Colorado Form Bankruptcy Online Details

The Bankruptcy Cover Sheet Petition is a legal document that must be filed with the bankruptcy court. It provides information about your assets, liabilities and living expenses. The petition is also an opportunity to list any pending lawsuits or other matters which may affect your eligibility for bankruptcy relief. The Bankruptcy Cover Sheet Petition can be confusing and difficult to complete without guidance from a lawyer who specializes in this area of law. This article will provide you with helpful tips on filling out the form correctly so that it has the best chance of being accepted by the court.

Below is the data concerning the PDF you were in search of to fill out. It will tell you the amount of time you'll need to complete bankruptcy cover sheet petition, what fields you will need to fill in and some further specific facts.

QuestionAnswer
Form NameBankruptcy Cover Sheet Petition
Form Length63 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 min 45 sec
Other namescolorado bankruptcy forms, s form chapter, denver county court forms, bankruptcy forms colorado

Form Preview Example

Local Bankruptcy Form 1002-1.1

COVER SHEET FOR PETITION

CHECK APPLICABLE BOXES TO SHOW ALL DOCUMENTS ATTACHED

Name of debtor(s):

[

] Attorney (firm name, address, telephone, and

 

registration number):

 

[

] No attorney (“pro se”)(home address, telephone):

 

 

 

Filing fee (revised 11/1/11 per directive of the Judicial Conference of the United States):

[ ] $306 for chapter 7

[ ] $1,213 for chapter 11 [ ] $246 for chapter 12 [ ] $281 for chapter 13

[ ] Other fee paid: $_________. Enter amount AND attach applicable application under FED.

R. BANKR. P. 1006 to pay in installments or pursuant to 28 U.S.C. § 1930(f) (if applicable).

Individual and business debtor(s) (except as otherwise noted):

[ ] Exhibit D Statement of Compliance with Credit Counseling Requirement for each individual debtor (a list of all authorized Credit Counselors for Colorado is found at http://www.usdoj.gov/ust or the court has a list that may be viewed in the Records/Public Information Room 114 of the court.)

[ ] Voluntary Petition – Official Form 1

[ ] Statement of Financial Affairs – Official Form 7

[ ] Summary of Schedules A–J – Official Form 6–Summary

[ ] Schedules A, B, C, D, E, F, G, H, I, and J – Official Forms 6A, 6B, 6C, 6D, 6E, 6F, 6Iand 6J

[ ] Declaration Concerning Debtor’s Schedules – Official Form 6–Declaration

[ ] Notice to Debtor by Non-Attorney Bankruptcy Petition Preparer – Official Form 19 (submitted only if debtor used the services of a bankruptcy petition preparer)

[ ] For each individual debtor, copies of all payment advices, paycheck stubs, or other evidence of all salary, commissions or income received within 60 days before the bankruptcy case was filed, copied on 8 ½ by 11 paper with the debtor’s first and last name printed on top of each page (and bankruptcy case number, if a number has been assigned); OR, as applicable, complete L.B. Form 1007-6.1 (“Statement Under Penalty of Perjury Concerning Payment Advices”) for each debtor.

[ ] A record of any interest in an education individual retirement account (“IRA”) (26 U.S.C. § 530(b)(1)) or qualified state tuition program (26 U.S.C. § 529(b)(1) plans).

[] Attorney Fee Disclosure Statement – Director’s Procedural Form B 203

[] Verification of Creditors’ Matrix – L.B. Form 1007-2.1

[] Creditors’ Matrix (see L.B.R. 1007-2 and L.B.R. 1007-2App. for instructions).

Additional items due from ALL individual debtors:

[] Statement of Social Security Number(s) – Official Form 21

Chapter 7 individual debtors also must file:

[] Statement of Current Monthly Income and Means Test Calculation – Official Form 22A*

[] Statement of Intention – Official Form 8 (due thirty days post-petition) (the failure to comply with this statement and file reaffirmation agreements or motions to redeem personal property that the debtor does not intend to surrender has ramifications 45 days after the first scheduled meeting of creditors under 11 U.S.C. § 362(h) of the Bankruptcy Code)

Chapter 11 individual debtors also must file:

[] Statement of Current Monthly Income – Official Form 22B Chapter 13 individual debtors also must file:

[] Statement of Current Monthly Income and Disposable Income Calculation – Official Form 22C*

[] Plan –L.B. Form 3015.1

*The links for the updated Internal Revenue Service and Census Bureau Information that may be needed to complete Statement of Current Monthly Income, Official Forms 22A and 22B, can be reached from the web site: http://www.usdoj.gov/ust/. (Not applicable in chapter 7 cases if debts are primarily business debts.)

Additional items due from chapter 11 debtors:

[] List of Twenty Largest Creditors – Official Form 4

[] Corporate Ownership Statement – Required by FED. R BANKR. P. 1007(a)(1) for corporations. L.B. Form 1007-4.1.

[] List of Equity Interest Holders – Required by FED. R. BANKR. P. 1007(a)(3) for

corporations. L.B. Form 1007-4.2.

[] Small business debtors must file the most recent 1) balance sheet, 2) statements of operations, 3) cash-flow statement and 4) federal income tax return; OR a verified statement that those documents do not exist and have not been prepared or filed.

[] Disclosure Regarding Receivers Bankruptcy Form 1007-7.1.

Date:

Printed name of party signing:

Signature of attorney (or debtor without counsel):

97

UNITED STATES BANKRUPTCY COURT

DISTRICT OF COLORADO

NOTICE REGARDING E-MAIL NOTIFICATION FOR DEBTORS WITHOUT AN

ATTORNEY AND PARTIES WITHOUT AN ATTORNEY

If you are not represented by an attorney and are a debtor or party in a bankruptcy case and you have an internet e-mail address, you can receive an electronic notice by e-mail whenever a filing is made in a case where you are a debtor or party. Benefits of receiving such notices are:

If your e-mail program supports viewing documents from hyper links and you have Adobe Acrobat Reader installed, you may be able to view the document filed through a hyperlink in the e-mail notice.

One look at the document is free (any additional opening(s) of the document will require a PACER account which may be obtained at the following web site: http://pacer.psc.uscourts.gov.)1

You will get immediate notification through e-mail when something is docketed in a case where you are a party.

To sign up for e-mail notification of filings made in a case where you are a debtor or party, provide the information requested below and return this form to the address stated.

By submitting this Notice, you are consenting to receive all notices required to be sent to you by the Bankruptcy Court by e-mail ONLY and you acknowledge and agree that such notices will NOT be sent to you by regular mail. You must keep the court notified of any changes in your e- mail address, which you may do by completing this form again and sending it to the court.

Please note: you are not allowed to file documents electronically with the Court or to communicate with the court through e-mail or fax transmission. (The only exceptions are our Court’s web based proof of claim program for qualified creditors and the creditor mailing matrix program for debtors.)

Your name: ____________________________________________________________________

(ONLY ONE NAME AND E-MAIL ADDRESS PER FORM)

Your case number or case number where you are a party: ________________________________

Your internet e-mail address: ______________________________________________________

Return Completed form to:

US Bankruptcy Court

721 19th St.

Denver, CO 80202

VISIT OUR WEBSITE FOR MORE INFORMATION: http://www.cob.uscourts.gov

1It is recommended that you download the document or print it out at that time.

B1 (Official Form 1) (04/13)

 

 

UNITED STATES BANKRUPTCY COURT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________ District of __________

 

 

 

 

 

VOLUNTARY PETITION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Debtor (if individual, enter Last, First, Middle):

 

 

 

Name of Joint Debtor (Spouse) (Last, First, Middle):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All Other Names used by the Debtor in the last 8 years

 

 

 

 

 

 

All Other Names used by the Joint Debtor in the last 8 years

 

 

 

(include married, maiden, and trade names):

 

 

 

 

 

 

(include married, maiden, and trade names):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN)/Complete EIN

 

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN)/Complete EIN

(if more than one, state all):

 

 

 

 

 

 

 

(if more than one, state all):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address of Debtor (No. and Street, City, and State):

 

 

 

Street Address of Joint Debtor (No. and Street, City, and State):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

 

 

 

 

 

 

ZIP CODE

 

County of Residence or of the Principal Place of Business:

 

 

 

 

 

County of Residence or of the Principal Place of Business:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address of Debtor (if different from street address):

 

 

 

Mailing Address of Joint Debtor (if different from street address):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

 

 

 

 

 

 

ZIP CODE

 

Location of Principal Assets of Business Debtor (if different from street address above):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

Type of Debtor

 

 

 

 

Nature of Business

 

 

 

Chapter of Bankruptcy Code Under Which

 

(Form of Organization)

 

 

 

(Check one box.)

 

 

 

 

 

the Petition is Filed (Check one box.)

 

(Check one box.)

 

 

 

 

Health Care Business

 

 

 

Chapter 7

Chapter 15 Petition for

 

 

 

 

 

 

 

 

 

 

Individual (includes Joint Debtors)

 

 

 

 

Single Asset Real Estate as defined in

 

Chapter 9

Recognition of a Foreign

See Exhibit D on page 2 of this form.

 

 

 

 

11 U.S.C. § 101(51B)

 

 

 

Chapter 11

Main Proceeding

Corporation (includes LLC and LLP)

 

 

 

Railroad

 

 

 

 

 

Chapter 12

Chapter 15 Petition for

Partnership

 

 

 

 

 

Stockbroker

 

 

 

 

 

Chapter 13

Recognition of a Foreign

Other (If debtor is not one of the above entities, check

 

Commodity Broker

 

 

 

 

Nonmain Proceeding

this box and state type of entity below.)

 

 

 

Clearing Bank

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

Chapter 15 Debtors

 

 

 

 

Tax-Exempt Entity

 

 

 

 

Nature of Debts

 

 

 

Country of debtor’s center of main interests:

 

 

 

(Check box, if applicable.)

 

 

 

 

(Check one box.)

 

 

 

 

 

 

 

 

 

 

 

 

 

Debts are primarily consumer

Debts are

 

 

 

 

 

 

 

Debtor is a tax-exempt organization

 

Each country in which a foreign proceeding by, regarding, or

 

 

debts, defined in 11 U.S.C.

primarily

 

under title 26 of the United States

 

§ 101(8) as “incurred by an

business debts.

against debtor is pending:

 

 

 

 

 

Code (the Internal Revenue Code).

 

individual primarily for a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

personal, family, or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

household purpose.”

 

 

 

 

 

Filing Fee (Check one box.)

 

 

 

 

 

 

 

 

Chapter 11 Debtors

 

 

 

 

 

 

 

 

 

 

 

 

 

Check one box:

 

 

 

 

 

 

 

Full Filing Fee attached.

 

 

 

 

 

 

 

Debtor is a small business debtor as defined in 11 U.S.C. § 101(51D).

Filing Fee to be paid in installments (applicable to individuals only). Must attach

Debtor is not a small business debtor as defined in 11 U.S.C. § 101(51D).

 

 

 

 

 

 

 

 

 

 

 

signed application for the court’s consideration certifying that the debtor is

 

Check if:

 

 

 

 

 

 

 

 

 

 

unable to pay fee except in installments. Rule 1006(b). See Official Form 3A.

 

Debtor’s aggregate noncontingent liquidated debts (excluding debts owed to

 

 

 

 

 

 

 

 

 

 

insiders or affiliates) are less than $2,490,925 (amount subject to adjustment

Filing Fee waiver requested (applicable to chapter 7 individuals only). Must

 

on 4/01/16 and every three years thereafter).

 

 

 

attach signed application for the court’s consideration. See Official Form 3B.

 

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check all applicable boxes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A plan is being filed with this petition.

 

 

 

 

 

 

 

 

 

 

 

 

 

Acceptances of the plan were solicited prepetition from one or more classes

 

 

 

 

 

 

 

 

 

 

of creditors, in accordance with 11 U.S.C. § 1126(b).

 

 

 

Statistical/Administrative Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS SPACE IS FOR

 

Debtor estimates that funds will be available for distribution to unsecured creditors.

 

 

 

 

 

 

 

COURT USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

Debtor estimates that, after any exempt property is excluded and administrative expenses paid, there will be no funds available for

 

 

 

 

 

distribution to unsecured creditors.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Estimated Number of Creditors

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1-49

50-99

100-199

200-999

1,000-

 

 

5,001-

 

10,001-

25,001-

 

50,001-

Over

 

 

 

 

 

 

 

 

5,000

 

 

10,000

 

25,000

50,000

 

 

100,000

100,000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Estimated Assets

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$0 to

$50,001 to

$100,001 to

$500,001

$1,000,001

$10,000,001

 

$50,000,001

$100,000,001

$500,000,001

More than

 

 

 

 

$50,000

$100,000

$500,000

to $1

to $10

to $50

to $100

to $500

to $1 billion

$1 billion

 

 

 

 

 

 

 

million

million

million

million

million

 

 

 

 

 

 

 

Estimated Liabilities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$0 to

$50,001 to

$100,001 to

$500,001

$1,000,001

$10,000,001

 

$50,000,001

$100,000,001

$500,000,001

More than

 

 

 

 

$50,000

$100,000

$500,000

to $1

to $10

to $50

to $100

to $500

to $1 billion

$1 billion

 

 

 

 

 

 

 

million

million

million

million

million

 

 

 

 

 

 

 

B1 (Official Form 1) (04/13)

Page 2

Voluntary Petition

Name of Debtor(s):

(This page must be completed and filed in every case.)

 

All Prior Bankruptcy Cases Filed Within Last 8 Years (If more than two, attach additional sheet.)

Location

 

Case Number:

Date Filed:

Where Filed:

 

 

 

Location

 

Case Number:

Date Filed:

Where Filed:

 

 

 

 

Pending Bankruptcy Case Filed by any Spouse, Partner, or Affiliate of this Debtor (If more than one, attach additional sheet.)

Name of Debtor:

 

Case Number:

Date Filed:

 

 

 

 

District:

 

Relationship:

Judge:

 

 

 

 

Exhibit A

 

Exhibit B

(To be completed if debtor is required to file periodic reports (e.g., forms 10K and

 

(To be completed if debtor is an individual

10Q) with the Securities and Exchange Commission pursuant to Section 13 or 15(d)

 

whose debts are primarily consumer debts.)

of the Securities Exchange Act of 1934 and is requesting relief under chapter 11.)

I, the attorney for the petitioner named in the foregoing petition, declare that I have

 

 

informed the petitioner that [he or she] may proceed under chapter 7, 11, 12, or 13

 

of title 11, United States Code, and have explained the relief available under each

 

such chapter. I further certify that I have delivered to the debtor the notice required

Exhibit A is attached and made a part of this petition.

by 11 U.S.C. § 342(b).

 

 

 

 

 

 

 

X

 

 

 

 

Signature of Attorney for Debtor(s)

(Date)

 

Exhibit C

Does the debtor own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety?

Yes, and Exhibit C is attached and made a part of this petition.

No.

Exhibit D

(To be completed by every individual debtor. If a joint petition is filed, each spouse must complete and attach a separate Exhibit D.)

Exhibit D, completed and signed by the debtor, is attached and made a part of this petition.

If this is a joint petition:

Exhibit D, also completed and signed by the joint debtor, is attached and made a part of this petition.

Information Regarding the Debtor - Venue

(Check any applicable box.)

Debtor has been domiciled or has had a residence, principal place of business, or principal assets in this District for 180 days immediately preceding the date of this petition or for a longer part of such 180 days than in any other District.

There is a bankruptcy case concerning debtor’s affiliate, general partner, or partnership pending in this District.

Debtor is a debtor in a foreign proceeding and has its principal place of business or principal assets in the United States in this District, or has no principal place of business or assets in the United States but is a defendant in an action or proceeding [in a federal or state court] in this District, or the interests of the parties will be served in regard to the relief sought in this District.

Certification by a Debtor Who Resides as a Tenant of Residential Property

(Check all applicable boxes.)

Landlord has a judgment against the debtor for possession of debtor’s residence. (If box checked, complete the following.)

