcy, were you a party in any lawsuit, court action, or administrative proceeding? List all such matters, including personal injury cases, small claims actions, divorces, collection suits, paternity actions, support or custody modifications, and contract disputes.

No Yes. Fill in the details.

Nature of the case Court or agency Status of the case

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

Case number ________________________ ________________________________________
City State ZIP Code

________________________________________
Case title_____________________________ Court Name Pending
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

    ---

    Name of Financial Institution Name Yes

    ---

    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

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Fill in this information to identify your case: Check the appropriate box as directed in lines 40 or 42:

Debtor 1 _________________________________________________________________ According to the calculations required by First Name Middle Name Last Name this Statement: Debtor 2 ________________________________________________________________ (Spouse, if filing) First Name Middle Name Last Name ‰ 1. There is no presumption of abuse. United States Bankruptcy Court for the: ____________________DistrictDistrictof __________of __________ ‰ 2. There is a presumption of abuse.

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

2IILFLDO )RUP 122A–2 Chapter 7 Means Test Calculation

To fill out this form, you will need your completed copy of Chapter 7 Statement of Your Current Monthly Income (Official Form 122A-1).

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any additional pages, write your name and case number (if known).

Part 1: Determine Your Adjusted Income

1. Copy your total current monthly income. ............................................................... Copy line 11 from Official Form 122A-1 hereÎ ........... $_________

2. Did you fill out Column B in Part 1 of Form 122A–1? ‰ No. Fill in $0 for the total on line 3. ‰ Yes. Is your spouse filing with you? ‰ No. Go to line 3. ‰ Yes. Fill in $0 for the total on line 3.

3. Adjust your current monthly income by subtracting any part of your spouse’s income not used to pay for the household expenses of you or your dependents. Follow these steps:

On line 11, Column B of Form 122A–1, was any amount of the income you reported for your spouse NOT regularly used for the household expenses of you or your dependents?

‰ No. Fill in 0 for the total on line 3. ‰ Yes. Fill in the information below:

State each purpose for which the income was used Fill in the amount you
For example, the income is used to pay your spouse’s tax debt or to support are subtracting from
people other than you or your dependents your spouse’s income

___________________________________________________ $______________

___________________________________________________ $______________

___________________________________________________ + $______________

Total. ................................................................................................. $______________ Copy total here ............... Î ņ $_________

4. Adjust your current monthly income. Subtract the total on line 3 from line 1. $_________

Official Form 122A–2 Chapter 7 Means Test Calculation page 1

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

Part 2: Calculate Your Deductions from Your Income

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

Deduct the expense amounts set out in lines 6-15 regardless of your actual expense. In later parts of the form, you will use some of your actual expenses if they are higher than the standards. Do not deduct any amounts that you subtracted from your spouse’s income in line 3 and do not deduct any operating expenses that you subtracted from income in lines 5 and 6 of Form 122A–1.

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

Whenever this part of the form refers to you, it means both you and your spouse if Column B of Form 122A–1 is filled in.

5. The number of people used in determining your deductions from income

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

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

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

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

People who are under 65 years of age

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

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

7c. Subtotal. Multiply line 7a by line 7b. $____________ Copy hereÎ $___________

People who are 65 years of age or older

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

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

7f. Subtotal. Multiply line 7d by line 7e. $____________ Copy hereÎ + $___________

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

Official Form 122A–2 Chapter 7 Means Test Calculation page 2

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

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

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

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

To answer the questions in lines 8-9, use the U.S. Trustee Program chart.

To find the chart, go online using the link specified in the separate instructions for this form. This chart may also be available at the bankruptcy clerk’s office.

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

9. Housing and utilities – Mortgage or rent expenses:

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

9b. Total average monthly payment for all mortgages and other debts secured by your home.

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

Name of the creditor Average monthly
payment

___________________________________ $____________

___________________________________ $____________

___________________________________ + $____________

Copy Repeat this
Total average monthly payment $____________ ņ $___________ amount on hereÎ line 33a.

