North Carolina Form 91C – Fill Out and Use This PDF

91C (09/13)

UNITED STATES BANKRUPTCY COURT

MIDDLE DISTRICT OF NORTH CAROLINA

In the Matter of:			)
			)	Case No.
			)
			)	DEBTOR'S CLAIM FOR
			)	PROPERTY EXEMPTIONS
		Debtor.	)
I,		, the undersigned debtor, hereby claim the following property as exempt pursuant to 11 U.S.C.

'522(b)(3)(A), (B), and (C), the Laws of the State of North Carolina, and non-bankruptcy federal law.

 Check if the debtor claims as exempt any amount of interest that exceeds $125,000 in value in property that the debtor or a dependent of the debtor uses as a residence.

1.REAL OR PERSONAL PROPERTY USED BY DEBTOR OR DEBTOR'S DEPENDENT AS RESIDENCE OR BURIAL PLOT. NCGS 1C-1601(a)(1).

Select appropriate exemption amount below:

Total net value not to exceed $35,000.

Total net value not to exceed $60,000. (Debtor is unmarried, 65 years of age or older, property was previously owned by debtor as a tenant by the entireties or joint tenant with rights of survivorship, and former co-owner is deceased.)

Description of	Market	Mtg. Holder or	Amt. Mtg.	Net
Property & Address	Value	Lien Holder(s)	or Lien	Value
______________________	___________	____________________	_________	_______

(a) Total Net Value	$
Total Net Exemption	$
(b) Unused portion of exemption, not to exceed $5,000.	$
(This amount, if any, may be carried forward and used to
claim an exemption in any property owned by the debtor.
(NCGS 1C-1601(a)(2)).

2.TENANCY BY THE ENTIRETY. The following property is claimed as exempt pursuant to 11 U.S.C. ' 522(b)(3)(B) and the laws of the State of North Carolina pertaining to property held as tenants by the entirety.

Description of	Market	Mtg. Holder or	Amt. Mtg.	Net
Property & Address	Value	Lien Holder(s)	or Lien	Value
______________________	___________	____________________	_________	_______

3.MOTOR VEHICLE. (NCGS 1C-1601(a)(3). Only one vehicle allowed under this paragraph with net value claimed as exempt not to exceed $3,500.)

Year, Make,	Market							Net
Model of Auto	Value	Lien Holder(s)			Amt. Lien			Value
______________________	___________	____________________			_________			_______
(a) Statutory allowance			$		3,500
(b) Amount from 1(b) above to be used in this paragraph.
(A part or all of 1(b) may be used as needed.)			$
	Total Net Exemption		$

91C (09/13)

4.TOOLS OF TRADE, IMPLEMENTS, OR PROFESSIONAL BOOKS. (NCGS 1C-1601(a)(5). Used by debtor or debtor's dependent. Total net value of all items claimed as exempt not to exceed $2,000.)

	Market					Net
Description	Value	Lien Holder(s)			Amt. Lien	Value
______________________	___________	____________________			_________	_______
______________________	___________	____________________			_________	_______
(a) Statutory allowance		$	2,000
(b) Amount from 1(b) above to be used in this paragraph.
(A part or all of 1 (b) may be used as needed.)		$

Total Net Exemption $

5.PERSONAL PROPERTY USED FOR HOUSEHOLD OR PERSONAL PURPOSES NEEDED BY DEBTOR OR DEBTOR'S DEPENDENTS. (NCGS 1C-1601(a)(4). Debtor's aggregate interest, not to exceed $5,000 in value for the debtor plus $1,000 for each dependent of the debtor, not to exceed $4,000 total for dependents.)