(Name of landlord that obtained judgment)

(Address of landlord)

Debtor claims that under applicable nonbankruptcy law, there are circumstances under which the debtor would be permitted to cure the entire monetary default that gave rise to the judgment for possession, after the judgment for possession was entered, and

Debtor has included with this petition the deposit with the court of any rent that would become due during the 30-day period after the filing of the petition.

Debtor certifies that he/she has served the Landlord with this certification. (11 U.S.C. § 362(l)).

B1 (Official Form 1) (04/13)

 

 

Page 3

Voluntary Petition

Name of Debtor(s):

 

 

 

 

(This page must be completed and filed in every case.)

 

 

 

 

 

 

 

 

 

Signatures

 

 

 

 

 

Signature(s) of Debtor(s) (Individual/Joint)

 

Signature of a Foreign Representative

I declare under penalty of perjury that the information provided in this petition is true

I declare under penalty of perjury that the information provided in this petition is true

and correct.

and correct, that I am the foreign representative of a debtor in a foreign proceeding,

[If petitioner is an individual whose debts are primarily consumer debts and has

and that I am authorized to file this petition.

chosen to file under chapter 7] I am aware that I may proceed under chapter 7, 11, 12

(Check only one box.)

 

 

 

 

or 13 of title 11, United States Code, understand the relief available under each such

 

 

 

 

 

 

 

 

 

 

chapter, and choose to proceed under chapter 7.

 

I request relief in accordance with chapter 15 of title 11, United States Code.

[If no attorney represents me and no bankruptcy petition preparer signs the petition] I

 

 

Certified copies of the documents required by 11 U.S.C. § 1515 are attached.

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,

 

Pursuant to 11 U.S.C. § 1511, I request relief in accordance with the

chapter of title 11 specified in this petition. A certified copy of the

specified in this petition.

 

order granting recognition of the foreign main proceeding is attached.

X

 

 

X

 

 

 

 

 

Signature of Debtor

 

(Signature of Foreign Representative)

 

 

 

X

 

 

 

 

 

 

 

 

 

Signature of Joint Debtor

 

(Printed Name of Foreign Representative)

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number (if not represented by attorney)

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

Signature of Attorney*

 

Signature of Non-Attorney Bankruptcy Petition Preparer

X

I declare under penalty of perjury that:

(1) I am a bankruptcy petition preparer as

 

Signature of Attorney for Debtor(s)

 

defined in 11 U.S.C. § 110; (2) I prepared this document for compensation and have

 

 

 

 

provided the debtor with a copy of this document and the notices and information

 

Printed Name of Attorney for Debtor(s)

required under 11 U.S.C. §§ 110(b), 110(h), and 342(b); and, (3) if rules or

 

 

 

 

guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum

 

Firm Name

 

fee for services chargeable by bankruptcy petition preparers, I have given the debtor

 

 

 

 

notice of the maximum amount before preparing any document for filing for a debtor

 

 

 

 

or accepting any fee from the debtor, as required in that section. Official Form 19 is

 

 

 

 

attached.

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Printed Name and title, if any, of Bankruptcy Petition Preparer

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

*In a case in which § 707(b)(4)(D) applies, this signature also constitutes a

 

Social-Security number (If the bankruptcy petition preparer is not an individual,

 

state the Social-Security number of the officer, principal, responsible person or

certification that the attorney has no knowledge after an inquiry that the information

 

partner of the bankruptcy petition preparer.) (Required by 11 U.S.C. § 110.)

in the schedules is incorrect.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Debtor (Corporation/Partnership)

 

 

 

 

 

 

I declare under penalty of perjury that the information provided in this petition is true

 

 

 

 

 

 

 

Address

 

 

 

 

and correct, and that I have been authorized to file this petition on behalf of the

 

 

 

 

 

 

debtor.

X

 

 

 

 

The debtor requests the relief in accordance with the chapter of title 11, United States

 

 

 

 

 

Signature

 

 

 

 

Code, specified in this petition.

 

 

 

 

 

 

X

 

 

 

 

 

 

 

Date

 

 

 

 

 

Signature of Authorized Individual

 

 

 

 

 

 

 

 

 

 

 

Signature of bankruptcy petition preparer or officer, principal, responsible person, or

 

Printed Name of Authorized Individual

 

partner whose Social-Security number is provided above.

 

 

 

 

 

 

 

 

 

Title of Authorized Individual

 

Names and Social-Security numbers of all other individuals who prepared or assisted

 

 

 

 

 

 

 

 

in preparing this document unless the

bankruptcy petition preparer is not an

 

Date

 

individual.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If more than one person prepared this document, attach additional sheets conforming

 

 

 

 

to the appropriate official form for each person.

 

 

 

 

A bankruptcy petition preparer’s failure to comply with the provisions of title 11 and

 

 

 

 

the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or

 

 

 

 

both. 11 U.S.C. § 110; 18 U.S.C. § 156.

 

 

 

 

B 1D (Official Form 1, Exhibit D) (12/09)

UNITED STATES BANKRUPTCY COURT

__________ District of __________

In re__________________________

Case No._____________

Debtor

(if known)

EXHIBIT D - INDIVIDUAL DEBTOR’S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT

Warning: You must be able to check truthfully one of the five statements regarding credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy case, and the court can dismiss any case you do file. If that happens, you will lose whatever filing fee you paid, and your creditors will be able to resume collection activities against you. If your case is dismissed and you file another bankruptcy case later, you may be required to pay a second filing fee and you may have to take extra steps to stop creditors’ collection activities.

Every individual debtor must file this Exhibit D. If a joint petition is filed, each spouse must complete and file a separate Exhibit D. Check one of the five statements below and attach any documents as directed.

1. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a credit counseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunities for available credit counseling and assisted me in performing a related budget analysis, and I have a certificate from the agency describing the services provided to me. Attach a copy of the certificate and a copy of any debt repayment plan developed through the agency.

2. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a credit counseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunities for available credit counseling and assisted me in performing a related budget analysis, but I do not have a certificate from the agency describing the services provided to me. You must file a copy of a certificate from the agency describing the services provided to you and a copy of any debt repayment plan developed through the agency no later than 14 days after your bankruptcy case is filed.

B 1D (Official Form 1, Exh. D) (12/09) – Cont.

Page 2

 

3. I certify that I requested credit counseling services from an approved agency but was unable to obtain the services during the seven days from the time I made my request, and the following exigent circumstances merit a temporary waiver of the credit counseling requirement so I can file my bankruptcy case now. [Summarize exigent circumstances here.]

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If your certification is satisfactory to the court, you must still obtain the credit counseling briefing within the first 30 days after you file your bankruptcy petition and promptly file a certificate from the agency that provided the counseling, together with a copy of any debt management plan developed through the agency. Failure to fulfill these requirements may result in dismissal of your case. Any extension of the 30-day deadline can be granted only for cause and is limited to a maximum of 15 days. Your case may also be dismissed if the court is not satisfied with your reasons for filing your bankruptcy case without first receiving a credit counseling briefing.

4. I am not required to receive a credit counseling briefing because of: [Check the applicable statement.] [Must be accompanied by a motion for determination by the court.]

Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental illness or mental deficiency so as to be incapable of realizing and making rational decisions with respect to financial responsibilities.);

Disability. (Defined in 11 U.S.C. § 109(h)(4) as physically impaired to the extent of being unable, after reasonable effort, to participate in a credit counseling briefing in person, by telephone, or through the Internet.);

Active military duty in a military combat zone.

5. The United States trustee or bankruptcy administrator has determined that the credit counseling requirement of 11 U.S.C. ' 109(h) does not apply in this district.

I certify under penalty of perjury that the information provided above is true and correct.

Signature of Debtor: ________________________

Date: _________________

B 1D (Official Form 1, Exhibit D) (12/09)

UNITED STATES BANKRUPTCY COURT

__________ District of __________

In re__________________________

Case No._____________

Debtor

(if known)

EXHIBIT D - INDIVIDUAL DEBTOR’S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT

Warning: You must be able to check truthfully one of the five statements regarding credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy case, and the court can dismiss any case you do file. If that happens, you will lose whatever filing fee you paid, and your creditors will be able to resume collection activities against you. If your case is dismissed and you file another bankruptcy case later, you may be required to pay a second filing fee and you may have to take extra steps to stop creditors’ collection activities.

Every individual debtor must file this Exhibit D. If a joint petition is filed, each spouse must complete and file a separate Exhibit D. Check one of the five statements below and attach any documents as directed.

1. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a credit counseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunities for available credit counseling and assisted me in performing a related budget analysis, and I have a certificate from the agency describing the services provided to me. Attach a copy of the certificate and a copy of any debt repayment plan developed through the agency.

2. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a credit counseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunities for available credit counseling and assisted me in performing a related budget analysis, but I do not have a certificate from the agency describing the services provided to me. You must file a copy of a certificate from the agency describing the services provided to you and a copy of any debt repayment plan developed through the agency no later than 14 days after your bankruptcy case is filed.

B 1D (Official Form 1, Exh. D) (12/09) – Cont.

Page 2

 

3. I certify that I requested credit counseling services from an approved agency but was unable to obtain the services during the seven days from the time I made my request, and the following exigent circumstances merit a temporary waiver of the credit counseling requirement so I can file my bankruptcy case now. [Summarize exigent circumstances here.]

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If your certification is satisfactory to the court, you must still obtain the credit counseling briefing within the first 30 days after you file your bankruptcy petition and promptly file a certificate from the agency that provided the counseling, together with a copy of any debt management plan developed through the agency. Failure to fulfill these requirements may result in dismissal of your case. Any extension of the 30-day deadline can be granted only for cause and is limited to a maximum of 15 days. Your case may also be dismissed if the court is not satisfied with your reasons for filing your bankruptcy case without first receiving a credit counseling briefing.

4. I am not required to receive a credit counseling briefing because of: [Check the applicable statement.] [Must be accompanied by a motion for determination by the court.]

Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental illness or mental deficiency so as to be incapable of realizing and making rational decisions with respect to financial responsibilities.);

Disability. (Defined in 11 U.S.C. § 109(h)(4) as physically impaired to the extent of being unable, after reasonable effort, to participate in a credit counseling briefing in person, by telephone, or through the Internet.);

Active military duty in a military combat zone.

5. The United States trustee or bankruptcy administrator has determined that the credit counseling requirement of 11 U.S.C. ' 109(h) does not apply in this district.

I certify under penalty of perjury that the information provided above is true and correct.

Signature of Debtor: ________________________

Date: _________________

B 1C (Official Form 1, Exhibit C) (9/01)

[If, to the best of the debtor’s knowledge, the debtor owns or has possession of property that poses or is alleged to pose a threat of imminent and identifiable harm to the public health or safety, attach this Exhibit “C” to the petition.]

UNITED STATES BANKRUPTCY COURT

 

 

__________ District of __________

 

In re

,

)

Case No.

 

Debtor

 

 

)

 

 

 

 

 

)

 

 

 

 

 

)

Chapter

EXHIBIT “C” TO VOLUNTARY PETITION

1.Identify and briefly describe all real or personal property owned by or in possession of the debtor that, to the best of the debtor’s knowledge, poses or is alleged to pose a threat of imminent and identifiable harm to the public health or safety (attach additional sheets if necessary):

2.With respect to each parcel of real property or item of personal property identified in question 1, describe the nature and location of the dangerous condition, whether environmental or otherwise, that poses or is alleged to pose a threat of imminent and identifiable harm to the public health or safety (attach additional sheets if necessary):

B7 (Official Form 7) (04/13)

UNITED STATES BANKRUPTCY COURT

__________ District of _________

In re:________________________________________,

Case No. ___________________________________

Debtor

(if known)

STATEMENT OF FINANCIAL AFFAIRS

This statement is to be completed by every debtor. Spouses filing a joint petition may file a single statement on which the information for both spouses is combined. If the case is filed under chapter 12 or chapter 13, a married debtor must furnish information for both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed. An individual debtor engaged in business as a sole proprietor, partner, family farmer, or self-employed professional, should provide the information requested on this statement concerning all such activities as well as the individual's personal affairs. To indicate payments, transfers and the like to minor children, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

Questions 1 - 18 are to be completed by all debtors. Debtors that are or have been in business, as defined below, also must complete Questions 19 - 25. If the answer to an applicable question is "None," mark the box labeled "None." If additional space is needed for the answer to any question, use and attach a separate sheet properly identified with the case name, case number (if known), and the number of the question.

DEFINITIONS

"In business." A debtor is "in business" for the purpose of this form if the debtor is a corporation or partnership. An individual debtor is "in business" for the purpose of this form if the debtor is or has been, within six years immediately preceding the filing of this bankruptcy case, any of the following: an officer, director, managing executive, or owner of 5 percent or more of the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership; a sole proprietor or self-employed full-time or part-time. An individual debtor also may be “in business” for the purpose of this form if the debtor engages in a trade, business, or other activity, other than as an employee, to supplement income from the debtor’s primary employment.

"Insider." The term "insider" includes but is not limited to: relatives of the debtor; general partners of the debtor and their relatives; corporations of which the debtor is an officer, director, or person in control; officers, directors, and any persons in control of a corporate debtor and their relatives; affiliates of the debtor and insiders of such affiliates; and any managing agent of the debtor. 11 U.S.C. § 101(2), (31).

____________________________________________________________________________________________________

1.Income from employment or operation of business

None State the gross amount of income the debtor has received from employment, trade, or profession, or from operation of the debtor's business, including part-time activities either as an employee or in independent trade or business, from the beginning of this calendar year to the date this case was commenced. State also the gross amounts received during the two years immediately preceding this calendar year. (A debtor that maintains, or has maintained, financial records on the basis of a fiscal rather than a calendar year may report fiscal year income. Identify the beginning and ending dates of the debtor's fiscal year.) If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income of both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

AMOUNT

SOURCE

B7 (Official Form 7) (04/13)

2

2.Income other than from employment or operation of business

None State the amount of income received by the debtor other than from employment, trade, profession, operation of the debtor's business during the two years immediately preceding the commencement of this case. Give particulars. If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income for each spouse whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

AMOUNT

SOURCE

____________________________________________________________________________________________________

3.Payments to creditors

Complete a. or b., as appropriate, and c.

