Fill - Free fillable Additional Documents Pro Se (US Courts) PDF form

Additional

Documents

– Pro Se –

Chapter 7

U. S. Bankruptcy

Court Northern

District of Illinois

Last Updated: April 1, 2019

Additional

Documents

Chapter 13

Individual

REMINDER: PLEASE SIGN ALL PAGES THAT REQUIRE A SIGNATURE

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 1 of 2

Official Form 106Sum

Summary of Your Assets and Liabilities and Certain Statistical Information 12/15

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct

information. Fill out all of your schedules first; then complete the information on this form.

If you are filing amended schedules after you file

your original forms, you must fill out a new Summary and check the box at the top of this page.

Part 1: Summarize Your Assets

Your assets

Value of what you own

1. Schedule A/B: Property (Official Form 106A/B)

1a. Copy line 55, Total real estate, from Schedule A/B ..........................................................................................................

$ ________________

1b. Copy line 62, Total personal property, from Schedule A/B ...............................................................................................

$ ________________

1c. Copy line 63, Total of all property on Schedule A/B .........................................................................................................

$ ________________

Part 2: Summarize Your Liabilities

Your liabilities

Amount you owe

2. Schedule D: Creditors Who Have Claims Secured by Property (Official Form 106D)

2a. Copy the total you listed in Column A, Amount of claim, at the bottom of the last page of Part 1 of Schedule D ............

$ ________________

3. Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 106E/F)

3a. Copy the total claims from Part 1 (priority unsecured claims) from line 6e of Schedule E/F ............................................

$ ________________

3b. Copy the total claims from Part 2 (nonpriority unsecured claims) from line 6j of Schedule E/F .......................................

+ $ ________________

Your total liabilities

$ ________________

Part 3: Summarize Your Income and Expenses

4. Schedule I: Your Income (Official Form 106I)

Copy your combined monthly income from line 12 of Schedule I ..........................................................................................

$ ________________

5. Schedule J: Your Expenses (Official Form 106J)

Copy your monthly expenses from line 22c of Schedule J ....................................................................................................

$ ________________

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of __________

Case number ___________________________________________

(

If known

)

Fill in this information to identify your case:

 Check if this is an

amended filing

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106Sum Summary of Your Assets and Liabilities and Certain Statistical Information page 2 of 2

Part 4: Answer These Questions for Administrative and Statistical Records

6.

Are you filing for bankruptcy under Chapters 7, 11, or 13?

 No. You have nothing to report on this part of the form. Check this box and submit this form to the court with your other schedules.

 Yes

7. What kind of debt do you have?

 Your debts are primarily consumer debts. Consumer debts are those “incurred by an individual primarily for a personal,

family, or household purpose.” 11 U.S.C. § 101(8).

Fill out lines 8-9g for statistical purposes. 28 U.S.C. § 159.

 Your debts are not primarily consumer debts. You have nothing to report on this part of the form. Check this box and submit

this form to the court with your other schedules.

8. From the Statement of Your Current Monthly Income: Copy your total current monthly income from Official

Form 122A-1 Line 11; OR, Form 122B Line 11; OR, Form 122C-1 Line 14.

$ _________________

9. Copy the following special categories of claims from Part 4, line 6 of Schedule E/F:

Total claim

From Part 4 on Schedule E/F, copy the following:

9a. Domestic support obligations (Copy line 6a.)

$_____________________

9b. Taxes and certain other debts you owe the government. (Copy line 6b.)

$_____________________

9c. Claims for death or personal injury while you were intoxicated. (Copy line 6c.)

$_____________________

9d. Student loans. (Copy line 6f.)

$_____________________

9e. Obligations arising out of a separation agreement or divorce that you did not report as

priority claims. (Copy line 6g.)

$_____________________

9f. Debts to pension or profit-sharing plans, and other similar debts. (Copy line 6h.)

+ $_____________________

9g. Total. Add lines 9a through 9f.

$_____________________

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Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106A/B

Schedule A/B: Property page 3

3.3.

Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instr

uctions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

$________________

Current value of the

portion you own?

$________________

3.4.

Make: ______________

Model: ______________

Year: ____________

Approximate mileage: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instr

uctions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

$________________

Current value of the

portion you own?

$________________

4. Watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories

Exam

ples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle

accessories

No

 Yes

4.1.

Make: ____________________

Model: ____________________

Year: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instr

uctions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

$________________

Current value of the

portion you own?

$________________

If you own or have more than one, list here:

4.2.

Make: ____________________

Model: ____________________

Year: ____________

Other information:

Who has an interest in the property? Check one.

Debtor 1 only

Debtor 2 only

Debtor 1 and Debtor 2 only

At least one of the debtors and another

 Check if this is community property (see

instr

uctions)

Do not deduct secured claims or exemptions. Put

the amount of any secured claims on Schedule D:

Creditors Who Have Claims Secured by Property.

Current value of the

entire property?

$________________

Current value of the

portion you own?

$________________

5. Add the dollar value of the portion you own for all of your entries from Part 2, including any entries for pages

y

ou have attached for Part 2. Write that number here

........................................................................................................................ 

$_________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106A/B

Schedule A/B: Property page 4

Part 3: Describe Your Personal and Household Items

Do you own or have any legal or equitable interest in any of the following items?

Current value of the

portion you own?

Do not deduct secured claims

or exemptions.

6. Household goods and furnishings

Examples: Major appliances, furniture, linens, china, kitchenware

 No

 Yes. Describe. ........

$___________________

7. Electronics

Examples: Televisions and radios; audio, video, stereo, and digital equipment; computers, printe

rs, scanners; music

collections; e

lectronic devices including cell phones, cameras, media players, games

 No

 Yes. Describe. .........

$________

___________

8. Collectibles of value

Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art ob

jects;

stamp, coin, or

baseball card collections; other collections, memorabilia, collectibles

 No

 Yes. Describe. .........

$________

___________

9. Equipment for sports and hobbies

Exam

ples: Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; ca

noes

and ka

yaks; carpentry tools; musical instruments

 No

 Yes. Describe. .........

$________

___________

10. Firearms

Exam

ples: Pistols, rifles, shotguns, ammunition, and related eq

uipment

 No

 Yes. Describe. .........

.

$________

___________

11. Clothes

Examples: Everyday clothes, furs, leather coats, designer wear, shoe

s, accessories

 No

 Yes. Describe. .........

.

$________

___________

12. Jewelry

Examples: Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watc

hes, gems,

gold, silver

 No

 Yes. Describe. ..........

$________

___________

13. Non-farm animals

Exam

ples: Dogs, cats, birds, horses

 No

 Yes. Describe. ..........

$________

___________

14. Any other personal and household items you did not already list, including any health aids you did not list

 No

 Yes. Give specific

information.

..............

$________

___________

15. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached

for Part 3. Write that number here

.................................................................................................................................................... 

$______________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106A/B

Schedule A/B: Property page 5

Part 4: Describe Your Financial Assets

Do you own or have any legal or equitable interest in any of the following?

Current value of the

portion you own?

Do not deduct secured claims

or exemptions.

16. Cash

Examples: Money you have in your wallet, in your home, in a safe deposit box, and on hand when you file your petition

 No

 Yes ................................................................................................................................................................



Cash: .......................

$__________________

17. Deposits of money

Examples: Checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerag

e houses,

and other similar

institutions. If you have multiple accounts with the same institution, list each.

 No

 Yes .....................

Institution name:

17.1. Checking account: _________________________________________________________

17.2. Checking account: _________________________________________________________

17.3. Savings account: _________________________________________________________

17.4. Savings account: _________________________________________________________

17.5. Certificates of deposit: _________________________________________________________

17.6. Other financial account: _________________________________________________________

17.7. Other financial account: _________________________________________________________

17.8. Other financial account: _________________________________________________________

17.9. Other financial account: _________________________________________________________

$__________________

18. Bonds, mutual funds, or publicly traded stocks

Examples: Bond funds, investment accounts with brokerage firms, money market ac

counts

 No

 Yes .................

Institution or issuer name:

_________________________________________________________________________________________

$__________________

19. Non-publicly traded stock and interests in incorporated and unincorporated businesses, including an interest in

an L

LC, partnership, and joint venture

 No

Yes. Give specific

information abou

t

them

.........................

Name of entity: % of ownership:

_____________________________________________________________________ ___________%

$________

__________

$__________________

0%

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106A/B

Schedule A/B: Property page 6

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

Negotiable instruments include personal checks, cashiers’ checks, promissory notes, and money orders.