		Market									Net
Description		Value		Lien Holder(s)			Amt. Lien				Value
Clothing & Personal		___________		____________________			_________				_______
Kitchen Appliances		___________		____________________			_________				_______
Stove		___________		____________________			_________				_______
Refrigerator		___________		____________________			_________				_______
Freezer		___________		____________________			_________				_______
Washing Machine		___________		____________________			_________				_______
Dryer		___________		____________________			_________				_______
China		___________		____________________			_________				_______
Silver		___________		____________________			_________				_______
Jewelry		___________		____________________			_________				_______
Living Room Furniture		___________		____________________			_________				_______
Den Furniture		___________		____________________			_________				_______
Bedroom Furniture		___________		____________________			_________				_______
Dining Room Furniture		___________		____________________			_________				_______
Lawn Furniture		___________		____________________			_________				_______
Television		___________		____________________			_________				_______
( ) Stereo ( ) Radio		___________		____________________			_________				_______
Musical Instruments		___________		____________________			_________				_______
( ) Piano ( ) Organ		___________		____________________			_________				_______
Air Conditioner		___________		____________________			_________				_______
Paintings & Art		___________		____________________			_________				_______
Lawn Mower		___________		____________________			_________				_______
Yard Tools		___________		____________________			_________				_______
Crops		___________		____________________			_________				_______
Animals		___________		____________________			_________				_______
Other (	)	___________		____________________			_________				_______
					Total Net Value $
(a) Statutory allowance for debtor						$	5,000
(b) Statutory allowance for debtor's dependents:					dependents
at $1,000 each (not to exceed $4,000 total for dependents)						$

91C (09/13)

(c) Amount from 1(b) above to be used in this paragraph.
(A part or all of 1 (b) may be used as needed.)			$
			Total Net Exemption $
6. LIFE INSURANCE. (As provided in Article X, Section 5 of North Carolina Constitution.)
Name of Insurance Company					Policy No.
Name of Insured					Policy Date

Name of Beneficiary

7.PROFESSIONALLY PRESCRIBED HEALTH AIDS (FOR DEBTOR OR DEBTOR'S DEPENDENTS). (NCGS 1C-1601(a)(7). No limit on value of number of items.)

Description:

__________________________________________________________________________________

8.DEBTOR'S RIGHT TO RECEIVE FOLLOWING COMPENSATION: (NCGS 1C-1601(a)(8). No limit on number or amount.)

A.	$		Compensation for personal injury to debtor or to person whom debtor was dependent for support.
B.	$		Compensation for death of person of whom debtor was dependent for support.
C.	$ __________		Compensation from private disability policies or annuities.

9.INDIVIDUAL RETIREMENT PLANS AS DEFINED IN THE INTERNAL REVENUE CODE AND ANY PLAN TREATED IN THE SAME MANNER AS AN INDIVIDUAL RETIREMENT PLAN UNDER THE INTERNAL REVENUE CODE (NCGS 1C-1601(a)(9). No limit on number or amount.) AND OTHER RETIREMENT FUNDS

DEFINED IN 11 U.S.C. § 522(b)(3)(c).

Detailed Description		Value

10.COLLEGE SAVINGS PLANS QUALIFIED UNDER SECTION 529 OF THE INTERNAL REVENUE CODE.

(NCGS 1C-1601(a)(10). Total net value not to exceed $25,000 and may not include any funds placed in a college saving plan within the preceding 12 months not in the ordinary course of the debtor’s financial affairs. This exemption applies only to the extent that the funds are for a child of the debtor and will actually be used for the child’s college or university expenses.

Detailed Description		Value

11.RETIREMENT BENEFITS UNDER A RETIREMENT PLAN OF OTHER STATE AND GOVERNMENTAL UNITS OF OTHER STATES, TO THE EXTEND THOSE BENEFITS ARE EXEMPT UNDER THE LAWS OF THAT STATE OR GOVERNMENTAL UNIT. (NCGS 1C-1601(a)(11). No limit on amount.)

Description:

__________________________________________________________________________________

12.ALIMONY, SUPPORT, SEPARATION MAINTENANCE AND CHILD SUPPORT. (NCGS 1C-1601(a)(12). No limit on amount to the extent such payments are reasonably necessary for the support of Debtor or dependent of Debtor.)