None

G

None

G

a. Individual or joint debtor(s) with primarily consumer debts: List all payments on loans, installment purchases of

goods or services, and other debts to any creditor made within 90 days immediately preceding the commencement of this case unless the aggregate value of all property that constitutes or is affected by such transfer is less than $600. Indicate with an asterisk (*) any payments that were made to a creditor on account of a domestic support obligation or as part of an alternative repayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR

DATES OF

AMOUNT

AMOUNT

 

PAYMENTS

PAID

STILL OWING

b.Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor made within 90 days immediately preceding the commencement of the case unless the aggregate value of all property that constitutes or is affected by such transfer is less than $6,225*. If the debtor is an individual, indicate with an asterisk

(*) any payments that were made to a creditor on account of a domestic support obligation or as part of an alternative repayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency. (Married debtors filing under chapter 12 or chapter 13 must include payments and other transfers by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR

DATES OF

AMOUNT

AMOUNT

 

PAYMENTS/

PAID OR

STILL

 

TRANSFERS

VALUE OF

OWING

 

 

TRANSFERS

 

*Amount subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

B7 (Official Form 7) (04/13)

3

None

G

c. All debtors: List all payments made within one year immediately preceding the commencement of this case

to or for the benefit of creditors who are or were insiders. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR

DATE OF

AMOUNT

AMOUNT

AND RELATIONSHIP TO DEBTOR

PAYMENT

PAID

STILL OWING

____________________________________________________________________________________________________

None

None

4. Suits and administrative proceedings, executions, garnishments and attachments

a.List all suits and administrative proceedings to which the debtor is or was a party within one year immediately preceding the filing of this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

CAPTION OF SUIT

NATURE OF

COURT OR AGENCY

STATUS OR

AND CASE NUMBER

PROCEEDING

AND LOCATION

DISPOSITION

b.Describe all property that has been attached, garnished or seized under any legal or equitable process within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS

DATE OF

DESCRIPTION

OF PERSON FOR WHOSE

SEIZURE

AND VALUE

BENEFIT PROPERTY WAS SEIZED

 

OF PROPERTY

_____________________________________________________________________________________________________

5.Repossessions, foreclosures and returns

None List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure or returned to the seller, within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS

DATE OF REPOSSESSION,

DESCRIPTION

OF CREDITOR OR SELLER

FORECLOSURE SALE,

AND VALUE

 

TRANSFER OR RETURN

OF PROPERTY

____________________________________________________________________________________________________

B7 (Official Form 7) (04/13)

4

6.Assignments and receiverships

None a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS

DATE OF

TERMS OF

OF ASSIGNEE

ASSIGNMENT

ASSIGNMENT

 

 

OR SETTLEMENT

None b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS

NAME AND LOCATION

DATE OF

DESCRIPTION

OF CUSTODIAN

OF COURT

ORDER

AND VALUE

 

CASE TITLE & NUMBER

 

Of PROPERTY

____________________________________________________________________________________________________

7.Gifts

None List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient. (Married debtors filing under chapter 12 or chapter 13 must include gifts or contributions by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS

RELATIONSHIP

DATE

DESCRIPTION

OF PERSON

TO DEBTOR,

OF GIFT

AND VALUE

OR ORGANIZATION

IF ANY

 

OF GIFT

____________________________________________________________________________________________________

8.Losses

None List all losses from fire, theft, other casualty or gambling within one year immediately preceding the commencement of this case or since the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include losses by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

DESCRIPTION

DESCRIPTION OF CIRCUMSTANCES AND, IF

DATE

AND VALUE OF

LOSS WAS COVERED IN WHOLE OR IN PART

OF LOSS

PROPERTY

BY INSURANCE, GIVE PARTICULARS

 

____________________________________________________________________________________________________

B7 (Official Form 7) (04/13)

5

9.Payments related to debt counseling or bankruptcy

None List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in bankruptcy within one year immediately preceding the commencement of this case.

NAME AND ADDRESS

DATE OF PAYMENT,

OF PAYEE

NAME OF PAYER IF

 

OTHER THAN DEBTOR

AMOUNT OF MONEY OR DESCRIPTION AND VALUE OF PROPERTY

____________________________________________________________________________________________________

10. Other transfers

None

a.List all other property, other than property transferred in the ordinary course of the business or financial affairs of the debtor, transferred either absolutely or as security within two years immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include transfers by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

None

G

NAME AND ADDRESS

DATE

DESCRIBE PROPERTY

OF TRANSFEREE,

 

TRANSFERRED AND

RELATIONSHIP TO DEBTOR

 

VALUE RECEIVED

b.List all property transferred by the debtor within ten years immediately preceding the commencement of this case to a self-settled trust or similar device of which the debtor is a beneficiary.

NAME OF TRUST OR OTHER

DATE(S) OF

AMOUNT OF MONEY OR DESCRIPTION

DEVICE

TRANSFER(S)

AND VALUE OF PROPERTY OR DEBTOR’S

 

 

INTEREST IN PROPERTY

____________________________________________________________________________________________________

11. Closed financial accounts

None List all financial accounts and instruments held in the name of the debtor or for the benefit of the debtor which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. Include checking, savings, or other financial accounts, certificates of deposit, or other instruments; shares and share accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and other financial institutions. (Married debtors filing under chapter 12 or chapter 13 must include information concerning accounts or instruments held by or for either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS

TYPE OF ACCOUNT, LAST FOUR

AMOUNT AND

OF INSTITUTION

DIGITS OF ACCOUNT NUMBER,

DATE OF SALE

 

AND AMOUNT OF FINAL BALANCE

OR CLOSING

____________________________________________________________________________________________________

B7 (Official Form 7) (04/13)

6

12. Safe deposit boxes

None List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include boxes or depositories of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS

NAMES AND ADDRESSES

DESCRIPTION

DATE OF TRANSFER

OF BANK OR

OF THOSE WITH ACCESS

OF

OR SURRENDER,

OTHER DEPOSITORY

TO BOX OR DEPOSITORY

CONTENTS

IF ANY

____________________________________________________________________________________________________

13. Setoffs

None List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS

DATE OF

AMOUNT

OF CREDITOR

SETOFF

OF SETOFF

____________________________________________________________________________________________________

14. Property held for another person

None List all property owned by another person that the debtor holds or controls.

NAME AND ADDRESS

DESCRIPTION AND

LOCATION OF PROPERTY

OF OWNER

VALUE OF PROPERTY

 

____________________________________________________________________________________________________

None

G

15. Prior address of debtor

If debtor has moved within three years immediately preceding the commencement of this case, list all premises which the debtor occupied during that period and vacated prior to the commencement of this case. If a joint petition is filed, report also any separate address of either spouse.

ADDRESS

NAME USED

DATES OF OCCUPANCY

____________________________________________________________________________

B7 (Official Form 7) (04/13)

7

16. Spouses and Former Spouses

None If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within eight years immediately preceding the commencement of the case, identify the name of the debtor’s spouse and of

any former spouse who resides or resided with the debtor in the community property state.

NAME

___________________________________________________________________________________________________

17. Environmental Information.

For the purpose of this question, the following definitions apply:

"Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material.

"Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites.

"Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law.

None a. List the name and address of every site for which the debtor has received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law:

SITE NAME

NAME AND ADDRESS

DATE OF

ENVIRONMENTAL

AND ADDRESS

OF GOVERNMENTAL UNIT

NOTICE

LAW

None b. List the name and address of every site for which the debtor provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

SITE NAME

NAME AND ADDRESS

DATE OF

ENVIRONMENTAL

AND ADDRESS

OF GOVERNMENTAL UNIT

NOTICE

LAW

None c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number.

NAME AND ADDRESS

DOCKET NUMBER

STATUS OR

OF GOVERNMENTAL UNIT

 

DISPOSITION

____________________________________________________________________________________________________

18 . Nature, location and name of business

None a. If the debtor is an individual, list the names, addresses, taxpayer-identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partner in a partnership, sole proprietor, or was self-employed in a trade, profession, or

B7 (Official Form 7) (04/13)

8

other activity either full- or part-time within six years immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities within six years immediately preceding the commencement of this case.

If the debtor is a partnership, list the names, addresses, taxpayer-identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within six years immediately preceding the commencement of this case.

If the debtor is a corporation, list the names, addresses, taxpayer-identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within six years immediately preceding the commencement of this case.

NAME

LAST FOUR DIGITS

ADDRESS

NATURE OF BUSINESS BEGINNING AND

 

OF SOCIAL-SECURITY

 

ENDING DATES

 

OR OTHER INDIVIDUAL

 

 

 

TAXPAYER-I.D. NO.

 

 

 

(ITIN)/ COMPLETE EIN

 

 

None b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C. § 101.

NAMEADDRESS

____________________________________________________________________________________________________

The following questions are to be completed by every debtor that is a corporation or partnership and by any individual debtor who is or has been, within six years immediately preceding the commencement of this case, any of the following: an officer, director, managing executive, or owner of more than 5 percent of the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership, a sole proprietor, or self-employed in a trade, profession, or other activity, either full- or part-time.

(An individual or joint debtor should complete this portion of the statement only if the debtor is or has been in business, as defined above, within six years immediately preceding the commencement of this case. A debtor who has not been in business within those six years should go directly to the signature page.)

____________________________________________________________________________________________________

19. Books, records and financial statements

None a. List all bookkeepers and accountants who within two years immediately preceding the filing of this bankruptcy case kept or supervised the keeping of books of account and records of the debtor.

NAME AND ADDRESS

DATES SERVICES RENDERED

None b. List all firms or individuals who within two years immediately preceding the filing of this bankruptcy case have audited the books of account and records, or prepared a financial statement of the debtor.

NAME

ADDRESS

DATES SERVICES RENDERED

B7 (Official Form 7) (04/13)

9

None c. List all firms or individuals who at the time of the commencement of this case were in possession of the books of account and records of the debtor. If any of the books of account and records are not available, explain.

NAME

ADDRESS

None d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case.

NAME AND ADDRESSDATE ISSUED

________________________________________________________________________________________________

20. Inventories

None a. List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory.

DATE OF INVENTORY

INVENTORY SUPERVISOR DOLLAR AMOUNT

 

OF INVENTORY

 

(Specify cost, market or other basis)

None b. List the name and address of the person having possession of the records of each of the inventories reported in a., above.

DATE OF INVENTORY

NAME AND ADDRESSES

 

OF CUSTODIAN

 

OF INVENTORY RECORDS

____________________________________________________________________________________________________

None

None

21 . Current Partners, Officers, Directors and Shareholders

a.If the debtor is a partnership, list the nature and percentage of partnership interest of each member of the partnership.

NAME AND ADDRESS

NATURE OF INTEREST PERCENTAGE OF INTEREST

b.If the debtor is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 percent or more of the voting or equity securities of the corporation.

 

 

NATURE AND PERCENTAGE

NAME AND ADDRESS

TITLE

OF STOCK OWNERSHIP

__________________________________________________________________________________________________

B7 (Official Form 7) (04/13)

10

22 . Former partners, officers, directors and shareholders

None a. If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case.

NAME

ADDRESS

DATE OF WITHDRAWAL

None b. If the debtor is a corporation, list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case.

NAME AND ADDRESSTITLEDATE OF TERMINATION

___________________________________________________________________________________________________

23 . Withdrawals from a partnership or distributions by a corporation

None If the debtor is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the commencement of this case.

NAME & ADDRESS

DATE AND PURPOSE

AMOUNT OF MONEY

OF RECIPIENT,

OF WITHDRAWAL

OR DESCRIPTION

RELATIONSHIP TO DEBTOR

 

AND VALUE OF PROPERTY

___________________________________________________________________

24. Tax Consolidation Group.

None If the debtor is a corporation, list the name and federal taxpayer-identification number of the parent corporation of any consolidated group for tax purposes of which the debtor has been a member at any time within six years immediately preceding the commencement of the case.

NAME OF PARENT CORPORATION TAXPAYER-IDENTIFICATION NUMBER (EIN)

____________________________________________________________________________________________________

25. Pension Funds.

None If the debtor is not an individual, list the name and federal taxpayer-identification number of any pension fund to which the debtor, as an employer, has been responsible for contributing at any time within six years immediately preceding the commencement of the case.

NAME OF PENSION FUND

TAXPAYER-IDENTIFICATION NUMBER (EIN)

* * * * * *

[If completed by an individual or individual and spouse]

B7 (Official Form 7) (04/13)

11

I declare under penalty of perjury that I have read the answers contained in the foregoing statement of financial affairs and any attachments thereto and that they are true and correct.

Date

 

Signature of Debtor

Date

 

Signature of Joint Debtor (if any)

 

 

 

____________________________________________________________________________

[If completed on behalf of a partnership or corporation]

I declare under penalty of perjury that I have read the answers contained in the foregoing statement of financial affairs and any attachments thereto and that they are true and correct to the best of my knowledge, information and belief.

Date

 

Signature

 

 

 

Print Name and Title

[An individual signing on behalf of a partnership or corporation must indicate position or relationship to debtor.]

___continuation sheets attached

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571

___________________________________________________________________________________________________

DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. §§ 110(b), 110(h), and 342(b); and, (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required by that section.

Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer

 

Social-Security No. (Required by 11 U.S.C. § 110.)

If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social-security number of the officer, principal, responsible person, or partner who signs this document.

Address

Signature of Bankruptcy Petition Preparer

 

Date

Names and Social-Security numbers of all other individuals who prepared or assisted in preparing this document unless the bankruptcy petition preparer is not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 18 U.S.C. § 156.

B6 Summary (Official Form 6 - Summary) (12/07)

United States Bankruptcy Court

_________ District Of __________

In re ___________________________________,

Case No. ___________________

Debtor

Chapter ____________

 

SUMMARY OF SCHEDULES

Indicate as to each schedule whether that schedule is attached and state the number of pages in each. Report the totals from Schedules A, B, D, E, F, I, and J in the boxes provided. Add the amounts from Schedules A and B to determine the total amount of the debtor’s assets. Add the amounts of all claims from Schedules D, E, and F to determine the total amount of the debtor’s liabilities. Individual debtors also must complete the “Statistical Summary of Certain Liabilities and Related Data” if they file a case under chapter 7, 11, or 13.

 

 

ATTACHED

 

 

 

 

NAME OF SCHEDULE

 

(YES/NO)

NO. OF SHEETS

ASSETS

LIABILITIES

OTHER

 

 

 

 

 

 

 

A - Real Property

 

 

 

$

 

 

 

 

 

 

 

 

 

B - Personal Property

 

 

 

$

 

 

 

 

 

 

 

 

 

C - Property Claimed

 

 

 

 

 

 

as Exempt

 

 

 

 

 

 

D - Creditors Holding

 

 

 

 

$

 

Secured Claims

 

 

 

 

 

 

E - Creditors Holding Unsecured

 

 

 

 

$

 

Priority Claims

 

 

 

 

 

 

(Total of Claims on Schedule E)

 

 

 

 

 

 

F - Creditors Holding Unsecured

 

 

 

 

$

 

Nonpriority Claims

 

 

 

 

 

 

 

 

 

 

 

 

 

G - Executory Contracts and

 

 

 

 

 

 

Unexpired Leases

 

 

 

 

 

 

 

 

 

 

 

 

 

H - Codebtors

 

 

 

 

 

 

 

 

 

 

 

 

 

I - Current Income of

 

 

 

 

 

$

Individual Debtor(s)

 

 

 

 

 

 

J - Current Expenditures of Individual

 

 

 

 

 

$

Debtors(s)

 

 

 

 

 

 

 

TOTAL

 

$

$

 

 

 

 

 

 

 

 

B 6 Summary (Official Form 6 - Summary) (12/07)

United States Bankruptcy Court

______ District Of ___________

In re ___________________________________,

Case No. ___________________

Debtor

Chapter ____________

 

STATISTICAL SUMMARY OF CERTAIN LIABILITIES AND RELATED DATA (28 U.S.C. § 159)

If you are an individual debtor whose debts are primarily consumer debts, as defined in § 101(8) of the Bankruptcy Code (11 U.S.C. § 101(8)), filing a case under chapter 7, 11 or 13, you must report all information requested below.

QCheck this box if you are an individual debtor whose debts are NOT primarily consumer debts. You are not required to report any information here.

This information is for statistical purposes only under 28 U.S.C. § 159.

Summarize the following types of liabilities, as reported in the Schedules, and total them.

 

Type of Liability

Amount

 

 

 

 

 

 

Domestic Support Obligations (from Schedule E)

$

 

 

 

 

 

 

Taxes and Certain Other Debts Owed to Governmental Units

$

 

 

(from Schedule E)

 

 

 

 

 

 

 

Claims for Death or Personal Injury While Debtor Was

$

 

 

Intoxicated (from Schedule E) (whether disputed or undisputed)

 

 

 

 

 

 

 

Student Loan Obligations (from Schedule F)

$

 

 

 

 

 

 

Domestic Support, Separation Agreement, and Divorce Decree

$

 

 

Obligations Not Reported on Schedule E

 

 

 

 

 

 

 

Obligations to Pension or Profit-Sharing, and Other Similar

$

 

 

Obligations (from Schedule F)

 

 

 

 

 

 

 

 

 

TOTAL

$

 

 

 

 

 

State the following:

 

 

 

Average Income (from Schedule I, Line 16)

$

 

 

 

 

 

 

Average Expenses (from Schedule J, Line 18)

$

 

 

 

 

 

 

Current Monthly Income (from Form 22A Line 12; OR, Form

$

 

 

22B Line 11; OR, Form 22C Line 20 )

 

 

State the following:

 

 

 

1. Total from Schedule D, “UNSECURED PORTION, IF

 

$

 

ANY” column

 

 

 

2. Total from Schedule E, “AMOUNT ENTITLED TO

$

 

 

PRIORITY” column.