Non-negotiable instruments are those you cannot transfer to someone by signing or delivering them.

 No

Yes. Give specific

information about

them

.......................

Issuer name:

______________________________________________________________________________________

$__________________

21. Retirement or pension accounts

Examples: Interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sha

ring plans

 No

 Yes. List each

account separate

ly.

Type of account: Institution name:

401(k) or similar plan: ___________________________________________________________________

Pension plan: ___________________________________________________________________

IRA: ___________________________________________________________________

Retirement account: ___________________________________________________________________

Keogh: ___________________________________________________________________

Additional account: ___________________________________________________________________

$__________________

22. Security deposits and prepayments

Your share of all unused deposits you have made so that you may continue service or use from a compan

y

Exam

ples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommuni

cations

companies, or others

 No

 Yes ..........................

Institution name or individual:

Electric: ______________________________________________________________________

Gas: ______________________________________________________________________

Heating oil: ______________________________________________________________________

Security deposit on rental unit: _____________________________________________________________

Prepaid rent: ______________________________________________________________________

Telephone: ______________________________________________________________________

Water: ______________________________________________________________________

Rented furniture: ______________________________________________________________________

Other: ______________________________________________________________________

$___________________

23. Annuities (A contract for a periodic payment of money to you, either for life or for a number of years)

 No

 Yes ..........................

Issuer name and description:

_______________________________________________________________________________________

$__________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106A/B

Schedule A/B: Property page 7

24. Interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program.

26 U.S.C. §§ 530(b)(1), 529A(b), and 529(b)(1).

 No

 Yes ....................................

Institution name and description. Separately file the records of any interests.11 U.S.C. § 521(c)

:

____________________________________________________________________________________

$_________________

25. Trusts, equitable or future interests in property (other than anything listed in line 1), and rights or powers

exercisable

for your benefit

 No

 Yes. Give specific

information about them

. ...

$__________________

26. Patents, copyrights, trademarks, trade secrets, and other intellectual property

Examples: Internet domain names, websites, proceeds from royalties and licensing agreements

 No

 Yes. Give specific

information about them

. ...

$__________________

27. Licenses, franchises, and other general intangibles

Examples: Building permits, exclusive licenses, cooperative association holdings, liquor licenses, professional licenses

 No

 Yes. Give specific

information about them

. ...

$__________________

Money or property owed to you?

Current value of the

portion you own?

Do not deduct secured

claims or exemptions.

28. Tax refunds owed to you

 No

 Yes. Give specific information

about them, including whether

you alrea

dy filed the returns

and the tax years. .......................

Federal: $_________________

State:

$_________________

Local

: $_________________

29. Family support

Examples: Past due or lump sum alimony, spousal support, child support, maintenance, divorce settlement, property

settlement

 No

 Yes. Give specific information. .............

Alimony

:

Maintenance:

Support:

Div

orce settlement:

Property settlement:

$________________

30. Other amounts someone owes you

Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compen

sation,

Social Security

benefits; unpaid loans you made to someone else

 No

 Yes. Give specific information. ..............

$______________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106A/B

Schedule A/B: Property page 8

31. Interests in insurance policies

Examples: Health, disability, or life insurance; health savings account (HSA); credit, homeowner’s, or renter’s insurance

 No

 Yes. Name the insurance company

of each policy and list its value

. ..

.

Company name: Beneficiary:

___________________________________________ ____________________________

Surrender or refund value:

$__________________

32. Any interest in property that is due you from someone who has died

If you are the beneficiary of a living trust, expect proceeds from a life insurance policy, or are currently entitled to receiv

e

propert

y because someone has died.

 No

 Yes. Give specific information. .............

$___________

__________

33. Claims against third parties, whether or not you have filed a lawsuit or made a demand for payment

Exam

ples: Accidents, employment disputes, insurance claims, or rights to sue

 No

 Yes. Describe each claim. ....................

$___________

___________

34. Other contingent and unliquidated claims of every nature, including counterclaims of the debtor and rights

to se

t off claims

 No

 Yes. Describe each claim. ....................

$_____________________

35. Any financial assets you did not already list

 No

 Yes. Give specific information. ...........

$_____________________

36. Add the dollar value of all of your entries from Part 4, including any entries for pages you have attached

for Part 4. Write that number here

.................................................................................................................................................... 

$_____________________

Part 5:

Describe Any Business-Related Property You Own or Have an Interest In. List any real estate in Part 1.

37. Do you own or have any legal or equitable interest in any business-related property?

 No. Go to Part 6.

 Yes. Go to line 38.

Current value of the

portion you own?

Do not deduct secured claims

or exemptions.

38. Accounts receivable or commissions you already earned

 No

 Yes. Describe .......

$_______

_

_____________

39. Office equipment, furnishings, and supplies

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, electronic devices

 No

 Yes. Describe .......

$__________

_

__________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106A/B

Schedule A/B: Property page 9

40. Machinery, fixtures, equipment, supplies you use in business, and tools of your trade

 No

 Yes. Describe .......

$______

_

______________

41. Inventory

 No

 Yes. Describe .......

$

_____

_

_______________

42. Interests in partnerships or joint ventures

 No

 Yes. Describe .......

Name of entity: % of ownership:

______________________________________________________________________ ________%

$________

_____________

$_____________________

43. Customer lists, mailing lists, or other compilations

 No

 Yes. Do your lists include personally identifiable information (as defined in 11 U.S.C. § 101(41A))?

 No

 Yes. Describe. .......

$____________________

44. Any business-related property you did not already list

 No

 Yes. Give specific

information

.........

______________________________________________________________________________________

$____________________

______________________________________________________________________________________

$____________________



______________________________________________________________________________________

$____________________



______________________________________________________________________________________

$____________________



______________________________________________________________________________________

$____________________

______________________________________________________________________________________

$____________________

45. Add the dollar value of all of your entries from Part 5, including any entries for pages you have attached

for Part 5. Write that number here

.................................................................................................................................................... 

$____________________

Part 6: Describe Any Farm- and Commercial Fishing-Related Property You Own or Have an Interest In.

If you own or have an interest in farmland, list it in Part 1.

46. Do you own or have any legal or equitable interest in any farm- or commercial fishing-related property?

 No. Go to Part 7.

 Yes. Go to line 47.



Current value of the

portion you own?

Do not deduct secured claims

or exemptions.

47. Farm animals

Exam

ples: Livestock, poultry, farm

-raised fish

 No

 Yes ..........................

$___________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106A/B

Schedule A/B: Property page 10

48. Crops—either growing or harvested

 No

 Yes. Give specific

information

. ............

$___________________

49. Farm and fishing equipment, implements, machinery, fixtures, and tools of trade

 No

 Yes ..........................

$___________________

50. Farm and fishing supplies, chemicals, and feed

 No

 Yes ..........................

$___________________

51. Any farm- and commercial fishing-related property you did not already list

 No

 Yes. Give specific

infor

mation

. ............

$___________________

52. Add the dollar value of all of your entries from Part 6, including any entries for pages you have attached

for Part 6. Write that number here

.................................................................................................................................................... 

$___________________

Part 7:

Describe All Property You Own or Have an Interest in That You Did Not List Above

53. Do you have other property of any kind you did not already list?

Examples: Season tickets, country club membership

 No

 Yes. Give specific

infor

mation

. ............

$________________

54. Add the dollar value of all of your entries from Part 7. Write that number here ................................................................. 

$________________

Part 8:

List the Totals of Each Part of this Form

55. Part 1: Total real estate, line 2 .............................................................................................................................................................. 

$________

________

56. Part 2: Total vehicles, line 5 $________________

57. Part 3: Total personal and household items, line 15 $________________

58. Part 4: Total financial assets, line 36 $________________

59. Part 5: Total business-related property, line 45 $________________

60. Part 6: Total farm- and fishing-related property, line 52 $________________

61. Part 7: Total other property not listed, line 54

+ $________________

62. Total personal property. Add lines 56 through 61. .................... $________________

Copy personal property total



+ $_________________

63. Total of all property on Schedule A/B. Add line 55 + line 62. ......................................................................................... $_________________

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

Official Form 106C

Schedule C: The Property You Claim as Exempt 04/19

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information.

Using the property you listed on Schedule A/B: Property (Official Form 106A/B) as your source, list the property that you claim as exempt. If more

space is needed, fill out and attach to this page as many copies of Part 2: Additional Page as necessary. On the top of any additional pages, write

your name and case number (if known).