91C (09/13)

Description:

__________________________________________________________________________________

13.ANY OTHER REAL OR PERSONAL PROPERTY WHICH DEBTOR DESIRES TO CLAIM AS EXEMPT THAT HAS NOT PREVIOUSLY BEEN CLAIMED ABOVE. (NCGS 1C-1601(a)(2). The amount claimed may not exceed the remaining amount available under paragraph 1(b) which has not been used for other exemptions.)

	Market			Net
Description	Value	Lien Holder(s)	Amt. Lien	Value
______________________	___________	____________________	_________	_______
______________________	___________	____________________	_________	_______

(a) Total Net Value of property claimed in paragraph 13.				$
(b) Total amount available from paragraph 1(b).	$
(c) Less amounts from paragraph 1(b) which were
Used in the following paragraphs:
Paragraph 3(b)	$
Paragraph 4(b)	$
Paragraph 5(c)	$
Net Balance Available from paragraph 1(b)				$
	Total Net Exemption			$

14.OTHER EXEMPTIONS CLAIMED UNDER THE LAWS OF THE STATE OF NORTH CAROLINA:

Aid to the Aged, Disabled and Families with Dependent Children, NCGS 108A-36 Aid to the Blind, NCGA 111-18

Yearly Allowance for Surviving Spouse, NCGS 30-15

North Carolina Local Government Employees Retirement Benefits, NCGS 128-31 North Carolina Teachers and State Employees Retirement Benefits, NCGS 135-9 Firemen=s Relief Fund Pensions, NCGS 58-86-90

Workers Compensation Benefits, NCGS 97-21

Unemployment Benefits, so long as not commingled and except for debts for necessities purchased while unemployed, NCGS 96-17

Group Insurance Proceeds, NCGS 58-58-165

Partnership Property, except on a claim against the partnership, NCGS 59-55 Wages of a Debtor Necessary for Support of Family, NCGS 1-362

Other
TOTAL VALUE OF PROPERTY CLAIMED AS EXEMPT	$

15.EXEMPTIONS CLAIMED UNDER NON-BANKRUPTCY FEDERAL LAW:

Foreign Service Retirement and Disability Payments, 22 U.S.C. ' 1104 Social Security Benefits, 42 U.S.C. ' 407

Injury of Death Compensation Payments from War Risk Hazards, 42 U.S.C. ' 601 Wages of Fishermen, Seamen and Apprentices, 46 U.S.C. ' 601

Civil Service Retirement Benefits, 5 U.S.C. '' 729, 2265

Longshoremen and Harbor Workers Compensation Act Death and Disability Benefits, 33 U.S.C. ' 916

Railroad Retirement Act Annuities and Pensions 45 U.S.C. ' 228(L) Veterans Benefits, 45 U.S.C. ' 352(E)

Special Pension Paid to Winners of Congressional Medal of Honor, 38 U.S.C. ' 3101 Federal Homestead Lands, on Debts Contracted Before the Issuance of the Patent,

43 U.S.C. ' 175

Other
TOTAL VALUE OF PROPERTY CLAIMED AS EXEMPT	$

91C (09/13)

16.RECENT PURCHASES

The exemptions provided in NCGS 1C-1601(a)(2), (3), (4), and (5) are inapplicable with respect to tangible personal property purchased by the debtor less than 90 days preceding the initiation of judgment collection proceedings or the filing of a petition for bankruptcy, unless the purchase of the property is directly traceable to the liquidation or conversion of property that may be exempt and no additional property was transferred into or used to acquire the replacement property.

List tangible personal property purchased by the debtor less than 90 days preceding the filing of the bankruptcy petition:

	Market			Net
Description	Value	Lien Holder(s)	Amt. Lien	Value
______________________	___________	____________________	_________	_______
______________________	___________	____________________	_________	_______

DATE:

Debtor