 

 

 

3. Total from Schedule E, “AMOUNT NOT ENTITLED TO

 

$

 

PRIORITY, IF ANY” column

 

 

 

4.

Total from Schedule F

 

$

 

5.

Total of non-priority unsecured debt (sum of 1, 3, and 4)

 

$

 

 

 

 

 

B6A (Official Form 6A) (12/07)

 

In re _____________________________________________,

Case No. ______________________________

Debtor

(If known)

SCHEDULE A - REAL PROPERTY

Except as directed below, list all real property in which the debtor has any legal, equitable, or future interest, including all property owned as a co- tenant, community property, or in which the debtor has a life estate. Include any property in which the debtor holds rights and powers exercisable for the debtor’s own benefit. If the debtor is married, state whether the husband, wife, both, orthe marital community own the property by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community .” If the debtor holds no interest in real property , write “None” under “Description and Location of Property.”

Do not include interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and Unexpired Leases.

If an entity claims to have a lien or hold a secured interest inany property, state the amount of the secured claim. See Schedule D. If no entity claims to hold a secured interest in the property, write “None” in the column labeled “Amount of Secured Claim.”

If the debtor is an individual or if a joint petition is filed, state the amount of any exemption claimed in the property only in Schedule C - Property Claimed as Exempt.

DESCRIPTION AND

LOCATION OF

PROPERTY

NATURE OF DEBTOR’S INTEREST IN PROPERTY

CURRENT VALUE

OF DEBTOR’S

INTEREST IN

PROPERTY, WITHOUT

DEDUCTING ANY SECURED CLAIM OR EXEMPTION

AMOUNT OF

SECURED

CLAIM

Total'

(Report also on Summary of Schedules.)

B 6B (Official Form 6B) (12/07)

 

In re _______________________________________________,

Case No. _________________________

Debtor

(If known)

SCHEDULE B - PERSONAL PROPERTY

Except as directed below, list all personal propertyof the debtorof whatever kind. If the debtor has no propertyin one or more of the categories, place an “x” in the appropriate position in the column labeled “None.” If additional space is needed in any category, attach a separate sheet properly identified with the case name, case number, and the number of the category. If the debtor is married, state whether thehusband, wife, both, or the marital community own the property by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community .” If the debtor is an individual or a joint petition is filed, state the amount of any exemptions claimed only in Schedule C - Property Claimed as Exempt.

Do not list interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and Unexpired Leases.

If the property is being held for the debtor by someone else, state that person’s name and address under “Description and Location of Property.” If the property is being held for a minor child, simply state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

 

 

 

CURRENT VALUE OF

 

N

 

DEBTOR’S INTEREST

 

DESCRIPTION AND LOCATION

IN PROPERTY, WITH-

TYPE OF PROPERTY

O

OUT DEDUCTING ANY

 

N

OF PROPERTY

SECURED CLAIM

 

E

 

OR EXEMPTION

1.Cash on hand.

2.Checking, savings or other finan- cial accounts, certificates of deposit or shares in banks, savings and loan, thrift, building and loan, and home- stead associations, or credit unions, brokerage houses, or cooperatives.

3.Security deposits with public util- ities, telephone companies, land- lords, and others.

4.Household goods and furnishings, including audio, video, and computer equipment.

5.Books; pictures and other art objects; antiques; stamp, coin, record, tape, compact disc, and other collections or collectibles.

6. Wearing apparel.

7.Furs and jewelry.

8.Firearms and sports, photo- graphic, and other hobby equipment.

9.Interests in insurance policies. Name insurance company of each policy and itemize surrender or refund value of each.

10.Annuities. Itemize and name each issuer.

11.Interests in an education IRA as defined in 26 U.S.C. § 530(b)(1) or under a qualified State tuition plan as defined in

26U.S.C. § 529(b)(1). Give particulars. (File separately the record(s) of any such interest(s). 11 U.S.C. § 521(c).)

B 6B (Official Form 6B) (12/07) -- Cont.

In re ______________________________________________,

Case No. _________________________

Debtor

(If known)

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

 

 

 

CURRENT VALUE OF

 

N

 

DEBTOR’S INTEREST

 

 

IN PROPERTY, WITH-

TYPE OF PROPERTY

O

DESCRIPTION AND LOCATION

OUT DEDUCTING ANY

 

N

OF PROPERTY

SECURED CLAIM

 

E

 

OR EXEMPTION

12.Interests in IRA, ERISA, Keogh, or other pension or profit sharing plans. Give particulars.

13.Stock and interests in incorporated and unincorporated businesses. Itemize.

14.Interests in partnerships or joint ventures. Itemize.

15.Government and corporate bonds and other negotiable and non- negotiable instruments.

16.Accounts receivable.

17.Alimony, maintenance, support, and property settlements to which the debtor is or may be entitled. Give particulars.

18.Other liquidated debts owed to debtor including tax refunds. Give particulars.

19.Equitable or future interests, life estates, and rights or powers exercisable for the benefit of the debtor other than those listed in Schedule A – Real Property.

20.Contingent and noncontingent

interests in estate of a decedent, death benefit plan, life insurance policy, or trust.

21.Other contingent and unliquidated claims of every nature, including tax refunds, counterclaims of the debtor, and rights to setoff claims. Give estimated value of each.

B 6B (Official Form 6B) (12/07) -- Cont.

 

In re _________________________________________________,

Case No. _________________________

Debtor

(If known)

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

 

 

 

CURRENT VALUE OF

 

N

 

DEBTOR’S INTEREST

 

 

IN PROPERTY, WITH-

TYPE OF PROPERTY

O

DESCRIPTION AND LOCATION

OUT DEDUCTING ANY

 

N

OF PROPERTY

SECURED CLAIM

 

E

 

OR EXEMPTION

22.Patents, copyrights, and other intellectual property. Give particulars.

23.Licenses, franchises, and other general intangibles. Give particulars.

24.Customer lists or other compilations containing personally identifiable information (as defined in 11 U.S.C.

§ 101(41A)) provided to the debtor by individuals in connection with obtaining a product or service from the debtor primarily for personal, family, or household purposes.

25.Automobiles, trucks, trailers,

and other vehicles and accessories.

26. Boats, motors, and accessories.

27. Aircraft and accessories.

28.Office equipment, furnishings, and supplies.

29.Machinery, fixtures, equipment, and supplies used in business.

30.Inventory.

31. Animals.

32.Crops - growing or harvested. Give particulars.

33. Farming equipment and implements.

34.Farm supplies, chemicals, and feed.

35.Other personal property of any kind not already listed. Itemize.

__________continuation sheets attached

Total'

$

(Include amounts from any continuation sheets attached. Report total also on

Summary of Schedules.)

B6C (Official Form 6C) (04/13)

In re ____________________________________________,

Case No. _________________________

Debtor

(If known)

SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

Debtor claims the exemptions to which debtor is entitled under: (Check one box)

G11 U.S.C. § 522(b)(2)

G11 U.S.C. § 522(b)(3)

GCheck if debtor claims a homestead exemption that exceeds $155,675.*

DESCRIPTION OF PROPERTY

SPECIFY LAW

PROVIDING EACH

EXEMPTION

VALUE OF CLAIMED EXEMPTION

CURRENT

VALUE OF PROPERTY WITHOUT DEDUCTING EXEMPTION

*Amount subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

B 6D (Official Form 6D) (12/07)

 

In re ____________________________________,

Case No. __________________________________

Debtor

(If known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

State the name, mailing address, including zip code, and last four digits of any account number of all entities holding claims secured by property of the debtor as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. List creditors holding all types of secured interests such as judgment liens, garnishments, statutory liens, mortgages, deeds of trust, and other security interests.

List creditors in alphabetical order to the extent practicable. If a minor child is the creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). If all secured creditors will not fit on this page, use the continuation sheet provided.

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an “X” in the column labeled “Codebtor,” include the entity on the appropriate schedule of creditors, and complete Schedule H – Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.”

If the claim is contingent, place an “X” in the column labeled “Contingent.” If the claim is unliquidated, place an “X” in the column labeled “Unliquidated.” If the claim is disputed, place an “X” in the column labeled “Disputed.” (You may need to place an “X” in more than one of these three columns.)

Total the columns labeled “Amount of Claim Without Deducting Value of Collateral” and “Unsecured Portion, if Any” in the boxes labeled “Total(s)” on the last sheet of the completed schedule. Report the total from the column labeled “Amount of Claim Without Deducting Value of Collateral” also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report the total from the column labeled “Unsecured Portion, if Any” on the Statistical Summary of Certain Liabilities and Related Data.

Check this box if debtor has no creditors holding secured claims to report on this Schedule D.

CREDITOR’S NAME AND

MAILING ADDRESS

INCLUDING ZIP CODE AND

AN ACCOUNT NUMBER

(See Instructions Above.)

ACCOUNT NO.

CODEBTOR

HUSBAND, WIFE, JOINT, OR COMMUNITY

DATE CLAIM WAS

INCURRED,

NATURE OF LIEN ,

AND

DESCRIPTION AND VALUE OF PROPERTY SUBJECT TO LIEN

VALUE $

CONTINGENT

UNLIQUIDATED

DISPUTED

AMOUNT OF CLAIM

UNSECURED

WITHOUT

PORTION, IF

DEDUCTING VALUE

ANY

OF COLLATERAL

 

ACCOUNT NO.

ACCOUNT NO.

____continuation sheets

attached

VALUE $

VALUE $

Subtotal

(Total of this page)

Total

(Use only on last page)

$

$

 

 

$

$

(Report also on Summary of

(If applicable, report

Schedules.)

also on Statistical

 

Summary of Certain

 

Liabilities and Related

 

Data.)

B 6D (Official Form 6D) (12/07) – Cont.

2

In re ____________________________________,

Case No. __________________________________

Debtor

(if known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

(Continuation Sheet)

CREDITOR’S NAME AND

CODEBTOR

MAILING ADDRESS

(See Instructions Above.)

INCLUDING ZIP CODE

 

AND AN ACCOUNT

 

NUMBER

 

ACCOUNT NO.

 

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

Sheet no. of continuation sheets attached to Schedule of Creditors Holding Secured

Claims

HUSBAND, WIFE, JOINT, OR COMMUNITY

DATE CLAIM WAS

INCURRED, NATURE

OF LIEN , AND

DESCRIPTION AND

VALUE OF PROPERTY

SUBJECT TO LIEN

VALUE $

VALUE $

VALUE $

VALUE $

VALUE $

Subtotal (s)(Total(s) of this page)

Total(s) (Use only on last page)

CONTINGENT

UNLIQUIDATED

DISPUTED

AMOUNT OF CLAIM

UNSECURED

WITHOUT

PORTION, IF

DEDUCTING VALUE

ANY

OF COLLATERAL

 

$

$

 

 

$

$

 

 

(Report also on

(If applicable,

Summary of Schedules.)

report also on

 

Statistical Summary

 

of Certain

 

Liabilities and

 

Related Data.)

B6E (Official Form 6E) (04/13)

In re

,

Case No.

 

Debtor

 

 

(if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS

A complete list of claims entitled to priority, listed separately by type of priority, is to be set forth on the sheets provided. Only holders of unsecured claims entitled to priority should be listed in this schedule. In the boxes provided on the attached sheets, state the name, mailing address, including zip code, and last four digits of the account number, if any, of all entities holding priority claims against the debtor or the property of the debtor, as of the date of the filing of the petition. Use a separate continuation sheet for each type of priority and label each with the type of priority.

The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the appropriate schedule of creditors, and complete Schedule H-Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife,

Joint, or Community." If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than one of these three columns.)

Report the total of claims listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all claims listed on this Schedule E in the box labeled “Total” on the last sheet of the completed schedule. Report this total also on the Summary of Schedules.

Report the total of amounts entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all amounts entitled to priority listed on this Schedule E in the box labeled “Totals” on the last sheet of the completed schedule. Individual debtors with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data.

Report the total of amounts not entitled to priority listed on each sheet in the box labeled “Subtotals” on each sheet. Report the total of all amounts not entitled to priority listed on this Schedule E in the box labeled “Totals” on the last sheet of the completed schedule. Individual debtors with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data.

Check this box if debtor has no creditors holding unsecured priority claims to report on this Schedule E.

TYPES OF PRIORITY CLAIMS (Check the appropriate box(es) below if claims in that category are listed on the attached sheets.)

Domestic Support Obligations

Claims for domestic support that are owed to or recoverable by a spouse, former spouse, or child of the debtor, or the parent, legal guardian, or responsible relative of such a child, or a governmental unit to whom such a domestic support claim has been assigned to the extent provided in 11 U.S.C. § 507(a)(1).

Extensions of credit in an involuntary case

Claims arising in the ordinary course of the debtor's business or financial affairs after the commencement of the case but before the earlier of the appointment of a trustee or the order for relief. 11 U.S.C. § 507(a)(3).

Wages, salaries, and commissions

Wages, salaries, and commissions, including vacation, severance, and sick leave pay owing to employees and commissions owing to qualifying independent sales representatives up to $12,475* per person earned within 180 days immediately preceding the filing of the original petition, or the cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(4).

Contributions to employee benefit plans

Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or the cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(5).

*Amount subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

B6E (Official Form 6E) (04/13) – Cont.

In re

,

Case No.

 

Debtor

 

 

(if known)

Certain farmers and fishermen

Claims of certain farmers and fishermen, up to $6,150* per farmer or fisherman, against the debtor, as provided in 11 U.S.C. § 507(a)(6).

Deposits by individuals

Claims of individuals up to $2,775* for deposits for the purchase, lease, or rental of property or services for personal, family, or household use, that were not delivered or provided. 11 U.S.C. § 507(a)(7).

Taxes and Certain Other Debts Owed to Governmental Units

Taxes, customs duties, and penalties owing to federal, state, and local governmental units as set forth in 11 U.S.C. § 507(a)(8).

Commitments to Maintain the Capital of an Insured Depository Institution

Claims based on commitments to the FDIC, RTC, Director of the Office of Thrift Supervision, Comptroller of the Currency, or Board of Governors of the Federal Reserve System, or their predecessors or successors, to maintain the capital of an insured depository institution. 11 U.S.C. § 507 (a)(9).

Claims for Death or Personal Injury While Debtor Was Intoxicated

Claims for death or personal injury resulting from the operation of a motor vehicle or vessel while the debtor was intoxicated from using alcohol, a drug, or another substance. 11 U.S.C. § 507(a)(10).

*Amounts are subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

____ continuation sheets attached

B6E (Official Form 6E) (04/13) – Cont.

In re __________________________________________,

Case No. _________________________________

Debtor

(if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS

(Continuation Sheet)

Type of Priority for Claims Listed on This Sheet

CREDITOR’S NAME,

CODEBTOR

WIFE,HUSBAND, ORJOINT, COMMUNITY

DATE CLAIM WAS

 

CONTINGENT

 

UNLIQUIDATED

 

DISPUTED

AMOUNT

AMOUNT

AMOUNT

 

 

 

 

 

 

 

 

MAILING ADDRESS

 

 

INCURRED AND

 

 

 

 

 

 

OF

ENTITLED

NOT

INCLUDING ZIP CODE,

 

 

CONSIDERATION

 

 

 

 

 

 

CLAIM

TO

ENTITLED

AND ACCOUNT NUMBER

 

 

FOR CLAIM

 

 

 

 

 

 

 

PRIORITY

TO

(See instructions above.)

 

 

 

 

 

 

 

 

 

 

 

PRIORITY, IF

 

 

 

 

 

 

 

 

 

 

 

 

ANY

 

 

 

 

 

 

 

 

 

 

 

 

 

Account No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sheet no. ___ of ___ continuation sheets attached to Schedule of

 

 

 

Subtotals'

$

$

 

Creditors Holding Priority Claims

 

 

 

(Totals of this page)

 

 

 

 

 

 

 

 

 

 

Total'

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

(Use only on last page of the completed

 

 

 

 

 

 

 

Schedule E. Report also on the Summary

 

 

 

 

 

 

 

of Schedules.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Totals'

 

$

$

 

 

 

(Use only on last page of the completed

 

 

 

 

 

 

 

Schedule E. If applicable, report also on

 

 

 

 

 

 

 

the Statistical Summary of Certain

 

 

 

 

 

 

 

Liabilities and Related Data.)