For each item of property you claim as exempt, you must specify the amount of the exemption you claim. One way of doing so is to state a

specific dollar amount as exempt. Alternatively, you may claim the full fair market value of the property being exempted up to the amount

of any applicable statutory limit. Some exemptions—such as those for health aids, rights to receive certain benefits, and tax-exempt

retirement funds—may be unlimited in dollar amount. However, if you claim an exemption of 100% of fair market value under a law that

limits the exemption to a particular dollar amount and the value of the property is determined to exceed that amount, your exemption

would be limited to the applicable statutory amount.

Part 1: Identify the Property You Claim as Exempt

1. Which set of exemptions are you claiming? Check one only, even if your spouse is filing with you.

 You are claiming state and federal nonbankruptcy exemptions. 11 U.S.C. § 522(b)(3)

 You are claiming federal exemptions. 11 U.S.C. § 522(b)(2)

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

Brief description of the property and line on

Schedule A/B that lists this property

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption.

Specific laws that allow exemption

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

any applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

any applicable statutory limit

____________________________

______

Brief

description:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

any applicable statutory limit

____________________________

Line from

Schedule A/B:

______

3. Are you claiming a homestead exemption of more than $170,350?

(Subject to adjustment on 4/01/22 and every 3 years after that for cases filed on or after the date of adjustment.)

 No

 Yes. Did you acquire the property covered by the exemption within 1,215 days before you filed this case?

 No

 Yes

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of __________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

 Check if this is an

amended filing

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 2: Additional Page

Brief description of the property and line

on Schedule A/B that lists this property

Current value of the

portion you own

Copy the value from

Schedule A/B

Amount of the exemption you claim

Check only one box for each exemption

Specific laws that allow exemption

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

any applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

an

y applicable statutory limit

____________________________

____________________________ ______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

an

y applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

any applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

an

y applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

an

y applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

any applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

an

y applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

an

y applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

any applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

an

y applicable statutory limit

____________________________

______

Brief

description:

Line from

Schedule A/B:

_________________________

$________________

 $ ____________

 100% of fair market value, up to

an

y applicable statutory limit

____________________________

______

2

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Official Form 106D Schedule D: Creditors Who Have Claims Secured by Property page 1 of ___

Official Form 106D

Schedule D: Creditors Who Have Claims Secured by Property 12/15

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct

information. If more space is needed, copy the Additional Page, fill it out, number the entries, and attach it to this form. On the top of any

additional pages, write your name and case number (if known).

1. Do any creditors have claims secured by your property?

 No. Check this box and submit this form to the court with your other schedules. You have nothing else to report on this form.

 Yes. Fill in all of the information below.

Part 1: List All Secured Claims

2. List all secured claims. If a creditor has more than one secured claim, list the creditor separately

for each claim. If more than one creditor has a particular claim, list the other creditors in Part 2.

As much as possible, list the claims in alphabetical order according to the creditor’s name.

Column A

Amount of claim

Do not deduct the

value of collateral.

Column B

Value of collateral

that supports this

claim

Column C

Unsecured

portion

If any

2.1

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

City State ZIP Code

Describe the property that secures the claim:

$_________________ $________________$____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured

car loan)

 Statutory lien (such as tax lien, mechanic’s lien)

 Judgment lien from a lawsuit

 Other (including a right to offset) ____________________

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

2.2

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

City State ZIP Code

Describe the property that secures the claim:

$_________________ $________________$____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Nature of lien

. Check all that apply.

 An agreement you made (such as mortgage or secured

car loan)

 Statutory lien (such as tax lien, mechanic’s lien)

 Judgment lien from a lawsuit

 Other (including a right to offset) ____________________

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here:

$________________

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of __________

Case number ___________________________________________

(

If known

)

Fill in this information to identify your case:

 Check if this is an

amended filing

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106D Additional Page of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___

Part 1:

Additional Page

After listing any entries on this page, number them beginning with 2.3, followed

by 2.4, and so forth.

Column A

Amount of claim

Do not deduct the

value of collateral.

Column B

Value of collateral

that supports this

claim

Column C

Unsecured

portion

If any

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

City State ZIP Code

Describe the property that secures the claim:

$_________________ $________________$____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured

car loan)

 Statutory lien (such as tax lien, mechanic’s lien)

 Judgment lien from a lawsuit

 Other (including a right to offset) ____________________

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

City State ZIP Code

Describe the property that secures the claim: $_________________ $________________$____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured

car loan)

 Statutory lien (such as tax lien, mechanic’s lien)

 Judgment lien from a lawsuit

 Other (including a right to offset) ____________________

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

City State ZIP Code

Describe the property that secures the claim:

$_________________ $________________$____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Nature of lien. Check all that apply.

 An agreement you made (such as mortgage or secured

car loan)

 Statutory lien (such as tax lien, mechanic’s lien)

 Judgment lien from a lawsuit

 Other (including a right to offset) ____________________

Who owes the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim relates to a

community debt

Date debt was incurred ____________ Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here:

$_________________

If this is the last page of your form, add the dollar value totals from all pages.

Write that number here:

$_________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106D Part 2 of Schedule D: Creditors Who Have Claims Secured by Property page ___ of ___

Part 2: List Others to Be Notified for a Debt That You Already Listed

Use this page only if you have others to be notified about your bankruptcy for a debt that you already listed in Part 1. For example, if a collection

agency is trying to collect from you for a debt you owe to someone else, list the creditor in Part 1, and then list the collection agency here. Similarly, if

you have more than one creditor for any of the debts that you listed in Part 1, list the additional creditors here. If you do not have additional persons to

be notified for any debts in Part 1, do not fill out or submit this page.

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

____________

_________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State

ZIP

Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

____________

_________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State

ZIP

Code

On which line in Part 1 did you enter the creditor? _____

Last 4 digits of account number ___ ___ ___ ___

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Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___

Official Form 106E/F

Schedule E/F: Creditors Who Have Unsecured Claims 12/15

Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY claims and Part 2 for creditors with NONPRIORITY claims.

List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule

A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any

creditors with partially secured claims that are listed in Schedule D: Creditors Who Have Claims Secured by Property. If more space is

needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of

any additional pages, write your name and case number (if known).

Part 1: List All of Your PRIORITY Unsecured Claims

1. Do any creditors have priority unsecured claims against you?

 No. Go to Part 2.

 Yes.

2. List all of your priority unsecured claims. If a creditor has more than one priority unsecured claim, list the creditor separately for each claim. For

each claim listed, identify what type of claim it is. If a claim has both priority and nonpriority amounts, list that claim here and show both priority and

nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor’s name. If you have more than two priority

unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.

(For an explanation of each type of claim, see the instructions for this form in the instruction booklet.)

Total claim Priority

amount

Nonpriority

amount

2.1

____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___

$_____________ $___________ $____________

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply

.

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were

intoxicated

 Other. Specify _________________________________

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

2.2

____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply

.

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were

intoxicated

 Other. Specify _________________________________

$_____________ $___________ $____________

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of __________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

 Check if this is an

amended filing

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 1: Your PRIORITY Unsecured Claims ─ Continuation Page

After listing any entries on this page, number them beginning with 2.3, followed by 2.4, and so forth.

Total claim Priority

amount

Nonpriority

amount

____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is:

Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were

intoxicated

 Other. Specify _________________________________

$____________ $__________ $____________

____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were

intoxicated

 Other. Specify _________________________________

$____________ $__________ $____________

____________________________________________

Priority Creditor’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of PRIORITY unsecured claim:

 Domestic support obligations

 Taxes and certain other debts you owe the government

 Claims for death or personal injury while you were

intoxicated

 Other. Specify _________________________________

$____________ $__________ $____________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 2: List All of Your NONPRIORITY Unsecured Claims

3. Do any creditors have nonpriority unsecured claims against you?

 No. You have nothing to report in this part. Submit this form to the court with your other schedules.

 Yes

4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one

nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already

included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured

claims fill out the Continuation Page of Part 2.

Total claim

4.1

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___

$__________________

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

 Debts to pension or profit-sharing plans, and other similar debts

 Other. Specify ______________________________________

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

4.2

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___

$__________________

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

 Debts to pension or profit-sharing plans, and other similar debts

 Other. Specify ______________________________________

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

4.3

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Last 4 digits of account number ___ ___ ___ ___

$_________________

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce

that you did not report as priority claims

 Debts to pension or profit-sharing plans, and other similar debts

 Other. Specify ______________________________________

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page

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

Total claim

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

 Debts to pension or profit-sharing plans, and other similar debts

 Other. Specify________________________________

$____________

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

 Debts to pension or profit-sharing plans, and other similar debts

 Other. Specify________________________________

$____________

_____________________________________________________________

Nonpriority Creditor’s Name

_____________________________________________________________

Number Street

_____________________________________________________________

City State ZIP Code

Who incurred the debt? Check one.