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

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

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

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

Official Form 122A–2 Chapter 7 Means Test Calculation page 3

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

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

    Vehicle 1 Describe Vehicle 1: _______________________________________________________________

    ---

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

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

    To calculate the average monthly payment here and on line 13e, add all amounts that are contractually due to each secured creditor in the 60 months after you filed for bankruptcy. Then divide by 60. Name of each creditor for Vehicle 1 Average monthly payment _____________________________________ $____________ _____________________________________ + $____________ Copy Repeat this Total average monthly payment $____________ ņ $____________ amount on hereÎ line 33b. Copy net 13c. Net Vehicle 1 ownership or lease expense Vehicle 1 Subtract line 13b from line 13a. If this amount is less than $0, enter $0. ............................. $____________ expense here ..... Î $_________

    Vehicle 2 Describe Vehicle 2: _______________________________________________________________

    ---

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

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

    Name of each creditor for Vehicle 2 Average monthly
    payment

    _____________________________________ $____________

    _____________________________________ + $____________

Copy Repeat this Total average monthly payment $____________ ņ $____________ amount on hereÎ line 33c.

Copy net
13f. Net Vehicle 2 ownership or lease expense Vehicle 2
Subtract line 13e from 13d. If this amount is less than $0, enter $0. ..................................... $____________ expense
here ... Î $________

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

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

2IILFLDO )RUP $± Chapter 7 Means Test Calculation page 4

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

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

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

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

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

19. Court-ordered payments: The total monthly amount that you pay as required by the order of a court or administrative agency, such as spousal or child support payments. $________

Do not include payments on past due obligations for spousal or child support. You will list these obligations in line 35.

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

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

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

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

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

2IILFLDO )RUP $± Chapter 7 Means Test Calculation page 5

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

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

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

    Health insurance $____________

    Disability insurance $____________

    Health savings account + $____________

    Total $____________ Copy total hereÎ ..................................... $________

Do you actually spend this total amount?

‰ No. How much do you actually spend? $___________ ‰ Yes

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

Protection against family violence. The reasonably necessary monthly expenses that you incur to maintain the safety of
$________
you and your family under the Family Violence Prevention and Services Act or other federal laws that apply.
By law, the court must keep the nature of these expenses confidential.

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

Education expenses for dependent children who are younger than 18. The monthly expenses (not more than $ *
per child) that you pay for your dependent children who are younger than 18 years old to attend a private or public
elementary or secondary school. $________
You must give your case trustee documentation of your actual expenses, and you must explain why the amount claimed is
reasonable and necessary and not already accounted for in lines 6-23.

* Subject to adjustment on 4/01/ , and every 3 years after that for cases begun on or after the date of adjustment.

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

Continuing charitable contributions. The amount that you will continue to contribute in the form of cash or financial + $_______
instruments to a religious or charitable organization. 26 U.S.C. § 170(c)(1)-(2).

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

2IILFLDO )RUP $± Chapter 7 Means Test Calculation page 6

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

Deductions for Debt Payment

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

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

Average monthly
payment
Mortgages on your home:

33a. Copy line 9b here ................................................................................................................ Î $_____________

Loans on your first two vehicles:

33b. Copy line 13b here. ............................................................................................................ Î $_____________

33c. Copy line 13e here. ........................................................................................................... Î $_____________

33d. List other secured debts:

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

‰ No
_______________________________ ________________________ $____________
‰ Yes

‰ No
_______________________________ ________________________ $____________
‰ Yes

‰ No
_______________________________ ________________________ + $____________
‰ Yes

Copy total
33e. Total average monthly payment. Add lines 33a through 33d. .................................................... $____________ hereÎ $_________

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

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

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

_______________________ ____________________ $__________ ÷ 60 = $_____________

_______________________ ____________________ $__________ ÷ 60 = $_____________

_______________________ ____________________ $__________ ÷ 60 = + $_____________

Copy total
Total $_____________ hereÎ $________

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

2IILFLDO )RUP $± Chapter 7 Means Test Calculation page 7

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

36. Are you eligible to file a case under Chapter 13? 11 U.S.C. § 109(e). For more information, go online using the link for Bankruptcy Basics specified in the separate instructions for this form. Bankruptcy Basics may also be available at the bankruptcy clerk’s office. ‰ No. Go to line 37. ‰ Yes. Fill in the following information.

    Projected monthly plan payment if you were filing under Chapter 13 $_____________

    Current multiplier for your district as stated on the list issued by the
    Administrative Office of the United States Courts (for districts in Alabama and
    North Carolina) or by the Executive Office for United States Trustees (for all
    other districts). x ______
    To find a list of district multipliers that includes your district, go online using the
    link specified in the separate instructions for this form. This list may also be
    available at the bankruptcy clerk’s office.
    Copy total
    Average monthly administrative expense if you were filing under Chapter 13 $_____________ hereÎ $_________

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

Total Deductions from Income

38.Add all of the allowed deductions.