 

 

 

 

 

 

 

B 6F (Official Form 6F) (12/07)

 

In re __________________________________________,

Case No. _________________________________

Debtor

(if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

State the name, mailing address, including zip code, and lastfour digits of any account number, of all entities holding unsecured claims without priorityagainst the debtor or the property of the debtor, as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). Do not include claims listed in Schedules D and E. If all creditors will not fit on this page, use the continuation sheet provided.

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an “X” in the column labeled “Codebtor,” include the entity on the appropriate schedule of creditors, and complete Schedule H - Codebtors. If a jointpetition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.”

If the claim is contingent, place an “X” in the column labeled “Contingent.” If the claim is unliquidated, place an “X” in the column labeled “Unliquidated.” If the claim is disputed, place an “X” in the column labeled “Disputed.” (You may need to place an “X” in more than one of these three columns.)

Report the total of all claims listed on this schedule in the box labeled “Total” on the last sheet of the completed schedule. Report this total also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report this total also on the Statistical Summary of Certain Liabilities and Related Data..

GCheck this box if debtor has no creditors holding unsecured claims to report on this Schedule F.

CREDITOR’S NAME,

CODEBTOR

HUSBAND, WIFE, JOINT, OR COMMUNITY

DATE CLAIM WAS

CONTINGENT

UNLIQUIDATED

 

AMOUNT OF

MAILING ADDRESS

INCURRED AND

DISPUTED

CLAIM

INCLUDING ZIP CODE,

CONSIDERATION FOR

 

AND ACCOUNT NUMBER

CLAIM.

 

(See instructions above.)

IF CLAIM IS SUBJECT TO

 

 

SETOFF, SO STATE.

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subtotal'

_____continuation sheets attached

Total'

 

(Use only on last page of the completed Schedule F.)

 

(Report also on Summary of Schedules and, if applicable, on the Statistical

 

Summary of Certain Liabilities and Related Data.)

$

$

B 6F (Official Form 6F) (12/07) - Cont.

In re __________________________________________,

Case No. _________________________________

Debtor

(if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

(Continuation Sheet)

CREDITOR’S NAME,

CODEBTOR

HUSBAND,WIFE, JOINT,OR COMMUNITY

DATE CLAIM WAS

CONTINGENT

UNLIQUIDATED

DISPUTED

AMOUNT OF

MAILING ADDRESS

INCURRED AND

CLAIM

INCLUDING ZIP CODE,

 

 

CONSIDERATION FOR

 

 

 

 

AND ACCOUNT NUMBER

 

 

CLAIM.

 

 

 

 

(See instructions above.)

 

 

IF CLAIM IS SUBJECT TO

 

 

 

 

 

 

 

SETOFF, SO STATE.

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCOUNT NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sheet no.______ of______ continuation sheets attached

Subtotal'

to Schedule of Creditors Holding Unsecured

 

Nonpriority Claims

 

Total'

(Use only on last page of the completed Schedule F.) (Report also on Summary of Schedules and, if applicable on the Statistical Summary of Certain Liabilities and Related Data.)

$

$

B 6G (Official Form 6G) (12/07)

 

 

 

In re

,

Case No.

 

Debtor

 

 

(if known)

SCHEDULE G - EXECUTORY CONTRACTS AND UNEXPIRED LEASES

Describe all executory contracts of any nature and all unexpired leases of real or personal property. Include any timeshare interests. State nature of debtor’s interest in contract, i.e., “Purchaser,” “Agent,” etc. State whether debtor is the lessor or lessee of a lease. Provide the names and complete mailing addresses of all other parties to each lease or contract described. If a minor child is a party to one of the leases or contracts, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

Check this box if debtor has no executory contracts or unexpired leases.

NAME AND MAILING ADDRESS,

INCLUDING ZIP CODE,

OF OTHER PARTIES TO LEASE OR CONTRACT.

DESCRIPTION OF CONTRACT OR LEASE AND NATURE OF DEBTOR’S INTEREST. STATE WHETHER LEASE IS FOR NONRESIDENTIAL REAL PROPERTY. STATE CONTRACT NUMBER OF ANY GOVERNMENT CONTRACT.

B 6H (Official Form 6H) (12/07)

 

 

 

In re

,

Case No.

 

Debtor

 

 

(if known)

SCHEDULE H - CODEBTORS

Provide the information requested concerning any person or entity, other than a spouse in a joint case, that is also liable on any debts listed by the debtor in the schedules of creditors. Include all guarantors and co-signers. If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the eight-year period immediately preceding the commencement of the case, identify the name of the debtor’s spouse and of any former spouse who resides or resided with the debtor in the community property state, commonwealth, or territory. Include all names used by the nondebtor spouse during the eight years immediately preceding the commencement of this case. If a minor child is a codebtor or a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m).

Check this box if debtor has no codebtors.

NAME AND ADDRESS OF CODEBTOR

NAME AND ADDRESS OF CREDITOR

B6I (Official Form 6I) (12/07)

 

 

 

In re

,

Case No.

 

Debtor

 

 

(if known)

SCHEDULE I - CURRENT INCOME OF INDIVIDUAL DEBTOR(S)

The column labeled “Spouse” must be completed in all cases filed by joint debtors and by every married debtor, whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed. Do not state the name of any minor child. The average monthly income calculated on this form may differ from the current monthly income calculated on Form 22A, 22B, or 22C.

 

Debtor’s Marital

 

DEPENDENTS OF DEBTOR AND SPOUSE

 

Status:

 

 

 

 

RELATIONSHIP(S):

AGE(S):

 

 

 

 

 

 

 

 

Employment:

DEBTOR

SPOUSE

 

Occupation

 

 

 

 

 

 

 

 

 

Name of Employer

 

 

 

How long employed

Address of Employer

INCOME: (Estimate of average or projected monthly income at time

DEBTOR

SPOUSE

 

 

case filed)

$________________

$______________

 

 

1.

Monthly gross wages, salary, and commissions

 

 

$________________

$______________

 

 

 

(Prorate if not paid monthly)

 

 

2.

Estimate monthly overtime

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

SUBTOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

$_______________

$_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

LESS PAYROLL DEDUCTIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

$

 

 

 

 

 

 

 

 

a. Payroll taxes and social security

 

 

 

 

 

 

 

 

 

 

 

 

b. Insurance

$

 

 

 

 

$

 

 

 

 

 

 

 

 

c. Union dues

$

 

 

 

 

$

 

 

 

 

 

 

 

 

d. Other (Specify):

$

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

SUBTOTAL OF PAYROLL DEDUCTIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

TOTAL NET MONTHLY TAKE HOME PAY

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

 

 

 

 

 

7.

Regular income from operation of business or profession or farm

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

$

 

 

 

 

 

 

 

 

(Attach detailed statement)

$

 

 

 

 

$

 

 

 

 

 

 

 

8.

Income from real property

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Interest and dividends

$

 

 

 

 

$

 

 

 

 

 

 

 

10.

Alimony, maintenance or support payments payable to the debtor for

$

 

 

 

 

$

 

 

 

 

 

 

 

 

the debtor’s use or that of dependents listed above

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Social security or government assistance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Specify):

 

 

 

 

 

 

$

 

 

 

 

$

 

 

 

 

 

 

 

12. Pension or

retirement income

 

 

$

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Other monthly income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Specify):

$

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

 

 

 

 

 

 

14. SUBTOTAL

OF LINES 7 THROUGH 13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. AVERAGE MONTHLY INCOME (Add amounts on lines 6 and 14)

$

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. COMBINED AVERAGE MONTHLY INCOME: (Combine column

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

totals from line 15)

(Report also on Summary of Schedules and, if applicable,

 

 

 

 

 

 

 

 

 

on Statistical Summary of Certain Liabilities and Related Data)

17. Describe any increase or decrease in income reasonably anticipated to occur within the year following the filing of this document:

B6J (Official Form 6J) (12/07)

 

 

 

In re

,

Case No.

 

Debtor

 

 

(if known)

SCHEDULE J - CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S)

Complete this schedule by estimating the average or projected monthly expenses of the debtor and the debtor’s family at time case filed. Prorate any payments made bi- weekly, quarterly, semi-annually, or annually to show monthly rate. The average monthly expenses calculated on this form may differ from the deductions from income allowed on Form22A or 22C.

Check this box if a joint petition is filed and debtor’s spouse maintains a separate household. Complete a separate schedule of expenditures labeled “Spouse.”

1. Rent or home mortgage payment (include lot rented for mobile home)

a. Are real estate taxes included?

Yes ________

No ________

b. Is property insurance included?

Yes ________

No ________

2.Utilities: a. Electricity and heating fuel

b.Water and sewer

c.Telephone

d.Other ___________________________________________________________________

3.Home maintenance (repairs and upkeep)

4.Food

5.Clothing

6.Laundry and dry cleaning

7.Medical and dental expenses

8.Transportation (not including car payments)

9.Recreation, clubs and entertainment, newspapers, magazines, etc.

10.Charitable contributions

11.Insurance (not deducted from wages or included in home mortgage payments) a. Homeowner’s or renter’s

b.Life

c.Health

d.Auto

e.Other ___________________________________________________________________

12.Taxes (not deducted from wages or included in home mortgage payments)

(Specify) ___________________________________________________________________________

13.Installment payments: (In chapter 11, 12, and 13 cases, do not list payments to be included in the plan)

a.Auto

b.Other ______________________________________________________________

c.Other ____________________________________________________________

14.Alimony, maintenance, and support paid to others

15.Payments for support of additional dependents not living at your home

16.Regular expenses from operation of business, profession, or farm (attach detailed statement)

17.Other __________________________________________________________________________

18.AVERAGE MONTHLY EXPENSES (Total lines 1-17. Report also on Summary of Schedules and, if applicable, on the Statistical Summary of Certain Liabilities and Related Data.)

19.Describe any increase or decrease in expenditures reasonably anticipated to occur within the year following the filing of this document:

20.STATEMENT OF MONTHLY NET INCOME

a.Average monthly income from Line 15 of Schedule I

b.Average monthly expenses from Line 18 above

c.Monthly net income (a. minus b.)

$ _____________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$ ______________

$______________

$______________

$______________

$______________

$______________

B6 Declaration (Official Form 6 - Declaration) (12/07)

 

In re _________________________________________ ,

Case No. ______________________________

Debtor

(if known)

DECLARATION CONCERNING DEBTOR'S SCHEDULES

DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR

I declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of _____ sheets, and that they are true and correct to the best of

my knowledge, information, and belief.

 

Date __________________________________

Signature: ________________________________________________

 

Debtor

Date __________________________________

Signature: ________________________________________________

 

(Joint Debtor, if any)

 

[If joint case, both spouses must sign.]

-------------------------------------------------------------------------------------------------------------------------------------------

DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. §§ 110(b), 110(h) and 342(b); and, (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required by that section.

_____________________________________________________

_____________________________

Printed or Typed Name and Title, if any,

Social Security No.

of Bankruptcy Petition Preparer

(Required by 11 U.S.C. § 110.)

If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person, or partner who signs this document.

_________________________________

_________________________________

_________________________________

Address

X _____________________________________________________

____________________

Signature of Bankruptcy Petition Preparer

Date

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person.

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156.

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

DECLARATION UNDER PENALTY OF PERJURY ON BEHALF OF A CORPORATION OR PARTNERSHIP

I, the __________________________________ [the president or other officer or an authorized agent of the corporation or a member or an authorized agent of the

partnership ] of the ___________________________________ [corporation or partnership] named as debtor in this case, declare under penalty of perjury that I have

read the foregoing summary and schedules, consisting of _____ sheets (Total shown on summary page plus 1), and that they are true and correct to the best of my

knowledge, information, and belief.

Date ______________________________________

Signature: _____________________________________________________________

____________________________________________________________

[Print or type name of individual signing on behalf of debtor.]

[An individual signing on behalf of a partnership or corporation must indicate position or relationship to debtor.]

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Penalty for making a false statement or concealing property: Fine of up to $500,000 or imprisonment for up to 5 years or both. 18 U.S.C. §§ 152 and 3571.

Local Bankruptcy Form 1007-2.1

[Caption as in Bankruptcy Official Form 16A]

VERIFICATION OF CREDITOR ADDRESS MAILING MATRIX

The above named debtor hereby verifies under penalty of perjury that the attached Creditor Address Mailing Matrix (list of creditors) is true and correct to the best of my knowledge.

Dated: ______________________

By: ________________________________

 

Signature of debtor

 

____________________________________

 

Printed name of debtor

 

By: ________________________________

 

Signature of joint-debtor

 

___________________________________

 

Printed name of joint-debtor

 

Home address

 

Telephone number

 

Facsimile number

 

E-mail address

B202 (Form 202) (08/07)

United States Bankruptcy Court

____________________ District of ____________________

In re _________________________

Case Number

_______________________

 

Chapter

_______________________

STATEMENT OF MILITARY SERVICE

The Servicemembers’ Civil Relief Act of 2003, Pub. L. No. 108-189, provides for the temporary suspension of certain judicial proceedings or transactions that may adversely affect military servicemembers, their dependents, and others. Each party to a bankruptcy case who might be eligible for relief under the act should complete this form and file it with the Bankruptcy Court.

IDENTIFICATION OF SERVICEMEMBER

Self (Debtor, Codebtor, Creditor, Other)

Non-Filing Spouse of Debtor (name)________________________________________

Other (Name of servicemember)__________________________________________

 

(Relationship of filer to servicemember)_______________________________

 

(Type of liability) ________________________________________________

TYPE OF MILITARY SERVICE

U.S. Armed Forces (Army, Navy, Air Force, Marine Corps, or Coast Guard) or commissioned officer of the Public Health Service or the National Oceanic and Atmospheric Administration (specify type

 

of service) _____________________________________________________________

Active Service since

____________________________________________(date)

Inductee - ordered to report on

____________________________________________(date)

Retired / Discharged

____________________________________________(date)

U.S. Military Reserves and National Guard

Active Service since

____________________________________________(date)

Impending Active Service -orders postmarked _______________________________(date)

 

Ordered to report on

____________________________________________(date)

Retired /Discharged

____________________________________________(date)

U.S. Citizen Serving with U.S. ally in war or military action (specify ally and war or action)

 

______________________________________________________________________

Active Service since

____________________________________________(date)

Retired/Discharged

____________________________________________(date)

DEPLOYMENT

Servicemember deployed overseas on _______________________________________(date) Anticipated completion of overseas tour-of-duty ______________________________(date)

SIGNATURE

 

____________________________________

___________________________

____________________________________

Date

 

(print name)

 

This statement is for information use only. Filing this statement with the Bankruptcy Court does not constitute an application for or invoke the benefits and relief available under the Servicemembers’ Civil Relief Act of 2003.

B22A (Official Form 22A) (Chapter 7) (04/13)

 

 

In re ______________________________

 

 

 

According to the information required to be entered on this statement

 

Debtor(s)

(check one box as directed in Part I, III, or VI of this statement):

 

Case Number: __________________

The presumption arises.

 

The presumption does not arise.

 

(If known)

 

The presumption is temporarily inapplicable.

 

 

 

 

 

 

 

 

CHAPTER 7 STATEMENT OF CURRENT MONTHLY INCOME

AND MEANS-TEST CALCULATION

In addition to Schedules I and J, this statement must be completed by every individual chapter 7 debtor. If none of the exclusions in Part I applies, joint debtors may complete one statement only. If any of the exclusions in Part I applies, joint debtors should complete separate statements if they believe this is required by § 707(b)(2)(C).

Part I. MILITARY AND NON-CONSUMER DEBTORS

 

 

 

 

Disabled Veterans. If you are a disabled veteran described in the Declaration in this Part IA, (1) check the box at the

 

 

 

 

beginning of the Declaration, (2) check the box for “The presumption does not arise” at the top of this statement, and (3)

 

 

 

 

complete the verification in Part VIII. Do not complete any of the remaining parts of this statement.