 Debtor 1 only

 Debtor 2 only

 Debtor 1 and Debtor 2 only

 At least one of the debtors and another

 Check if this claim is for a community debt

Is the claim subject to offset?

 No

 Yes

Last 4 digits of account number ___ ___ ___ ___

When was the debt incurred? ____________

As of the date you file, the claim is: Check all that apply.

 Contingent

 Unliquidated

 Disputed

Type of NONPRIORITY unsecured claim:

 Student loans

 Obligations arising out of a separation agreement or divorce that

you did not report as priority claims

 Debts to pension or profit-sharing plans, and other similar debts

 Other. Specify________________________________

$____________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

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

6. Total the amounts of certain types of unsecured claims. This information is for statistical reporting purposes only. 28 U.S.C. § 159.

A

dd the amounts for each type of unsecured cl

aim.

Total claim

Total claims

from Part 1

6a. Domestic support obligations 6a.

$_________________________

6b. Taxes and certain other debts you owe the

government 6b.

$_________________________

6c. Claims for death or personal injury while you were

intoxicated

6c.

$_________________________

6d. Other. Add all other priority unsecured claims.

Write that amount here. 6d.

+ $_________________________

6e. Total. Add lines 6a through 6d. 6e.

$_________________________

Total claim

Total claims

from Part 2

6f. Student loans 6f.

$_________________________

6g. Obligations arising out of a separation agreement

or divorce that you did not report as priority

claims 6g.

$_________________________

6h. Debts to pension or profit-sharing plans, and other

similar debts 6h.

$_________________________

6i. Other. Add all other nonpriority unsecured claims.

Write that amount here. 6i.

+ $_________________________

6j. Total. Add lines 6f through 6i. 6j.

$_________________________

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Official Form 106G Schedule G: Executory Contracts and Unexpired Leases page 1 of ___

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases 12/15

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct

information. If more space is needed, copy the additional page, fill it out, number the entries, and attach it to this page. On the top of any

additional pages, write your name and case number (if known).

1. Do

you have any executory contracts or unexpired leases?

 No. Check this box and file this form with the court with your other schedules. You have nothing else to report on this form.

 Yes. Fill in all of the information below even if the contracts or leases are listed on Schedule A/B: Property (Official Form 106A/B).

2. List

separately each person or company with whom you have the contract or lease. Then state what each contract or lease is for (for

example, rent, vehicle lease, cell phone). See the instructions for this form in the instruction booklet for more examples of executory c

ontracts and

unexpire

d leases.

Person or company with whom you have the contract or lease State what the contract or lease is for

2.1

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.2

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.3

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.4

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2.5

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

Debtor __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse If filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of ________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

 Check if this is an

amended filing

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106G

Schedule G: Executory Contracts and Unexpired Leases page ___ of ___

Additional Page if You Have More Contracts or Leases

Person or company with whom you have the contract or lease What the contract or lease is for

2._

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2._

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2._

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2._

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2._

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2._

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2._

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2._

_____________________________________________________________________

Name

_____________________________________________________________________

Number Street

_____________________________________________________________________

City State ZIP Code

2

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Official Form 106H Schedule H: Your Codebtors page 1 of ___

Official Form 106H

Schedule H: Your Codebtors 12/15

Codebtors are people or entities who are also liable for any debts you may have. Be as complete and accurate as possible. If two married people

are filing together, both are equally responsible for supplying correct information. If more space is needed, copy the Additional Page, fill it out,

and number the entries in the boxes on the left. Attach the Additional Page to this page. On the top of any Additional Pages, write your name and

case number (if known). Answer every question.

1. Do you have any codebtors? (If you are filing a joint case, do not list either spouse as a codebtor.)

 No

 Yes

2. Within the last 8 years, have you lived in a community property state or territory? (Community property states and territories include

Arizona, California, Idaho, Louisiana, Nevada, New

Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)

 No. Go to line 3.

 Yes. Did your spouse, former spouse, or legal equivalent live with you at the time?

 No

 Yes. In which community state or territory did you live? __________________. Fill in the name and current address of that person.

______________________________________________________________________

Name of your spouse, former spouse, or legal equivalent

______________________________________________________________________

Number Street

______________________________________________________________________

City State ZIP Code

3. In Column 1, list all of your codebtors. Do not include your spouse as a codebtor if your spouse is filing with you. List the person

show

n in line 2 again as a codebtor only if that person is a guarantor or cosigner. Make sure you have

listed the creditor on

Schedule D (Official Form 106D), Schedule E/F (Official Form 106E/F), or Schedule G (Official Form 106G). Use Schedule D,

Schedule E/F, or Schedule G

to fill out Column 2.

Column 1: Your codebtor Column 2: The creditor to whom you owe the debt

Check all schedules that apply:

3.1

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3.2

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3.3

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of ________

Case number ____________________________________________

(

If known

)

Fill in this information to identify your case:

 Check if this is an

amended filing

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106H Schedule H: Your Codebtors page ___ of ___

Additional Page to List More Codebtors

Column 1: Your codebtor Column 2: The creditor to whom you owe the debt

Check all schedules that apply:

3._

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3._

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3._

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3._

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3._

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3._

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3._

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

3

._

________________________________________________________________________________

Name

________________________________________________________________________________

Number Street

________________________________________________________________________________

City State ZIP Code

 Schedule D, line ______

Schedule E/F, line ______

 Schedule G, line ______

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Official Form 106I Schedule I: Your Income page 1

Official Form 106I

Schedule I: Your Income 12/15

Be as complete and accurate as possible. If two married people are filing together (Debtor 1 and Debtor 2), both are equally responsible for

supplying correct information. If you are married and not filing jointly, and your spouse is living with you, include information about your spouse.

If you are separated and your spouse is not filing with you, do not include information about your spouse. If more space is needed, attach a

separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question.

Part 1: Describe Employment

1. Fill in your employment

infor

mation.

If you have more

than one job,

attach a separat

e page wi

th

information about additional

emplo

yers.

Include part-time

, seasonal, or

self-

employed work

.

Occupation ma

y

include student

or homemake

r, if it applies.

Debtor 1 Debtor 2 or non-filing spouse

Employment status

 Employed

 Not employed

 Employed

 Not employed

Occupation

__________________________________ __________________________________

Employer’s name __________________________________ __________________________________

Employer’s address

_

____

_

_________________________________

Number Street

_

_______________

_

______________________

_

___________

_

__________________________

_

__________

_

___________________________

City State ZIP Code

_

_____

_

_________________________________

Number Street

_

________________

_

______________________

__

___________

_

__________________________

__

__________

_

___________________________

City State

ZIP

Code

How long employed there?

_______ _______

Part 2: Give Details About Monthly Income

Estimate monthly income as of the date you file this form. If you have nothing to report for any line, write $0 in the space. Include your non-filing

spouse unless you are separated.

If you or your non-filing spouse have more than one employer, combine the information for all employers for that person on the lines

below. If you need more space, attach a separate sheet to this form.

For Debtor 1 For Debtor 2 or

non-filing spouse

2. List monthly gross wages, salary, and commissions (before all payroll

deductions). If no

t paid monthly, calculate what the monthly wage

would be.

2.

$___________

$____________

3. Estimate and list monthly overtime pay. 3.

+ $___________ + $____________

4. Calculate gross income. Add line 2 + line 3. 4. $__________ $____________

Debtor 1 ____________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ____________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of ___________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Check if this is:

 An amended filing

 A supplement showing postpetition chapter 13

income as of the following date:

________________

MM / DD / YYYY

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106I Schedule I: Your Income page 2

For Debtor 1

For Debtor 2 or

non-filin

g

s

p

ouse

Copy line 4 here ...............................................................................................  4.

$___________ $_____________

5. List all payroll deductions:

5a. Tax, Medicare, and Social Security deductions 5a.

$____________

$_____________

5b. Mandatory contributions for retirement plans 5b. $____________ $_____________

5c. Voluntary contributions for retirement plans 5c. $____________ $_____________

5d. Required repayments of retirement fund loans 5d. $____________ $_____________

5e. Insurance 5e. $____________ $_____________

5f. Domestic support obligations 5f. $____________ $_____________

5g. Union dues 5g.

$____________ $_____________

5h. Other deductions. Specify: __________________________________ 5h.