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

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

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

Total deductions $______________ Copy total here ............................... Î $_________

Part 3: Determine Whether There Is a Presumption of Abuse

39. Calculate monthly disposable income for 60 months

    39a. Copy line 4, adjusted current monthly income ..... $_____________

    39b. Copy line 38, Total deductions. ......... í $_____________

    39c. Monthly disposable income. 11 U.S.C. § 707(b)(2). Copy $_____________ hereÎ $____________ Subtract line 39b from line 39a.

For the next 60 months (5 years) ........................................................................................................... x 60

Copy
39d. Total. Multiply line 39c by 60. .................................................................................................................. $____________ hereÎ $________

Find out whether there is a presumption of abuse. Check the box that applies:

‰ The line 39d is less than $ *. On the top of page 1 of this form, check box 1, There is no presumption of abuse. Go to Part 5.

‰ The line 39d is more than $1 *. On the top of page 1 of this form, check box 2, There is a presumption of abuse. You may fill out Part 4 if you claim special circumstances. Then go to Part 5.

‰ The line 39d is at least $ *, but not more than $ *. Go to line 41.

* Subject to adjustment on 4/01/ , and every 3 years after that for cases filed on or after the date of adjustment.

2IILFLDO )RUP $± Chapter 7 Means Test Calculation page 8

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

41. 41a. Fill in the amount of your total nonpriority unsecured debt. If you filled out A
Summary of Your Assets and Liabilities and Certain Statistical Information Schedules
(Official Form 106Sum), you may refer to line 3b on that form............................................................
$___________
x .25

41b. 25% of your total nonpriority unsecured debt. 11 U.S.C. § 707(b)(2)(A)(i)(I). Copy
$___________ hereÎ $________ Multiply line 41a by 0.25. ..........................................................................................................................

42. Determine whether the income you have left over after subtracting all allowed deductions is enough to pay 25% of your unsecured, nonpriority debt. Check the box that applies:

‰ Line 39d is less than line 41b. On the top of page 1 of this form, check box 1, There is no presumption of abuse. Go to Part 5.

‰ Line 39d is equal to or more than line 41b. On the top of page 1 of this form, check box 2, There is a presumption of abuse. You may fill out Part 4 if you claim special circumstances. Then go to Part 5.

Part 4: Give Details About Special Circumstances

43.Do you have any special circumstances that justify additional expenses or adjustments of current monthly income for which there is no reasonable alternative? 11 U.S.C. § 707(b)(2)(B).

‰ No. Go to Part 5. ‰ Yes. Fill in the following information. All figures should reflect your average monthly expense or income adjustment for each item. You may include expenses you listed in line 25.

You must give a detailed explanation of the special circumstances that make the expenses or income
adjustments necessary and reasonable. You must also give your case trustee documentation of your actual
expenses or income adjustments.

Average monthly expense
Give a detailed explanation of the special circumstances
or income adjustment

_______________________________________________________________________________ $__________________

_______________________________________________________________________________ $__________________

_______________________________________________________________________________ $__________________

_______________________________________________________________________________ $__________________

Part 5: Sign Below

By signing here, I declare under penalty of perjury that the information on this statement and in any attachments is true and correct.
8___________________________________________________ 8___________________________________
Signature of Debtor 1 Signature of Debtor 2

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

2IILFLDO )RUP $± Chapter 7 Means Test Calculation page 9

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UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA

In re ) ) ) Case No. ) ) ____________________________________)

VERIFICATION OF MASTER ADDRESS LIST

I (we) declare under penalty of perjury that the attached Master Address List is a true, correct, and

complete list of creditors and their addresses in this case.

I (we) acknowledge the following:

x Filing a Master Address List with incomplete or incorrect addresses may mean that creditor(s) with
incomplete or incorrect address(es) may not receive notification of this Bankruptcy case.

x The debtor(s) and the debtor’s(s’) attorney or bankruptcy petition preparer, if any, share responsibility
for the accuracy and completeness of the attached Master Address List.

x The Court will use the addresses on the attached Master Address List for all items that the Court mails,
and will not rely on other documents filed in this case (such as schedules and statements required by
the Bankruptcy Code and the Federal Rules of Bankruptcy Procedure) to obtain or verify the
addresses of creditors.