 

1A

 

 

Declaration of Disabled Veteran. By checking this box, I declare under penalty of perjury that I am a disabled veteran

 

 

 

 

 

 

 

 

(as defined in 38 U.S.C. § 3741(1)) whose indebtedness occurred primarily during a period in which I was on active duty

 

 

 

 

(as defined in 10 U.S.C. § 101(d)(1)) or while I was performing a homeland defense activity (as defined in 32 U.S.C.

 

 

 

§901(1)).

 

 

 

 

 

 

 

 

 

Non-consumer Debtors. If your debts are not primarily consumer debts, check the box below and complete the

 

1B

 

 

verification in Part VIII. Do not complete any of the remaining parts of this statement.

 

 

 

 

 

 

 

 

Declaration of non-consumer debts. By checking this box, I declare that my debts are not primarily consumer debts.

 

 

 

 

 

Reservists and National Guard Members; active duty or homeland defense activity. Members of a reserve component of the Armed Forces and members of the National Guard who were called to active duty (as defined in 10 U.S.C.

§101(d)(1)) after September 11, 2001, for a period of at least 90 days, or who have performed homeland defense activity (as defined in 32 U.S.C. § 901(1)) for a period of at least 90 days, are excluded from all forms of means testing during the time of active duty or homeland defense activity and for 540 days thereafter (the “exclusion period”). If you qualify for this temporary exclusion, (1) check the appropriate boxes and complete any required information in the Declaration of Reservists and National Guard Members below, (2) check the box for “The presumption is temporarily inapplicable” at the top of this statement, and (3) complete the verification in Part VIII. During your exclusion period you are not required to complete the balance of this form, but you must complete the form no later than 14 days after the date on which your exclusion period ends, unless the time for filing a motion raising the means test presumption expires in your case before your exclusion period ends.

 

Declaration of Reservists and National Guard Members. By checking this box and making the appropriate entries

1C

below, I declare that I am eligible for a temporary exclusion from means testing because, as a member of a reserve

 

 

component of the Armed Forces or the National Guard

 

a.

I was called to active duty after September 11, 2001, for a period of at least 90 days and

 

 

I remain on active duty /or/

 

 

I was released from active duty on ________________, which is less than 540 days before

 

this bankruptcy case was filed;

 

 

OR

 

b.

I am performing homeland defense activity for a period of at least 90 days /or/

 

 

I performed homeland defense activity for a period of at least 90 days, terminating on

 

 

_______________, which is less than 540 days before this bankruptcy case was filed.

B 22A (Official Form 22A) (Chapter 7) (04/13)

2

 

 

 

 

 

Part II. CALCULATION OF MONTHLY INCOME FOR § 707(b)(7) EXCLUSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital/filing status. Check the box that applies and complete the balance of this part of this statement as directed.

 

 

 

a.

Unmarried. Complete only Column A (“Debtor’s Income”) for Lines 3-11.

 

 

 

 

 

b.

Married, not filing jointly, with declaration of separate households. By checking this box, debtor declares under

 

 

 

 

 

penalty of perjury: “My spouse and I are legally separated under applicable non-bankruptcy law or my spouse and I

2

 

 

 

are living apart other than for the purpose of evading the requirements of § 707(b)(2)(A) of the Bankruptcy Code.”

 

 

 

Complete only Column A (“Debtor’s Income”) for Lines 3-11.

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Married, not filing jointly, without the declaration of separate households set out in Line 2.b above. Complete both

 

 

 

 

 

Column A (“Debtor’s Income”) and Column B (“Spouse’s Income”) for Lines 3-11.

 

 

 

 

 

d.

Married, filing jointly. Complete both Column A (“Debtor’s Income”) and Column B (“Spouse’s Income”) for

 

 

 

 

 

Lines 3-11.

 

 

 

 

 

 

 

 

 

All figures must reflect average monthly income received from all sources, derived during

Column A

Column B

 

 

 

the six calendar months prior to filing the bankruptcy case, ending on the last day of the

Debtor’s

Spouse’s

 

 

 

month before the filing. If the amount of monthly income varied during the six months, you

Income

Income

 

 

 

must divide the six-month total by six, and enter the result on the appropriate line.

 

 

 

3

 

Gross wages, salary, tips, bonuses, overtime, commissions.

$

$

 

 

 

Income from the operation of a business, profession or farm. Subtract Line b from Line a

 

 

 

 

 

and enter the difference in the appropriate column(s) of Line 4. If you operate more than one

 

 

 

 

 

business, profession or farm, enter aggregate numbers and provide details on an attachment.

 

 

 

 

 

Do not enter a number less than zero. Do not include any part of the business expenses

 

 

 

4

 

entered on Line b as a deduction in Part V.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

Gross receipts

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

Ordinary and necessary business expenses

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

 

Business income

Subtract Line b from Line a

 

 

$

$

 

 

 

Rent and other real property income. Subtract Line b from Line a and enter the difference

 

 

 

 

 

 

in the appropriate column(s) of Line 5. Do not enter a number less than zero. Do not include

 

 

 

 

 

 

any part of the operating expenses entered on Line b as a deduction in Part V.

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

Gross receipts

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

Ordinary and necessary operating expenses

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

 

Rent and other real property income

Subtract Line b from Line a

 

 

$

$

 

6

 

Interest, dividends and royalties.

 

 

 

 

$

$

 

7

 

Pension and retirement income.

 

 

 

 

$

$

 

 

 

Any amounts paid by another person or entity, on a regular basis, for the household

 

 

 

8

 

expenses of the debtor or the debtor’s dependents, including child support paid for that

 

 

 

 

purpose. Do not include alimony or separate maintenance payments or amounts paid by

 

 

 

 

 

your spouse if Column B is completed. Each regular payment should be reported in only one

 

 

 

 

 

column; if a payment is listed in Column A, do not report that payment in Column B.

$

$

 

 

 

Unemployment compensation. Enter the amount in the appropriate column(s) of Line 9.

 

 

 

 

 

However, if you contend that unemployment compensation received by you or your spouse

 

 

 

9

 

was a benefit under the Social Security Act, do not list the amount of such compensation in

 

 

 

 

Column A or B, but instead state the amount in the space below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unemployment compensation claimed to

 

 

 

 

 

 

 

 

 

 

 

be a benefit under the Social Security Act

Debtor $ ________

Spouse $ _________

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B 22A (Official Form 22A) (Chapter 7) (04/13)

3

 

 

 

Income from all other sources. Specify source and amount. If necessary, list additional

 

 

 

 

 

sources on a separate page. Do not include alimony or separate maintenance payments

 

 

 

 

 

paid by your spouse if Column B is completed, but include all other payments of

 

 

 

 

 

alimony or separate maintenance. Do not include any benefits received under the Social

 

 

 

10

 

Security Act or payments received as a victim of a war crime, crime against humanity, or as a

 

 

 

 

victim of international or domestic terrorism.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

$

 

 

 

 

 

 

 

b.

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total and enter on Line 10

 

 

$

$

 

11

 

Subtotal of Current Monthly Income for § 707(b)(7). Add Lines 3 thru 10 in Column A,

 

 

 

 

and, if Column B is completed, add Lines 3 through 10 in Column B. Enter the total(s).

$

$

 

 

 

 

 

 

Total Current Monthly Income for § 707(b)(7). If Column B has been completed, add

 

 

 

12

 

Line 11, Column A to Line 11, Column B, and enter the total. If Column B has not been

$

 

 

 

 

completed, enter the amount from Line 11, Column A.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part III. APPLICATION OF § 707(b)(7) EXCLUSION

 

 

 

 

 

 

 

13

 

Annualized Current Monthly Income for § 707(b)(7). Multiply the amount from Line 12 by the number

 

 

 

 

12 and enter the result.

$

 

 

 

Applicable median family income. Enter the median family income for the applicable state and household

 

 

14

 

size. (This information is available by family size at www.usdoj.gov/ust/ or from the clerk of the

 

 

 

bankruptcy court.)

 

 

 

 

 

 

 

 

a. Enter debtor’s state of residence: _______________ b. Enter debtor’s household size: __________

$

 

 

 

Application of Section 707(b)(7). Check the applicable box and proceed as directed.

 

 

15

 

The amount on Line 13 is less than or equal to the amount on Line 14. Check the box for “The presumption does

 

 

 

not arise” at the top of page 1 of this statement, and complete Part VIII; do not complete Parts IV, V, VI or VII.

 

 

 

The amount on Line 13 is more than the amount on Line 14. Complete the remaining parts of this statement.

 

 

 

 

 

Complete Parts IV, V, VI, and VII of this statement only if required. (See Line 15.)

Part IV. CALCULATION OF CURRENT MONTHLY INCOME FOR § 707(b)(2)

16

Enter the amount from Line 12.

 

 

 

$

 

Marital adjustment. If you checked the box at Line 2.c, enter on Line 17 the total of any income listed in

 

 

 

Line 11, Column B that was NOT paid on a regular basis for the household expenses of the debtor or the

 

 

 

debtor’s dependents. Specify in the lines below the basis for excluding the Column B income (such as

 

 

 

payment of the spouse’s tax liability or the spouse’s support of persons other than the debtor or the debtor’s

 

 

 

dependents) and the amount of income devoted to each purpose. If necessary, list additional adjustments on

 

 

17

a separate page. If you did not check box at Line 2.c, enter zero.

 

 

 

 

 

 

a.

 

$

 

 

 

 

 

b.

 

$

 

 

 

 

 

c.

 

$

 

 

 

 

 

Total and enter on Line 17.

 

 

 

$

18

Current monthly income for § 707(b)(2). Subtract Line 17 from Line 16 and enter the result.

 

$

 

 

 

 

 

 

 

 

B 22A (Official Form 22A) (Chapter 7) (04/13)

4

 

 

 

 

 

Part V. CALCULATION OF DEDUCTIONS FROM INCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subpart A: Deductions under Standards of the Internal Revenue Service (IRS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Standards: food, clothing and other items. Enter in Line 19A the “Total” amount from IRS

 

 

 

 

 

 

National Standards for Food, Clothing and Other Items for the applicable number of persons. (This

 

 

 

 

19A

 

information is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) The applicable

 

 

 

 

 

 

number of persons is the number that would currently be allowed as exemptions on your federal income tax

 

 

 

 

 

 

return, plus the number of any additional dependents whom you support.

 

 

 

 

$

 

 

 

 

National Standards: health care. Enter in Line a1 below the amount from IRS National Standards for Out-

 

 

 

 

 

 

of-Pocket Health Care for persons under 65 years of age, and in Line a2 the IRS National Standards for Out-

 

 

 

 

 

 

of-Pocket Health Care for persons 65 years of age or older. (This information is available at

 

 

 

 

 

 

www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.)

Enter in Line b1 the applicable number of

 

 

 

 

 

 

persons who are under 65 years of age, and enter in Line b2 the applicable number of persons who are 65

 

 

 

 

 

 

years of age or older. (The applicable number of persons in each age category is the number in that category

 

 

 

 

 

 

that would currently be allowed as exemptions on your federal income tax return, plus the number of any

 

 

 

 

 

 

additional dependents whom you support.) Multiply Line a1 by Line b1 to obtain a total amount for persons

 

 

 

 

19B

 

under 65, and enter the result in Line c1.

Multiply Line a2 by Line b2 to obtain a total amount for persons 65

 

 

 

 

 

 

and older, and enter the result in Line c2. Add Lines c1 and c2 to obtain a total health care amount, and

 

 

 

 

 

 

enter the result in Line 19B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Persons under 65 years of age

 

Persons 65 years of age or older

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a1.

Allowance per person

 

 

a2.

 

Allowance per person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b1.

Number of persons

 

 

b2.

 

Number of persons

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c1.

Subtotal

 

 

c2.

 

Subtotal

 

 

 

 

$

 

 

 

 

Local Standards: housing and utilities; non-mortgage expenses. Enter the amount of the IRS Housing and

 

 

 

 

 

 

Utilities Standards; non-mortgage expenses for the applicable county and family size. (This information is

 

 

 

 

20A

 

available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court). The applicable family size

 

 

 

 

 

 

consists of the number that would currently be allowed as exemptions on your federal income tax return, plus

 

 

 

 

 

 

the number of any additional dependents whom you support.

 

 

 

 

 

$

 

 

 

 

Local Standards: housing and utilities; mortgage/rent expense. Enter, in Line a below, the amount of the

 

 

 

 

 

 

IRS Housing and Utilities Standards; mortgage/rent expense for your county and family size (this

 

 

 

 

 

 

information is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court) (the applicable

 

 

 

 

 

 

family size consists of the number that would currently be allowed as exemptions on your federal income tax

 

 

 

 

 

 

return, plus the number of any additional dependents whom you support); enter on Line b the total of the

 

 

 

 

20B

 

Average Monthly Payments for any debts secured by your home, as stated in Line 42; subtract Line b from

 

 

 

 

 

Line a and enter the result in Line 20B. Do not enter an amount less than zero.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

IRS Housing and Utilities Standards; mortgage/rental expense

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Average Monthly Payment for any debts secured by your home,

 

 

 

 

 

 

 

 

 

 

 

if any, as stated in Line 42

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Net mortgage/rental expense

 

 

 

 

Subtract Line b from Line a.

 

 

$

 

 

 

 

Local Standards: housing and utilities; adjustment. If you contend that the process set out in Lines 20A

 

 

 

 

 

 

and 20B does not accurately compute the allowance to which you are entitled under the IRS Housing and

 

 

 

 

 

 

Utilities Standards, enter any additional amount to which you contend you are entitled, and state the basis for

 

 

 

 

21

 

your contention in the space below:

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________________________________________________

 

 

 

 

 

 

_______________________________________________________________________________________

 

$

 

 

 

 

_______________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B 22A (Official Form 22A) (Chapter 7) (04/13)

5

 

 

 

Local Standards: transportation; vehicle operation/public transportation expense. You are entitled to

 

 

 

 

 

an expense allowance in this category regardless of whether you pay the expenses of operating a vehicle and

 

 

 

 

 

regardless of whether you use public transportation.

 

 

 

 

 

 

 

Check the number of vehicles for which you pay the operating expenses or for which the operating expenses

 

 

 

 

 

are included as a contribution to your household expenses in Line 8.

 

 

 

 

 

22A

 

0

1

2 or more.

 

 

 

 

 

 

 

If you checked 0, enter on Line 22A the “Public Transportation” amount from IRS Local Standards:

 

 

 

 

 

Transportation. If you checked 1 or 2 or more, enter on Line 22A the “Operating Costs” amount from IRS

 

 

 

 

 

Local Standards: Transportation for the applicable number of vehicles in the applicable Metropolitan

 

 

 

 

 

Statistical Area or Census Region. (These amounts are available at www.usdoj.gov/ust/ or from the clerk of

 

 

 

 

 

the bankruptcy court.)

 

 

 

$

 

 

 

Local Standards: transportation; additional public transportation expense. If you pay the operating

 

 

 

 

 

expenses for a vehicle and also use public transportation, and you contend that you are entitled to an

 

 

 

22B

 

additional deduction for your public transportation expenses, enter on Line 22B the “Public Transportation”

 

 

 

 

 

amount from IRS Local Standards: Transportation. (This amount is available at www.usdoj.gov/ust/ or from

 

 

 

 

 

the clerk of the bankruptcy court.)

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Local Standards: transportation ownership/lease expense; Vehicle 1. Check the number of vehicles for

 

 

 

 

 

which you claim an ownership/lease expense. (You may not claim an ownership/lease expense for more than

 

 

 

 

 

two vehicles.)

 

 

 

 

 

 

 

 

1

2 or more.

 

 

 

 

 

 

 

Enter, in Line a below, the “Ownership Costs” for “One Car” from the IRS Local Standards: Transportation

 

 

 

 

 

(available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court); enter in Line b the total of the

 

 

 

23

 

Average Monthly Payments for any debts secured by Vehicle 1, as stated in Line 42; subtract Line b from

 

 

 

 

 

Line a and enter the result in Line 23. Do not enter an amount less than zero.