+ $____________ + $_____________

6. Add the payroll deductions. Add lines 5a + 5b + 5c + 5d + 5e +5f + 5g + 5h. 6.

$____________ $_____________

7. Calculate total monthly take-home pay. Subtract line 6 from line 4. 7. $____________ $_____________

8. List all other income regularly received:

8a. Net income from rental property and from operating a business,

profes

sion, or farm

Attach a statement for each property and business showing gross

receipts, ordinary and necessary business expenses, and the total

monthly net income.

8a.

$____________ $_____________

8b. Interest and dividends 8b.

$____________

$_____________

8c. Family support payments that you, a non-filing spouse, or a dependent

regularly receive

Include alimony, spousal support, child support, maintenance, divorce

settlement, and property settlement. 8c.

$____________ $_____________

8d. Unemployment compensation 8d.

$____________ $_____________

8e. Social Security 8e.

$____________ $_____________

8f. Other government assistance that you regularly receive

Include cash assistance and the value (if known) of any non-cash assistance

that you receive, such as food stamps (benefits under the Supplemental

Nutrition Assistance Program) or housing subsidies.

Specify: ___________________________________________________ 8f.

$____________ $_____________

8g. Pension or retirement income 8g.

$____________ $_____________

8h. Other monthly income. Specify: _______________________________ 8h.

+ $____________ + $_____________

9. Add all other income. Add lines 8a + 8b + 8c + 8d + 8e + 8f +8g + 8h. 9.

$____________

$_____________

10. Calculate monthly income. Add line 7 + line 9.

Add the entries in line 10 for Debtor 1 and Debtor 2 or non

-filing spouse.

10

.

$___________

+

$_____________

=

$_____________

11. State all other regular contributions to the expenses that you list in Schedule J.

Include contributions from an unm

arried partner, members of your household, your dependents, your roommates,

and other

friends or relative

s

.

Do not include a

ny amounts already included in lines 2-10 or amounts that are not available to pay expenses listed in Schedule J

.

Specify: _______________________________________________________________________________ 11. +

$_____________

12. Add the amount in the last column of line 10 to the amount in line 11. The result is the combined monthly income.

Write that amoun

t on the Summary of Your Assets and Liabilities and Certain Statistical Information, if it applies 12.

$_____________

Combined

monthly income

13. Do you expect an increase or decrease within the year after you file this form?

 No.

 Yes. Explain:

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Official Form 106J Schedule J: Your Expenses page 1

Official Form 106J

Schedule J: Your Expenses 12/15

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct

information. If more space is needed, attach another sheet to this form. On the top of any additional pages, write your name and case number

(if known). Answer every question.

Part 1: Describe Your Household

1. Is this a joint case?

 No. Go to line 2.

 Yes. Does Debtor 2 live in a separate household?

 No

 Yes. Debtor 2 must file Official Form 106J-2, Expenses for Separate Household of Debtor 2.

2. Do you have dependents?

Do not list Debtor

1 and

Debtor 2.

Do not state the dependents’

names.

 No

 Yes. Fill out this information for

each dependent ..........................

Dependent’s relationship to

Debtor 1 or Debtor 2

Dependent’s

age

Does dependent live

with you?

_________________________ ________

 No

 Y

es

_________________________ ________

 No



Yes

_________

________________ ________

 No



Yes

_________________________ ________

 No



Yes

_________

________________ ________

 No



Yes

3. Do your expenses include

expens

es of people other than

yourself and your dependents?

 No

 Yes

Part 2: Estimate Your Ongoing Monthly Expenses

Estimate your expenses as of your bankruptcy filing date unless you are using this form as a supplement in a Chapter 13 case to report

expenses as of a date after the bankruptcy is filed. If this is a supplemental Schedule J, check the box at the top of the form and fill in the

applicable date.

Include expenses paid for with non-cash government assistance if you know the value of

such assistance and have included it on Schedule I: Your Income (Official Form 106I.)

Your expenses

4. The rental or home ownership expenses for your residence. Include first mortgage payments and

an

y rent for the ground or

lot.

4.

$________

_____________

If not included in line 4:

4a. Real estate taxes 4a. $_____________________

4b. Property, homeowner’s, or renter’s insurance 4b. $_____________________

4c. Home maintenance, repair, and upkeep expenses 4c. $_____________________

4d. Homeowner’s association or condominium dues 4d. $_____________________

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of __________

Case number ___________________________________________

(If known)

Fill in this information to identif

y

our case:

Check if this is:

 An amended filing

 A supplement showing postpetition chapter 13

expenses as of the following date:

________________

MM / DD / YYYY

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106J-2 Schedule J-2: Expenses for Separate Household of Debtor 2 page 2

Your expenses

5. Additional mortgage payments for your residence, such as home equity loans 5.

$_____________________

6. Utilities:

6a. Electricity, heat, natural gas 6a. $_____________________

6b. Water, sewer, garbage collection 6b. $_____________________

6c. Telephone, cell phone, Internet, satellite, and cable services 6c. $_____________________

6d. Other. Specify: _______________________________________________ 6d. $_____________________

7. Food and housekeeping supplies 7. $_____________________

8. Childcare and children’s education costs 8. $_____________________

9. Clothing, laundry, and dry cleaning 9. $_____________________

10. Personal care products and services 10. $_____________________

11. Medical and dental expenses 11. $_____________________

12. Transportation. Include gas, maintenance, bus or train fare.

Do not include car payments.

12.

$_____________________

13. Entertainment, clubs, recreation, newspapers, magazines, and books 13. $_____________________

14. Charitable contributions and religious donations 14. $_____________________

15. Insurance.

Do not include insurance deducte

d from your pay or included in lines 4 or 20.

1

15a. Life insurance 15a. $_____________________

15b. Health insurance 15b. $_____________________

15c. Vehicle insurance 15c. $_____________________

15d. Other insurance. Specify:_______________________________________ 15d. $_____________________

16. Taxes. Do not include taxes deducted from your pay or included in lines 4 or 20.

Specify: ________________________________________________________ 16.

$________

_____________

17. Installment or lease payments:

17a. Car payments for Vehicle 1 17a.

$_____________________

17b. Car payments for Vehicle 2 17b.

$_____________________

17c. Other. Specify:_______________________________________________ 17c.

$_____________________

17d. Other. Specify:_______________________________________________ 17d.

$_____________________

18. Your payments of alimony, maintenance, and support that you did not report as deducted from

your pay on line 5, Schedule I, Your Income (Official Form 106I).

18.

$________

_____________

19. Other payments you make to support others who do not live with you.

Specify:_______________________________________________________ 19. $_____________________

20. Other real property expenses not included in lines 4 or 5 of this form or on Schedule I: Your Income.

20a. Mortgages on other property 20a.

$_____________________

20b. Real estate taxes 20b.

$_____________________

20c. Property, homeowner’s, or renter’s insurance 20c.

$_____________________

20d. Maintenance, repair, and upkeep expenses 20d.

$_____________________

20e. Homeowner’s association or condominium dues 20e.

$_____________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 106J-2 Schedule J-2: Expenses for Separate Household of Debtor 2 page 3

21. Other. Specify: _________________________________________________ 21.

+$_____________________

22. Your monthly expenses. Add lines 5 through 21.

The result is the monthly expenses of Debtor 2. Copy the result to line 22b of Schedule J to calculate

the

total expenses fo

r Debtor 1 and D

ebtor 2.

22.

$_____________________

23. Line not used on this form.

24. Do you expect an increase or decrease in your expenses within the year after you file this form?

For e

xample, do you expect to finish paying for your car loan within the year or do you expect

your

mortgage p

ayment to increase or decrease because of a modification to the terms of your mortgage?

 No.

 Yes.

Explain here:

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Official Form 106Dec Declaration About an Individual Debtor’s Schedules

Official Form 106Dec

Declaration About an Individual Debtor’s Schedules 12/15

If two married people are filing together, both are equally responsible for supplying correct information.

You must file this form whenever you file bankruptcy schedules or amended schedules. Making a false statement, concealing property, or

obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20

years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

Sign Below

Did you pay or agree to pay someone who is NOT an attorney to help you fill out bankruptcy forms?

No

Yes. Name of person__________________________________________________. Attach Bankruptcy Petition Preparer’s Notice, Declaration, and

Signature (Official Form 119).

Under penalty of perjury, I declare that I have read the summary and schedules filed with this declaration and

that they are true and correct.