DATED:_____________________________ ___________________________________ Debtor’s Signature

DATED:_____________________________ ___________________________________ Joint Debtor’s (if any) signature

Submit this form and your Master Address List to one of the following addresses:

Sacramento Division Fresno Division
501 I Street, Suite 3-200 2500 Tulare Street, Suite 2501
Sacramento, CA 95814 Fresno, CA 93721

EDC 2-100 (Rev. 6/25)

UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA

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

Revised 3/2024 For information regarding current filing fees, please see our website at www.caeb.uscourts.gov.

Chapter 7: Liquidation This notice is for you if:
You are an individual filing for bankruptcy,
and
Chapter 7 is for individuals who have financial
difficulty preventing them from paying their Your debts are primarily consumer debts.
debts and who are willing to allow their non- Consumer debts are defined in 11 U.S.C.
exempt property to be used to pay their § 101(8) as “incurred by an individual
creditors. The primary purpose of filing under primarily for a personal, family, or
chapter 7 is to have your debts discharged. The household purpose.”
bankruptcy discharge relieves you after
bankruptcy from having to pay many of your
pre-bankruptcy debts. Exceptions exist for
particular debts, and liens on property may still

The types of bankruptcy that are be enforced after discharge. For example, a available to individuals creditor may have the right to foreclose a home mortgage or repossess an automobile.Individuals who meet the qualifications may file under one of four different chapters of the However, if the court finds that you haveBankruptcy Code: committed certain kinds of improper conduct described in the Bankruptcy Code, the court Chapter 7 — Liquidation may deny your discharge. Chapter 11 — Reorganization You should know that even if you file Chapter 12 — Voluntary repayment plan chapter 7 and you receive a discharge, some for family farmers or debts are not discharged under the law. fishermen Therefore, you may still be responsible to pay:

Chapter 13 — Voluntary repayment plan for individuals with regular most taxes; income most student loans; domestic support and property settlementYou should have an attorney review your obligations;decision to file for bankruptcy and the choice of chapter.

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

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

If your income is above the median for your state, you must file a second form —the Chapter 11 is often used for reorganizing a Chapter 7 Means Test Calculation (Official business, but is also available to individuals. Form 122A–2). The calculations on the form— The provisions of chapter 11 are too sometimes called the Means Test—deduct complicated to summarize briefly. from your income living expenses and payments on certain debts to determine any amount available to pay unsecured creditors. If

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

Read These Important Warnings

Because bankruptcy can have serious long-term financial and legal consequences, including loss of your property, you should hire an attorney and carefully consider all of your options before you file. Only an attorney can give you legal advice about what can happen as a result of filing for bankruptcy and what your options are. If you do file for bankruptcy, an attorney can help you fill out the forms properly and protect you, your family, your home, and your possessions. Although the law allows you to represent yourself in bankruptcy court, you should understand that many people find it difficult to represent themselves successfully. The rules are technical, and a mistake or inaction may harm you. If you file without an attorney, you are still responsible for knowing and following all of the legal requirements. You should not file for bankruptcy if you are not eligible to file or if you do not intend to file the necessary documents. Bankruptcy fraud is a serious crime; you could be fined and imprisoned if you commit fraud in your bankruptcy case. Making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

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

Similar to chapter 13, chapter 12 permits debts, as adjusted by the plan, within 3 years or family farmers and fishermen to repay their 5 years, depending on your income and other debts over a period of time using future factors. earnings and to discharge some debts that are not paid. After you make all the payments under your plan, many of your debts are discharged. The debts that are not discharged and that you may still be responsible to pay include: Chapter 13: Repayment plan for domestic support obligations, individuals with regular income most student loans, __________________________________________ certain taxes, debts for fraud or theft, debts for fraud or defalcation while acting in a fiduciary capacity, Chapter 13 is for individuals who have regular income and would like to pay all or part of most criminal fines and restitution their debts in installments over a period of time obligations, and to discharge some debts that are not paid. certain debts that are not listed in your You are eligible for chapter 13 only if your bankruptcy papers, debts are not more than certain dollar amounts certain debts for acts that caused death or set forth in 11 U.S.C. § 109. personal injury, and certain long-term secured debts.

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

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

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

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

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

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