 

 

 

 

 

 

a.

IRS Transportation Standards, Ownership Costs

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Average Monthly Payment for any debts secured by Vehicle 1,

 

 

 

 

 

 

 

 

 

as stated in Line 42

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Net ownership/lease expense for Vehicle 1

Subtract Line b from Line a.

 

 

$

 

 

 

Local Standards: transportation ownership/lease expense; Vehicle 2. Complete this Line only if you

 

 

 

 

 

checked the “2 or more” Box in Line 23.

 

 

 

 

 

 

 

Enter, in Line a below, the “Ownership Costs” for “One Car” from the IRS Local Standards: Transportation

 

 

 

 

 

(available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court); enter in Line b the total of the

 

 

 

 

 

Average Monthly Payments for any debts secured by Vehicle 2, as stated in Line 42; subtract Line b from

 

 

 

24

 

Line a and enter the result in Line 24. Do not enter an amount less than zero.

 

 

 

 

 

 

a.

IRS Transportation Standards, Ownership Costs

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Average Monthly Payment for any debts secured by Vehicle 2,

 

 

 

 

 

 

 

 

 

as stated in Line 42

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Net ownership/lease expense for Vehicle 2

Subtract Line b from Line a.

 

 

$

 

 

 

Other Necessary Expenses: taxes. Enter the total average monthly expense that you actually incur for all

 

 

 

25

 

federal, state and local taxes, other than real estate and sales taxes, such as income taxes, self-employment

 

 

 

 

 

taxes, social-security taxes, and Medicare taxes. Do not include real estate or sales taxes.

 

$

 

 

 

Other Necessary Expenses: involuntary deductions for employment. Enter the total average monthly

 

 

 

26

 

payroll deductions that are required for your employment, such as retirement contributions, union dues, and

 

 

 

 

 

uniform costs. Do not include discretionary amounts, such as voluntary 401(k) contributions.

 

$

 

 

 

 

 

 

 

 

 

 

 

27

 

Other Necessary Expenses: life insurance. Enter total average monthly premiums that you actually pay for

 

 

 

 

term life insurance for yourself. Do not include premiums for insurance on your dependents, for whole

 

$

 

 

 

life or for any other form of insurance.

 

 

 

 

 

 

Other Necessary Expenses: court-ordered payments. Enter the total monthly amount that you are

 

 

 

28

 

required to pay pursuant to the order of a court or administrative agency, such as spousal or child support

 

 

 

 

 

payments. Do not include payments on past due obligations included in Line 44.

 

$

 

 

 

 

 

 

 

 

 

 

 

B 22A (Official Form 22A) (Chapter 7) (04/13)

6

 

 

 

 

Other Necessary Expenses: education for employment or for a physically or mentally challenged child.

 

 

 

 

29

 

Enter the total average monthly amount that you actually expend for education that is a condition of

 

 

 

 

 

employment and for education that is required for a physically or mentally challenged dependent child for

 

 

 

 

 

 

 

 

 

 

 

 

whom no public education providing similar services is available.

$

 

 

 

 

 

Other Necessary Expenses: childcare. Enter the total average monthly amount that you actually expend on

 

 

 

 

30

 

childcare—such as baby-sitting, day care, nursery and preschool. Do not include other educational

$

 

 

 

 

 

payments.

 

 

 

 

 

Other Necessary Expenses: health care. Enter the total average monthly amount that you actually expend

 

 

 

 

31

 

on health care that is required for the health and welfare of yourself or your dependents, that is not

 

 

 

 

 

reimbursed by insurance or paid by a health savings account, and that is in excess of the amount entered in

 

 

 

 

 

 

 

 

 

 

 

 

Line 19B. Do not include payments for health insurance or health savings accounts listed in Line 34.

$

 

 

 

 

 

 

 

 

Other Necessary Expenses: telecommunication services. Enter the total average monthly amount that you

32actually pay for telecommunication services other than your basic home telephone and cell phone service— such as pagers, call waiting, caller id, special long distance, or internet service—to the extent necessary for

 

your health and welfare or that of your dependents. Do not include any amount previously deducted.

$

 

 

 

33

Total Expenses Allowed under IRS Standards. Enter the total of Lines 19 through 32.

$

 

 

 

Subpart B: Additional Living Expense Deductions

Note: Do not include any expenses that you have listed in Lines 19-32

Health Insurance, Disability Insurance, and Health Savings Account Expenses. List the monthly expenses in the categories set out in lines a-c below that are reasonably necessary for yourself, your spouse, or your dependents.

 

 

a.

Health Insurance

$

 

 

34

 

 

 

 

 

 

 

b.

Disability Insurance

$

 

 

 

 

 

 

 

 

 

 

 

c.

Health Savings Account

$

 

 

 

 

 

 

 

 

 

 

Total and enter on Line 34

$

If you do not actually expend this total amount, state your actual total average monthly expenditures in the space below:

$ ____________

Continued contributions to the care of household or family members. Enter the total average actual

35monthly 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.

$

Protection against family violence. Enter the total average reasonably necessary monthly expenses that you

36actually incurred to maintain the safety of your family under the Family Violence Prevention and Services Act or other applicable federal law. The nature of these expenses is required to be kept confidential by the

court.

$

 

 

 

Home energy costs. Enter the total average monthly amount, in excess of the allowance specified by IRS

 

 

37

 

Local Standards for Housing and Utilities, that you actually expend for home energy costs. You must

 

 

 

provide your case trustee with documentation of your actual expenses, and you must demonstrate that

 

 

 

 

$

 

 

 

the additional amount claimed is reasonable and necessary.

 

 

 

Education expenses for dependent children less than 18. Enter the total average monthly expenses that

 

 

 

 

you actually incur, not to exceed $156.25* per child, for attendance at a private or public elementary or

 

 

38

 

secondary school by your dependent children less than 18 years of age. You must provide your case trustee

 

 

 

 

with documentation of your actual expenses, and you must explain why the amount claimed is

$

 

 

 

reasonable and necessary and not already accounted for in the IRS Standards.

*Amount subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

B 22A (Official Form 22A) (Chapter 7) (04/13)

7

 

 

Additional food and clothing expense. Enter the total average monthly amount by which your food and

 

 

 

 

clothing expenses exceed the combined allowances for food and clothing (apparel and services) in the IRS

 

 

 

39

National Standards, not to exceed 5% of those combined allowances. (This information is available at

 

 

 

 

www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) You must demonstrate that the additional

 

 

 

 

amount claimed is reasonable and necessary.

$

 

 

40

Continued charitable contributions. Enter the amount that you will continue to contribute in the form of

 

 

 

 

cash or financial instruments to a charitable organization as defined in 26 U.S.C. § 170(c)(1)-(2).

$

 

41

Total Additional Expense Deductions under § 707(b). Enter the total of Lines 34 through 40

$

Subpart C: Deductions for Debt Payment

 

Future payments on secured claims. For each of your debts that is secured by an interest in property that

 

 

 

you own, list the name of the creditor, identify the property securing the debt, state the Average Monthly

 

 

 

Payment, and check whether the payment includes taxes or insurance. The Average Monthly Payment is the

 

 

 

total of all amounts scheduled as contractually due to each Secured Creditor in the 60 months following the

 

 

 

filing of the bankruptcy case, divided by 60. If necessary, list additional entries on a separate page. Enter

 

 

 

the total of the Average Monthly Payments on Line 42.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of

Property Securing the Debt

 

Average

Does payment

 

 

 

42

 

 

Creditor

 

 

Monthly

include taxes

 

 

 

 

 

 

 

 

 

Payment

or insurance?

 

 

 

 

 

a.

 

 

$

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

$

yes

no

 

 

 

 

 

c.

 

 

$

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total: Add

 

 

 

 

 

$

 

 

 

 

 

Lines a, b and c.

 

 

 

 

 

 

Other payments on secured claims. If any of debts listed in Line 42 are secured by your primary

 

 

 

residence, a motor vehicle, or other property necessary for your support or the support of your dependents,

 

 

 

you may include in your deduction 1/60th of any amount (the “cure amount”) that you must pay the creditor

 

 

 

in addition to the payments listed in Line 42, in order to maintain possession of the property. The cure

 

 

 

amount would include any sums in default that must be paid in order to avoid repossession or foreclosure.

 

 

 

List and total any such amounts in the following chart. If necessary, list additional entries on a separate

 

 

 

page.

 

 

 

 

 

 

 

 

 

43

 

 

Name of

Property Securing the Debt

 

1/60th of the Cure Amount

 

 

 

 

 

 

Creditor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Total: Add Lines a, b and c

 

 

 

Payments on prepetition priority claims. Enter the total amount, divided by 60, of all priority claims, such

 

 

44

as priority tax, child support and alimony claims, for which you were liable at the time of your bankruptcy

 

 

 

filing. Do not include current obligations, such as those set out in Line 28.

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

B 22A (Official Form 22A) (Chapter 7) (04/13)

 

 

8

 

 

Chapter 13 administrative expenses. If you are eligible to file a case under chapter 13, complete the

 

 

 

 

following chart, multiply the amount in line a by the amount in line b, and enter the resulting administrative

 

 

 

 

expense.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

Projected average monthly chapter 13 plan payment.

$

 

 

 

 

45

 

b.

Current multiplier for your district as determined under schedules issued

 

 

 

 

 

 

 

 

by the Executive Office for United States Trustees. (This information is

 

 

 

 

 

 

 

 

available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy

 

 

 

 

 

 

 

 

court.)

x

 

 

 

 

 

 

c.

Average monthly administrative expense of chapter 13 case

Total: Multiply Lines

 

$

 

 

 

 

 

 

a and b

 

 

 

46

Total Deductions for Debt Payment. Enter the total of Lines 42 through 45.

 

 

$

 

 

 

 

 

 

 

 

 

 

47

Subpart D: Total Deductions from Income

Total of all deductions allowed under § 707(b)(2). Enter the total of Lines 33, 41, and 46.

$

Part VI. DETERMINATION OF § 707(b)(2) PRESUMPTION

 

48

 

Enter the amount from Line 18

(Current monthly income for § 707(b)(2))

$

 

49

 

Enter the amount from Line 47

(Total of all deductions allowed under § 707(b)(2))

$

 

50

 

Monthly disposable income under § 707(b)(2). Subtract Line 49 from Line 48 and enter the result

$

 

 

 

60-month disposable income under § 707(b)(2). Multiply the amount in Line 50 by the number 60 and

 

51

 

 

 

 

 

enter the result.

 

$

 

 

 

 

Initial presumption determination. Check the applicable box and proceed as directed.

The amount on Line 51 is less than $7,475*. Check the box for “The presumption does not arise” at the top of page 1 of this statement, and complete the verification in Part VIII. Do not complete the remainder of Part VI.

52 The amount set forth on Line 51 is more than $12,475*. Check the box for “The presumption arises” at the top of page 1 of this statement, and complete the verification in Part VIII. You may also complete Part VII. Do not complete the remainder of Part VI.

The amount on Line 51 is at least $7,475*, but not more than $12,475*. Complete the remainder of Part VI (Lines 53 through 55).

53

Enter the amount of your total non-priority unsecured debt

$

 

 

 

54Threshold debt payment amount. Multiply the amount in Line 53 by the number 0.25 and enter the result. $ Secondary presumption determination. Check the applicable box and proceed as directed.

The amount on Line 51 is less than the amount on Line 54. Check the box for “The presumption does not arise” at

55the top of page 1 of this statement, and complete the verification in Part VIII.

The amount on Line 51 is equal to or greater than the amount on Line 54. Check the box for “The presumption arises” at the top of page 1 of this statement, and complete the verification in Part VIII. You may also complete Part VII.

Part VII: ADDITIONAL EXPENSE CLAIMS

Other Expenses. List and describe any monthly expenses, not otherwise stated in this form, that are required for the health and welfare of you and your family and that you contend should be an additional deduction from your current monthly income under § 707(b)(2)(A)(ii)(I). If necessary, list additional sources on a separate page. All figures should reflect your average monthly expense for each item. Total the expenses.

56

 

 

 

 

Expense Description

Monthly Amount

 

 

 

 

 

 

 

 

a.

$

 

 

b.

$

 

 

c.

$

 

 

Total: Add Lines a, b and c

$

*Amounts are subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

B 22A (Official Form 22A) (Chapter 7) (04/13)

9

Part VIII: VERIFICATION

57

I declare under penalty of perjury that the information provided in this statement is true and correct. (If this is a joint case, both debtors must sign.)

Date: ________________________

Signature: ________________________

 

(Debtor)

Date: ________________________

Signature: ________________________

 

(Joint Debtor, if any)

B19 (Official Form 19) (12/07)

United States Bankruptcy Court

_____ District Of _______________

In re _______________________________,

Case No. _________________

Debtor

Chapter ______________

 

DECLARATION AND SIGNATURE OF NON-ATTORNEY

BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared the accompanying document(s) listed below for compensation and have provided the debtor with a copy of the document(s) and the attached notice as required by 11 U.S.C. §§ 110(b), 110(h), and 342(b); and (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required by that section.

Accompanying documents:

Printed or Typed Name and Title, if any, of

___________________________________

Bankruptcy Petition Preparer:

___________________________________

 

 

___________________________________

Social-Security No. of Bankruptcy Petition

___________________________________

Preparer (Required by 11 U.S.C. § 110):

___________________________________

 

 

If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social-security number of the officer, principal, responsible person, or partner who signs this document.

_________________________________

 

_________________________________

 

Address

 

X _______________________________

____________________

Signature of Bankruptcy Petition Preparer

Date

Names and social-security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person.

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156.

B19 (Official Form 19) (12/07) - Cont.

2

NOTICE TO DEBTOR BY NON-ATTORNEY BANKRUPTCY PETITION PREPARER

[Must be filed with any document(s) prepared by a bankruptcy petition preparer.]

I am a bankruptcy petition preparer. I am not an attorney and may not practice law or give legal advice. Before preparing any document for filing as defined in § 110(a)(2) of the Bankruptcy Code or accepting any fees, I am required by law to provide you with this notice concerning bankruptcy petition preparers. Under the law, § 110 of the Bankruptcy Code (11 U.S.C. § 110), I am forbidden to offer you any legal advice, including advice about any of the following:

whether to file a petition under the Bankruptcy Code (11 U.S.C. § 101 et seq.);

whether commencing a case under chapter 7, 11, 12, or 13 is appropriate;

whether your debts will be eliminated or discharged in a case under the Bankruptcy Code;

whether you will be able to retain your home, car, or other property after commencing a case under the Bankruptcy Code;

the tax consequences of a case brought under the Bankruptcy Code;

the dischargeability of tax claims;

whether you may or should promise to repay debts to a creditor or enter into a reaffirmation agreement with a creditor to reaffirm a debt;

how to characterize the nature of your interests in property or your debts; or

bankruptcy procedures and rights.

[The notice may provide additional examples of legal advice that a bankruptcy petition preparer is not authorized to give.]

In addition, under 11 U.S.C. § 110(h), the Supreme Court or the Judicial Conference of the United States may promulgate rules or guidelines setting a maximum allowable fee chargeable by a bankruptcy petition preparer. As required by law, I have notified you of this maximum allowable fee, if any, before preparing any document for filing or accepting any fee from you.

____________________________________

_______________________________

Signature of Debtor

Date

Joint Debtor (if any)

Date

[In a joint case, both spouses must sign.]

B280

(10/05)

United States Bankruptcy Court

_______________ District Of ________________

In re _____________________________

 

Debtor

Case No. ____________

Chapter _____________

DISCLOSURE OF COMPENSATION OF BANKRUPTCY PETITION PREPARER

[Must be filed with the petition if a bankruptcy petition preparer prepares the petition. 11 U.S.C. § 110(h)(2).]