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Date

_________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of __________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

 Check if this is an

amended filing

Northern District of Illinois

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

Official Form 107

Statement of Financial Affairs for Individuals Filing for Bankruptcy 04/19

Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct

information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case

number (if known). Answer every question.

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

1. What is your current marital status?

 Married

 Not married

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

 No

 Yes. List all of the places you lived in the last 3 years. Do not include where you live now.

Debtor 1: Dates Debtor 1

lived there

Debtor 2: Dates Debtor 2

lived there

__________________________________________

Number Street

__________________________________________

City State ZIP Code

From ________

To ________

 Same as Debtor 1

___________________________________________

Number Street

___________________________________________

City State ZIP Code

 Same as Debtor 1

From ________

To ________

__________________________________________

Number Street

__________________________________________

City State ZIP Code

From ________

To ________

 Same as Debtor 1

___________________________________________

Number Street

___________________________________________

City State ZIP Code

 Same as Debtor 1

From ________

To _

_______

3. Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory? (Community property

states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)

 No

 Yes. Make sure you fill out Schedule H: Your Codebtors (Official Form 106H).

Part 2:

Explain the Sources of Your Income

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________ District of ______________

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

 Check if this is an

amended filing

Northern District of Illinois

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

4. Did you have any income from employment or from operating a business during this year or the two previous calendar years?

Fill in the total amount of income you received from all jobs and all businesses, including part-time activities.

If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.

 No

  Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income

Check all that apply.

Gross income

(before deductions and

exclusions)

Sources of income

Check all that apply.

Gross income

(before deductions and

exclusions)

From January

1 of current year until

the date you filed for bankruptcy:

 Wages, commissions,

bonuses, tips

 Operating a business

$________________

 Wages, commissions,

bonuses, tips

 Operating a business

$________________

For last calendar year:

(January 1 to December 31, _________)

YYYY

 Wages, commissions,

bonuses, tips

 Operating a business

$________________

 Wages, commissions,

bonuses, tips

 Operating a business

$________________

For the calendar year before that:

(January 1 to December 31, _________)

YYYY

 Wages, commissions,

bonuses, tips

 Operating a business

$________________

 Wages, commissions,

bonuses, tips

 Operating a business

$________________

5. Did you receive any other income during this year or the two previous calendar years?

Include income regardless of whether that income is taxable. Examples of other income are alimony; child support; Social Security

,

unemploy

ment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; roy

alties; and

gambling and lottery

winnings. If you are filing a joint case and you have income that you received together, list it only once

under Debtor 1.

List each source and the gross income from each source separately

. Do not include income that y

ou listed in line 4.

 No

 Yes. Fill in the details.

Debtor 1 Debtor 2

Sources of income

Describe below.

Gross income from

each source

(before deductions and

exclusions)

Sources of income

Describe below.

Gross income from

each source

(before deductions and

exclusions)

From January 1 of current year until

the date you filed for bankruptcy:

__________________

$_________________

_____________________

$_________________

$

_________________

For last calendar year:

(January 1 to December 31, ______)

YYYY

__________________

$_________________

_____________________

$_________________

For the calendar year before that:

(January 1 to December 31, ______)

YYYY

__________________

$_________________

_____________________

$_________________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

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

7. Within 1 year before you filed for bankruptcy, did you make a payment on a debt you owed anyone who was an insider?

Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner;

corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing

agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations,

such as child support and alimony.

 No

 Yes. List all payments to an insider.

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

Dates of

payment

Total amount

paid

Amount you still

owe

Reason for this payment

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

_________

$____________ $____________

8. Within 1 year before you filed for bankruptcy, did you make any payments or transfer any property on account of a debt that benefited

an insider?

Include payments on debts guaranteed or cosigned by an insider.

 No

 Yes. List all payments that benefited an insider.

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

Dates of

payment

Total amount

paid

Amount you still

owe

Reason for this payment

Include creditor’s name

_________

$____________ $____________

____________________________________________

Insider’s Name

____________________________________________

Number Street

____________________________________________

City State ZIP Code

_________

$____________ $____________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 5

Part 4: Identify Legal Actions, Repossessions, and Foreclosures

9. Within 1 year before you filed for bankruptcy, were you a party in any lawsuit, court action, or administrative proceeding?

List all such matters, including personal injury cases, small claims actions, divorces, collection suits, paternity actions, support or custody modifications,

and contract disputes.

 No

 Yes. Fill in the details.

Case title_____________________________

____________________________________

Case number ________________________

Nature of the case Court or agency Status of the case

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

 Pending

 On appeal

 Concluded

Case title_____________________________

____________________________________

Case number ________________________

________________________________________

Court Name

________________________________________

Number Street

________________________________________

City State ZIP Code

 Pending

 On appeal

 Concluded

10. Within 1 year before you filed for bankruptcy, was any of your property repossessed, foreclosed, garnished, attached, seized, or levied?

Check all that apply and fill in the details below.

 No. Go to line 11.

 Yes. Fill in the information below.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

City State ZIP Code

Describe the property Date Value of the property

__________ $______________

Explain what happened

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized, or levied.

_________________________________________

Creditor’s Name

_________________________________________

Number Street

_________________________________________

City State ZIP Code

Describe the property Date

V

alue of the propert

y

__________ $______________

Explain what happened

 Property was repossessed.

 Property was foreclosed.

 Property was garnished.

 Property was attached, seized, or levied.

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 6

11. Within 90 days before you filed for bankruptcy, did any creditor, including a bank or financial institution, set off any amounts from your

accounts or refuse to make a payment because you owed a debt?

 No

 Yes. Fill in the details.

______________________________________

Creditor’s Name

______________________________________

Number Street

______________________________________

City State ZIP Code

Describe the action the creditor took Date action

was taken

Amount

____________ $________________

Last 4 digits of account number: XXXX–___ ___ ___ ___

12. Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of

creditors, a court-appointed receiver, a custodian, or another official?

 No

 Yes

Part 5: List Certain Gifts and Contributions

13. Within 2 years before you filed for bankruptcy, did you give any gifts with a total value of more than $600 per person?

 No

 Yes. Fill in the details for each gift.

Gifts with a total value of more than $600

per person

Describe the gifts Dates you gave

the gifts

Value

______________________________________

Person to Whom You Gave the Gift

______________________________________

Number Street

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

$_____________

Gifts with a total value of more than $600

per person

Describe the gifts Dates you gave

the gifts

Value

______________________________________

Person to Whom You Gave the Gift

______________________________________

Number Street

______________________________________

City State ZIP Code

Person’s relationship to you ______________

_________

$_____________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 7

14. Within 2 years before you filed for bankruptcy, did you give any gifts or contributions with a total value of more than $600 to any charity?

 No

 Yes. Fill in the details for each gift or contribution.

Gifts or contributions to charities

that total more than $600

Describe what you contributed Date you

contributed

Value

_____________________________________

Charity’s Name

_____________________________________

Number Street

_____________________________________

City State ZIP Code

_________

$_____________

Part 6: List Certain Losses

15. Within 1 year before you filed for bankruptcy or since you filed for bankruptcy, did you lose anything because of theft, fire, other

disaster, or gambling?

 No

 Yes. Fill in the details.

Describe the property you lost and

how the loss occurred

Describe any insurance coverage for the loss

Include the amount that insurance has paid. List pending insurance

claims on line 33 of Schedule A/B: Property.

Date of your

loss

Value of property

lost

_________ $_____________

Part 7: List Certain Payments or Transfers

16. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone

you consulted about seeking bankruptcy or preparing a bankruptcy petition?

Include any attorneys, bankruptcy petition preparers, or credit counseling agencies for services required in your bankruptcy.

 No

 Yes. Fill in the details.

___________________________________

Person Who Was Paid

___________________________________

Number Street

___________________________________

City State ZIP Code

____________________________________________

Email or website address

Description and value of any property transferred Date payment or

transfer was

made

Amount of payment

_________

$_____________

___________________________________

Person Who Made the Payment, if Not You

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 8

____________________________________

Person Who Was Paid

____________________________________

Number Street

____________________________________

City State ZIP Code

________________________________________________

Email or website address

Description and value of any property transferred Date payment or

transfer was made

Amount of

payment

_________

$_____________

___________________________________

Person Who Made the Payment, if Not You

17. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone who

promised to help you deal with your creditors or to make payments to your creditors?

Do not include any payment or transfer that you listed on line 16.

 No

 Yes. Fill in the details.