1.Under 11 U.S.C. § 110(h), I declare under penalty of perjury that I am not an attorney or employee of an attorney, that I prepared or caused to be prepared one or more documents for filing by the above-named debtor(s) in connection with this bankruptcy case, and that compensation paid to me within one year before the filing of the bankruptcy petition, or agreed to be paid to me, for services rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follows:

For document preparation services I have agreed to accept

$______________

Prior to the filing of this statement I have received

$______________

Balance Due

$______________

2.I have prepared or caused to be prepared the following documents (itemize): and provided the following services (itemize):

3.The source of the compensation paid to me was:

Debtor

Other (specify)

4.The source of compensation to be paid to me is:

Debtor

Other (specify)

5.The foregoing is a complete statement of any agreement or arrangement for payment to me for preparation of the petition filed by the debtor(s) in this bankruptcy case.

6.To my knowledge no other person has prepared for compensation a document for filing in connection with this bankruptcy case except as listed below:

NAME

SOCIAL SECURITY NUMBER

 

x___________________________________

______________________________

_________________

Signature

Social Security number of bankruptcy

Date

____________________________________

petition preparer (If the bankruptcy

 

Printed name and title, if any, of Bankruptcy

petition preparer is not an individual,

 

Petition Preparer

state the Social Security number of the

 

Address:_____________________________

officer, principal, responsible person or

 

 

partner of the bankruptcy petition preparer.)

 

____________________________________

(Required by 11 U.S.C. § 110.)

 

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110; 18 U.S.C. § 156.

B21 (OFFICIAL FORM 21) (12/07)

STATEMENT OF SOCIAL-SECURITY NUMBER OR

INDIVIDUAL TAXPAYER-IDENTIFICATION NUMBER (ITIN)

[Caption as in Form 16A.]

STATEMENT OF SOCIAL-SECURITY NUMBER(S)

(or other Individual Taxpayer-Identification Number(s) (ITIN(s)))

1.Name of Debtor (Last, First, Middle):_______________________________

(Check the appropriate box and, if applicable, provide the required information.)

GDebtor has a Social-Security Number and it is: _ _ _-_ _-_ _ _ _

(If more than one, state all.)

GDebtor does not have a Social-Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is: ___________________.

(If more than one, state all.)

GDebtor does not have either a Social-Security Number or an Individual Taxpayer-Identification Number (ITIN).

2.Name of Joint Debtor (Last, First, Middle):___________________________

(Check the appropriate box and, if applicable, provide the required information.)

GJoint Debtor has a Social-Security Number and it is: _ _ _-_ _-_ _ _ _

(If more than one, state all.)

GJoint Debtor does not have a Social-Security Number but has an Individual Taxpayer-Identi- fication Number (ITIN) and it is: ________________.

(If more than one, state all.)

GJoint Debtor does not have either a Social-Security Number or an Individual Taxpayer-Identification Number (ITIN).

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

X

______________________________________________

 

Signature of Debtor

Date

X

______________________________________________

 

Signature of Joint Debtor

Date

______________________________________________________________________________

*Joint debtors must provide information for both spouses.

Penalty for making a false statement: Fine of up to $250,000 or up to 5 years imprisonment or both. 18 U.S.C. §§ 152 and 3571.

(check at least one):
(check at least one):

B 8 (Official Form 8) (12/08)

UNITED STATES BANKRUPTCY COURT

__________ District of __________

In re ____________________________,

Case No. ___________________

Debtor

Chapter 7

CHAPTER 7 INDIVIDUAL DEBTOR'S STATEMENT OF INTENTION

PART A – Debts secured by property of the estate. (Part A must be fully completed for EACH debt which is secured by property of the estate. Attach additional pages if necessary.)

Property No. 1

 

 

Creditor's Name:

 

Describe Property Securing Debt:

 

 

 

Property will be (check one):

 

 

Surrendered

Retained

If retaining the property, I intend to

Redeem the property

Reaffirm the debt

Other. Explain ________________________________ (for example, avoid lien using 11 U.S.C. § 522(f)).

Property is (check one):

 

 

Claimed as exempt

Not claimed as exempt

 

 

 

Property No. 2 (if necessary)

 

 

Creditor's Name:

 

Describe Property Securing Debt:

 

 

 

Property will be (check one):

 

 

Surrendered

Retained

If retaining the property, I intend to

Redeem the property

Reaffirm the debt

Other. Explain ________________________________ (for example, avoid lien using 11 U.S.C. § 522(f)).

Property is (check one):

 

Claimed as exempt

Not claimed as exempt

B 8 (Official Form 8) (12/08)

Page 2

 

PART B – Personal property subject to unexpired leases. (All three columns of Part B must be completed for

each unexpired lease. Attach additional pages if necessary.)

Property No. 1

Lessor’s Name:

Describe Leased Property:

Lease will be Assumed pursuant

 

 

to 11 U.S.C. § 365(p)(2):

 

 

YES

NO

 

 

 

 

Property No. 2 (if necessary)

 

 

 

 

 

 

Lessor’s Name:

Describe Leased Property:

Lease will be Assumed pursuant

 

 

to 11 U.S.C. § 365(p)(2):

 

 

YES

NO

 

 

 

 

Property No. 3 (if necessary)

 

 

 

 

 

 

Lessor’s Name:

Describe Leased Property:

Lease will be Assumed pursuant

 

 

to 11 U.S.C. § 365(p)(2):

 

 

YES

NO

_____ continuation sheets attached (if any)

I declare under penalty of perjury that the above indicates my intention as to any property of my estate securing a debt and/or personal property subject to an unexpired lease.

Date: ____________________

___________________________________________

 

Signature of Debtor

 

___________________________________________

 

Signature of Joint Debtor

B 8 (Official Form 8) (12/08)

Page 3

 

CHAPTER 7 INDIVIDUAL DEBTOR'S STATEMENT OF INTENTION

(Continuation Sheet)

PART A - Continuation

Property No.

 

 

Creditor's Name:

 

Describe Property Securing Debt:

 

 

 

Property will be (check one):

 

 

Surrendered

Retained

If retaining the property, I intend to (check at least one):

Redeem the property

Reaffirm the debt

Other. Explain ________________________________ (for example, avoid lien using 11 U.S.C. § 522(f)).

Property is (check one):

 

 

 

Claimed as exempt

Not claimed as exempt

 

 

 

 

 

PART B - Continuation

 

 

 

 

 

 

 

Property No.

 

 

 

 

 

 

Lessor’s Name:

Describe Leased Property:

Lease will be Assumed pursuant

 

 

to 11 U.S.C. § 365(p)(2):

 

 

YES

NO

 

 

 

 

Property No.

 

 

 

 

 

 

Lessor’s Name:

Describe Leased Property:

Lease will be Assumed pursuant

 

 

to 11 U.S.C. § 365(p)(2):

 

 

YES

NO

B 201A (Form 201A) (11/11)

UNITED STATES BANKRUPTCY COURT

NOTICE TO CONSUMER DEBTOR(S) UNDER §342(b)

OF THE BANKRUPTCY CODE

In accordance with § 342(b) of the Bankruptcy Code, this notice to individuals with primarily consumer

debts: (1) Describes briefly the services available from credit counseling services; (2) Describes briefly the purposes, benefits and costs of the four types of bankruptcy proceedings you may commence; and (3) Informs you about bankruptcy crimes and notifies you that the Attorney General may examine all information you supply in connection with a bankruptcy case.

You are cautioned that bankruptcy law is complicated and not easily described. Thus, you may wish to seek the advice of an attorney to learn of your rights and responsibilities should you decide to file a petition. Court employees cannot give you legal advice.

Notices from the bankruptcy court are sent to the mailing address you list on your bankruptcy petition. In order to ensure that you receive information about events concerning your case, Bankruptcy Rule 4002 requires that you notify the court of any changes in your address. If you are filing a joint case (a single bankruptcy case for two individuals married to each other), and each spouse lists the same mailing address on the bankruptcy petition, you and your spouse will generally receive a single copy of each notice mailed from the bankruptcy court in a jointly- addressed envelope, unless you file a statement with the court requesting that each spouse receive a separate copy of all notices.

1.Services Available from Credit Counseling Agencies

With limited exceptions, § 109(h) of the Bankruptcy Code requires that all individual debtors who file for bankruptcy relief on or after October 17, 2005, receive a briefing that outlines the available opportunities for credit counseling and provides assistance in performing a budget analysis. The briefing must be given within 180 days before the bankruptcy filing. The briefing may be provided individually or in a group (including briefings conducted by telephone or on the Internet) and must be provided by a nonprofit budget and credit counseling agency approved by the United States trustee or bankruptcy administrator. The clerk of the bankruptcy court has a list that you may consult of the approved budget and credit counseling agencies. Each debtor in a joint case must complete the briefing.

In addition, after filing a bankruptcy case, an individual debtor generally must complete a financial management instructional course before he or she can receive a discharge. The clerk also has a list of approved financial management instructional courses. Each debtor in a joint case must complete the course.

2.The Four Chapters of the Bankruptcy Code Available to Individual Consumer Debtors

Chapter 7: Liquidation ($245 filing fee, $46 administrative fee, $15 trustee surcharge: Total fee $306) Chapter 7 is designed for debtors in financial difficulty who do not have the ability to pay their existing

debts. Debtors whose debts are primarily consumer debts are subject to a “means test” designed to determine whether the case should be permitted to proceed under chapter 7. If your income is greater than the median income for your state of residence and family size, in some cases, the United States trustee (or bankruptcy administrator), the trustee, or creditors have the right to file a motion requesting that the court dismiss your case under § 707(b) of the Code. It is up to the court to decide whether the case should be dismissed.

Under chapter 7, you may claim certain of your property as exempt under governing law. A trustee may have the right to take possession of and sell the remaining property that is not exempt and use the sale proceeds to pay your creditors.

The purpose of filing a chapter 7 case is to obtain a discharge of your existing debts. If, however, you are found to have committed certain kinds of improper conduct described in the Bankruptcy Code, the court may deny

Form B 201A, Notice to Consumer Debtor(s)

Page 2

your discharge and, if it does, the purpose for which you filed the bankruptcy petition will be defeated.

Even if you receive a general discharge, some particular debts are not discharged under the law. Therefore, you may still be responsible for most taxes and student loans; debts incurred to pay nondischargeable taxes; domestic support and property settlement obligations; most fines, penalties, forfeitures, and criminal restitution obligations; certain debts which are not properly listed in your bankruptcy papers; and debts for death or personal injury caused by operating a motor vehicle, vessel, or aircraft while intoxicated from alcohol or drugs. Also, if a creditor can prove that a debt arose from fraud, breach of fiduciary duty, or theft, or from a willful and malicious injury, the bankruptcy court may determine that the debt is not discharged.

Chapter 13: Repayment of All or Part of the Debts of an Individual with Regular Income ($235 filing fee, $46 administrative fee: Total fee $281)

Chapter 13 is designed for individuals with regular income who would like to pay all or part of

their debts in installments over a period of time. You are only eligible for chapter 13 if your debts do not exceed certain dollar amounts set forth in the Bankruptcy Code.

Under chapter 13, you must file with the court a plan to repay your creditors all or part of the money that you owe them, using your future earnings. The period allowed by the court to repay your debts may be three years or five years, depending upon your income and other factors. The court must approve your plan before it can take effect.

After completing the payments under your plan, your debts are generally discharged except for domestic support obligations; most student loans; certain taxes; most criminal fines and restitution obligations; certain debts which are not properly listed in your bankruptcy papers; certain debts for acts that caused death or personal injury; and certain long term secured obligations.

Chapter 11: Reorganization ($1000 filing fee, $46 administrative fee: Total fee $1046)

Chapter 11 is designed for the reorganization of a business but is also available to consumer debtors. Its provisions are quite complicated, and any decision by an individual to file a chapter 11 petition should be reviewed with an attorney.

Chapter 12: Family Farmer or Fisherman ($200 filing fee, $46 administrative fee: Total fee $246) Chapter 12 is designed to permit family farmers and fishermen to repay their debts over a period of time from

future earnings and is similar to chapter 13. The eligibility requirements are restrictive, limiting its use to those whose income arises primarily from a family-owned farm or commercial fishing operation.

3.Bankruptcy Crimes and Availability of Bankruptcy Papers to Law Enforcement Officials

A person who knowingly and fraudulently conceals assets or makes a false oath or statement under penalty of perjury, either orally or in writing, in connection with a bankruptcy case is subject to a fine, imprisonment, or both. All information supplied by a debtor in connection with a bankruptcy case is subject to examination by the Attorney General acting through the Office of the United States Trustee, the Office of the United States Attorney, and other components and employees of the Department of Justice.

WARNING: Section 521(a)(1) of the Bankruptcy Code requires that you promptly file detailed information regarding your creditors, assets, liabilities, income, expenses and general financial condition. Your bankruptcy case may be dismissed if this information is not filed with the court within the time deadlines set by the Bankruptcy Code, the Bankruptcy Rules, and the local rules of the court. The documents and the deadlines for filing them are listed on Form B200, which is posted at http://www.uscourts.gov/bkforms/bankruptcy_forms.html#procedure.

B 201B (Form 201B) (12/09)

 

United States Bankruptcy Court

 

_______________ District Of _______________

In re

 

Case No. _________

 

Debtor

Chapter __________

 

 

 

CERTIFICATION OF NOTICE TO CONSUMER DEBTOR(S)

 

UNDER § 342(b) OF THE BANKRUPTCY CODE

Certification of [Non-Attorney] Bankruptcy Petition Preparer

I, the [non-attorney] bankruptcy petition preparer signing the debtor’s petition, hereby certify that I delivered to the debtor the attached notice, as required by § 342(b) of the Bankruptcy Code.

________________________________________

Printed name and title, if any, of Bankruptcy Petition Preparer Address:

________________________________________

X_______________________________________

Signature of Bankruptcy Petition Preparer or officer, principal, responsible person, or partner whose Social Security number is provided above.

___________________________________

Social Security number (If the bankruptcy petition preparer is not an individual, state the Social Security number of the officer, principal, responsible person, or partner of the bankruptcy petition preparer.) (Required by 11 U.S.C. § 110.)

Certification of the Debtor

I (We), the debtor(s), affirm that I (we) have received and read the attached notice, as required by § 342(b) of the Bankruptcy

Code.

_________________________________________

X___________________________________

Printed Name(s) of Debtor(s)

Signature of Debtor

Date

Case No. (if known) ____________________

X___________________________________

Date

Signature of Joint Debtor (if any)

 

 

__________________________________________________________________________________________

Instructions: Attach a copy of Form B 201A, Notice to Consumer Debtor(s) Under § 342(b) of the Bankruptcy Code.

Use this form to certify that the debtor has received the notice required by 11 U.S.C. § 342(b) only if the certification has NOT been made on the Voluntary Petition, Official Form B1. Exhibit B on page 2 of Form B1 contains a certification by the debtor’s attorney that the attorney has given the notice to the debtor. The Declarations made by debtors and bankruptcy petition preparers on page 3 of Form B1 also include this certification.

Local Bankruptcy Form 1007-6.1

[Caption as in Bankruptcy Official Form 16A]

STATEMENT UNDER PENALTY OF PERJURY

CONCERNING PAYMENT ADVICES

I*,

(debtor’s name)

, state as follows:

I did not file with the court copies of some or all payment advices or other evidence of payment received within 60 days before the date of the filing of the petition from any employer because:

Check applicable boxes:

[ ] I was not employed during the period immediately preceding the filing of the

above-referenced case,

(insert the dates that you were not employed)

;

 

 

 

 

[] I was employed during the period immediately preceding the filing of the above referenced case but did not receive any payment advices or other evidence of payment from my employer within 60 days before the date of the filing of the petition;

[] I am self-employed and do not receive any evidence of payment from an employer;

[] Other (please provide explanation): ______________________________________. I declare under penalty of perjury that the foregoing statement is true and correct.

Dated: ______________________

By: __________________________________

 

Signature of debtor

 

_____________________________________

 

Printed name of debtor

 

Home address

 

Telephone number

 

Facsimile number

 

E-mail address

* A separate form must be signed for each debtor.

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