____________________________________

Person Who Was Paid

____________________________________

Number Street

____________________________________

City State ZIP Code

Description and value of any property transferred Date payment or

transfer was

made

Amount of payment

_________

$____________

18. Within 2 years before you filed for bankruptcy, did you sell, trade, or otherwise transfer any property to anyone, other than property

transferred in the ordinary course of your business or financial affairs?

Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property).

Do not include gifts and transfers that you have already listed on this statement.

 No

 Yes. Fill in the details.

___________________________________

Person Who Received Transfer

___________________________________

Number Street

___________________________________

City State ZIP Code

Description and value of property

transferred

Describe any property or payments received

or debts paid in exchange

Date transfer

was made

_________

Person’s relationship to you _____________

___________________________________

Person Who Received Transfer

___________________________________

Number Street

___________________________________

City State ZIP Code

_________

Person’s relationship to you _____________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 9

19. Within 10 years before you filed for bankruptcy, did you transfer any property to a self-settled trust or similar device of which you

are a beneficiary? (These are often called asset-protection devices.)

 No

 Yes. Fill in the details.

Name of trust __________________________

______________________________________

Description and value of the property transferred Date transfer

was made

_________

Part 8:

List Certain Financial Accounts, Instruments, Safe Deposit Boxes, and Storage Units

20. Within 1 year before you filed for bankruptcy, were any financial accounts or instruments held in your name, or for your benefit,

closed, sold, moved, or transferred?

Include checking, savings, money market, or other financial accounts; certificates of deposit; shares in banks, credit unions,

brokerage houses, pension funds, cooperatives, associations, and other financial institutions.

 No

 Yes. Fill in the details.

____________________________________

Name of Financial Institution

____________________________________

Number Street

____________________________________

City State ZIP Code

Last 4 digits of account number Type of account or

instrument

Date account was

closed, sold, moved,

or transferred

Last balance before

closing or transfer

XXXX–___ ___ ___ ___

Checking

 Savings

 Money market

 Brokerage

 Other__________

_________ $___________

____________________________________

Name of Financial Institution

____________________________________

Number Street

____________________________________

City State ZIP Code

XXXX–___ ___ ___ ___

Checking

 Savings

 Money market

 Brokerage

 Other__________

_________ $___________

21. Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for

securities, cash, or other valuables?

 No

 Yes. Fill in the details.

____________________________________

Name of Financial Institution

____________________________________

Number Street

____________________________________

City State ZIP Code

Who else had access to it? Describe the contents Do you still

have it?

_______________________________________

Name

_______________________________________

Number Street

_______________________________________

City State ZIP Code

 No

 Yes



Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 10

22. Have you stored property in a storage unit or place other than your home within 1 year before you filed for bankruptcy?

 No

 Yes. Fill in the details.

___________________________________

Name of Storage Facility

___________________________________

Number Street

___________________________________

City State ZIP Code

Who else has or had access to it? Describe the contents Do you still

have it?

_______________________________________

Name

_______________________________________

Number Street

_______________________________________

City State ZIP Code

 No

 Yes



Part 9: Identify Property You Hold or Control for Someone Else

23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for,

or hold in trust for someone.

 No

 Yes. Fill in the details.

___________________________________

Owner’s Name

___________________________________

Number Street

___________________________________

City State ZIP Code

Where is the property? Describe the property Value

________________________________________

_

Number Street

________________________________________

_

________________________________________

_

City State ZIP Code

$__________

Part 10: Give Details About Environmental Information

For the purpose of Part 10, the following definitions apply:

 Environmental law means any federal, state, or local statute or regulation concerning pollution, contamination, releases of

hazardous or toxic substances, wastes, or material into the air, land, soil, surface water, groundw

ater, or other medium,

including statutes or regulations controlling the cleanup of these substances, wastes, or material.

 Site means any location, facility, or property as defined under any environmental law, whether you now own, operate, or

utilize it or used to own, operate, or utilize it, including disposal sites.

 Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance, toxic

substance, hazardous material, pollutant, contaminant, or similar term.

Report all notices, releases, and proceedings that you know about, regardless of when they occurred.

24. Has any governmental unit notified you that you may be liable or potentially liable under or in violation of an environmental law?

 No

 Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 11

25. Have you notified any governmental unit of any release of hazardous material?

 No

 Yes. Fill in the details.

____________________________________

Name of site

____________________________________

Number Street

____________________________________

City State ZIP Code

Governmental unit Environmental law, if you know it Date of notice

_______________________________

Governmental unit

_______________________________

Number Street

_______________________________

City State ZIP Code

_________

26. Have you been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders.

 No

 Yes. Fill in the details.

Case title______________________________

______________________________________

Case number

Court or agency Nature of the case

Status of the

case

________________________________

Court Name

________________________________

Number Street

________________________________

City State ZIP Code

 Pending

 On appeal

Concluded



Part 11: Give Details About Your Business or Connections to Any Business

27. Within 4 years before you filed for bankruptcy, did you own a business or have any of the following connections to any business?

 A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time

 A member of a limited liability company (LLC) or limited liability partnership (LLP)

 A partner in a partnership

 An officer, director, or managing executive of a corporation

 An owner of at least 5% of the voting or equity securities of a corporation

 No. None of the above applies. Go to Part 12.

 Yes. Check all that apply above and fill in the details below for each business.

____________________________________

Business Name

____________________________________

Number Street

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

____________________________________

Business Name

____________________________________

Number Street

____________________________________

City State ZIP Code

Describe the nature of the business Employer Identification number

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________

First Name Middle Name Last Name

Official Form 107 Statement of Financial Affairs for Individuals Filing for Bankruptcy page 12

____________________________________

Business Name

____________________________________

Number Street

____________________________________

City State ZIP Code

Describe the nature of the business

Employer Identification number

Do not include Social Security number or ITIN.

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

Name of accountant or bookkeeper Dates business existed

From _______ To _______

28. Within 2 years before you filed for bankruptcy, did you give a financial statement to anyone about your business? Include all financial

institutions, creditors, or other parties.

 No

 Yes. Fill in the details below.

____________________________________

Name

____________________________________

Number Street

____________________________________

City State ZIP Code

Date issued

____________

MM / DD / YYYY

Part 12: Sign Below

I have read the answers on this Statement of Financial Affairs and any attachments, and I declare under penalty of perjury that the

answers are true and correct. I understand that making a false statement, concealing property, or obtaining money or property by fraud

in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both.

18 U.S.C. §§ 152, 1341, 1519, and 3571.

______________________________________________ _____________________________

Signature of Debtor 1 Signature of Debtor 2

Date ________________ Date _________________

Did you attach additional pages to Your Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107)?

 No

 Yes

Did you pay or agree to pay someone who is not an attorney to help you fill out bankruptcy forms?

 No

 Yes. Name of person_____________________________________________________________. Attach the Bankruptcy Petition Preparer’s Notice,

Declaration, and Signature (Official Form 119).

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Official Form 113 Chapter 13 Plan

Page 1

Official Form 113

Chapter 13 Plan 12/17

Part 1:

Notices

To Debtors: This form sets out options that may be appropriate in some cases, but the presence of an option on the form does not

indicate that the option is appropriate in your circumstances or that it is permissible in your judicial district. Plans that

do not comply with local rules and judicial rulings may not be confirmable.

In the following notice to creditors, you must check each box that applies.

To Creditors: Your rights may be affected by this plan. Your claim may be reduced, modified, or eliminated.

You should read this plan carefully and discuss it with your attorney if you have one in this bankruptcy case. If you do not

have an attorney, you may wish to consult one.

If you oppose the plan’s treatment of your claim or any provision of this plan, you or your attorney must file an objection to

confirmation at least 7 days before the date set for the hearing on confirmation, unless otherwise ordered by the Bankruptcy

Court. The Bankruptcy Court may confirm this plan without further notice if no objection to confirmation is filed. See

Bankruptcy Rule 3015. In addition, you may need to file a timely proof of claim in order to be paid under any plan.

The following matters may be of particular importance. Debtors must check one box on each line to state whether or not the plan

includes each of the following items. If an item is checked as “Not Included” or if both boxes are checked, the provision will

be ineffective if set out later in the plan.

1.1 A limit on the amount of a secured claim, set out in Section 3.2, which may result in a partial

payment or no payment at all to the secured creditor

 Included  Not included

1.2 Avoidance of a judicial lien or nonpossessory, nonpurchase-money security interest, set out in

Section 3.4

 Included  Not included

1.3 Nonstandard provisions, set out in Part 8  Included  Not included

Part 2:

Plan Payments and Length of Plan

2.1 Debtor(s) will make regular payments to the trustee as follows:

$ ___________ per_______ for _____ months

[and $ ___________ per_______ for _____ months.] Insert additional lines if needed.

If fewer than 60 months of payments are specified, additional monthly payments will be made to the extent necessary to make the

payments to creditors specified in this plan.



Check if this is an amended

plan, and list below the

sections of the plan that have

been changed.

_________________________________

Debtor 1 __________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the:

______________________ District of ______________

(State)

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Debtor ___________________________________________________________________________ Case number ___________________________

Official Form 113 Chapter 13 Plan

Page 2

2.2 Regular payments to the trustee will be made from future income in the following manner:

Check all that apply.

 Debtor(s) will make payments pursuant to a payroll deduction order.

 Debtor(s) will make payments directly to the trustee.

 Other (specify method of payment):____________________________.

2.3 Income tax refunds.

Check one.

 Debtor(s) will retain any income tax refunds received during the plan term.

 Debtor(s) will supply the trustee with a copy of each income tax return filed during the plan term within 14 days of filing the return and will

turn over to the trustee all income tax refunds received during the plan term.

 Debtor(s) will treat income tax refunds as follows:

____________________________________________________________________________________________________

2.4 Additional payments.

Check one.

 None. If “None” is checked, the rest of § 2.4 need not be completed or reproduced.

 Debtor(s) will make additional payment(s) to the trustee from other sources, as specified below. Describe the source, estimated amount,

and date of each anticipated payment.

___________________________________________________________________________________________________________

2.5 The total amount of estimated payments to the trustee provided for in §§ 2.1 and 2.4 is $ __________________.

Part 3::

Treatment of Secured Claims

3.1 Maintenance of payments and cure of default, if any.

Check one.

 None. If “None” is checked, the rest of § 3.1 need not be completed or reproduced.

 The debtor(s) will maintain the current contractual installment payments on the secured claims listed below, with any changes required by

the applicable contract and noticed in conformity with any applicable rules. These payments will be disbursed either by the trustee or

directly by the debtor(s), as specified below. Any existing arrearage on a listed claim will be paid in full through disbursements by the

trustee, with interest, if any, at the rate stated. Unless otherwise ordered by the court, the amounts listed on a proof of claim filed before the

filing deadline under Bankruptcy Rule 3002(c) control over any contrary amounts listed below as to the current installment payment and

arrearage. In the absence of a contrary timely filed proof of claim, the amounts stated below are controlling. If relief from the automatic stay

is ordered as to any item of collateral listed in this paragraph, then, unless otherwise ordered by the court, all payments under this

paragraph as to that collateral will cease, and all secured claims based on that collateral will no longer be treated by the plan. The final

column includes only payments disbursed by the trustee rather than by the debtor(s).

Name of creditor Collateral Current installment

payment

(including escrow )

Amount of

arrearage (if

any)

Interest rate on

arrearage

(if applicable)

Monthly plan

payment on

arrearage

Estimated total

payments by

trustee

_________________ ____________

$___________

Disbursed by:

 Trustee

 Debtor(s)

$___________ _______% $___________ $____________

_________________ ____________

$___________

Disbursed by:

 Trustee

 Debtor(s)

$___________ _______% $___________ $____________

Insert additional claims as needed.

Debtor ___________________________________________________________________________ Case number ___________________________

Official Form 113 Chapter 13 Plan

Page 3

3.2 Request for valuation of security, payment of fully secured claims, and modification of undersecured claims. Check one.

 None. If “None” is checked, the rest of § 3.2 need not be completed or reproduced.

The remainder of this paragraph will be effective only if the applicable box in Part 1 of this plan is checked.

 The debtor(s) request that the court determine the value of the secured claims listed below. For each non-governmental secured claim

listed below, the debtor(s) state that the value of the secured claim should be as set out in the column headed Amount of secured

claim. For secured claims of governmental units, unless otherwise ordered by the court, the value of a secured claim listed in a proof of

claim filed in accordance with the Bankruptcy Rules controls over any contrary amount listed below. For each listed claim, the value of

the secured claim will be paid in full with interest at the rate stated below.

The portion of any allowed claim that exceeds the amount of the secured claim will be treated as an unsecured claim under Part 5 of this

plan. If the amount of a creditor’s secured claim is listed below as having no value, the creditor’s allowed claim will be treated in its entirety

as an unsecured claim under Part 5 of this plan. Unless otherwise ordered by the court, the amount of the creditor’s total claim listed on the

proof of claim controls over any contrary amounts listed in this paragraph.

The holder of any claim listed below as having value in the column headed Amount of secured claim will retain the lien on the property interest

of the debtor(s) or the estate(s) until the earlier of:

(a) payment of the underlying debt determined under nonbankruptcy law, or

(b) discharge of the underlying debt under 11 U.S.C. § 1328, at which time the lien will terminate and be released by the creditor.

Name of creditor

Estimated amount

of creditor’s total

claim

Collateral Value of

collateral

Amount of

claims senior to

creditor’s claim

Amount of

secured claim

Interest

rate

Monthly

payment to

creditor

Estimated total

of monthly

payments

_____________

$_______

__________

$______ $_______ $______

___%

$_______ $_______

_____________

$_______

__________

$______ $_______ $______

___%

$_______ $_______

Insert additional claims as needed.

3.3 Secured claims excluded from 11 U.S.C. § 506.

Check one.

 None. If “None” is checked, the rest of § 3.3 need not be completed or reproduced.

 The claims listed below were either:

(1) incurred within 910 days before the petition date and secured by a purchase money security interest in a motor vehicle acquired for the

personal use of the debtor(s), or

(2) incurred within 1 year of the petition date and secured by a purchase money security interest in any other thing of value.

These claims will be paid in full under the plan with interest at the rate stated below. These payments will be disbursed either by the trustee or

directly by the debtor(s), as specified below. Unless otherwise ordered by the court, the claim amount stated on a proof of claim filed before the

filing deadline under Bankruptcy Rule 3002(c) controls over any contrary amount listed below. In the absence of a contrary timely filed proof of

claim, the amounts stated below are controlling. The final column includes only payments disbursed by the trustee rather than by the debtor(s).

Name of creditor Collateral

Amount of claim

Interest

rate

Monthly plan

payment

Estimated total

payments by trustee

______________________________ ______________________ $___________

_____%

$________

Disbursed by:

 Trustee



Debtor(s)

$_________________

______________________________ ______________________ $___________

_____%

$________

Disbursed by:

 Trustee



Debtor(s)

$_________________

Insert additional claims as needed.

Debtor ___________________________________________________________________________ Case number ___________________________

Official Form 113 Chapter 13 Plan

Page 4

3.4 Lien avoidance.

Check one.

 None. If “None” is checked, the rest of § 3.4 need not be completed or reproduced.

The remainder of this paragraph will be effective only if the applicable box in Part 1 of this plan is checked.

 The judicial liens or nonpossessory, nonpurchase money security interests securing the claims listed below impair exemptions to which the

debtor(s) would have been entitled under 11 U.S.C. § 522(b). Unless otherwise ordered by the court, a judicial lien or security interest

securing a claim listed below will be avoided to the extent that it impairs such exemptions upon entry of the order confirming the plan. The

amount of the judicial lien or security interest that is avoided will be treated as an unsecured claim in Part 5 to the extent allowed. The

amount, if any, of the judicial lien or security interest that is not avoided will be paid in full as a secured claim under the plan. See 11 U.S.C.

§ 522(f) and Bankruptcy Rule 4003(d).

If more than one lien is to be avoided, provide the information separately for each lien.

Information regarding judicial

lien or security interest

Calculation of lien avoidance

Treatment of remaining

secured claim

Name of creditor

a. Amount of lien

$______________

Amount of secured claim after

avoidance (line a minus line f)

$_______________________

__________________

b. Amount of all other liens $______________

Collateral

c. Value of claimed exemptions + $______________

Interest rate (if applicable)

__________________

d. Total of adding lines a, b, and c $______________

_____

%

Lien identification (such as

judgment date, date of lien

recording, book and page number)

e. Value of debtor(s)’ interest in

property

− $______________

Monthly payment on secured

claim

$_______________________

__________________

f. Subtract line e from line d. $______________

Estimated total payments on

secured claim

$_______________________

Extent of exemption impairment

(Check applicable box):

 Line f is equal to or greater than line a.

The entire lien is avoided. (Do not complete the next column.)

 Line f is less than line a.

A portion of the lien is avoided. (Complete the next column.)

Insert additional claims as needed.

3.5 Surrender of collateral.

Check one.

 None. If “None” is checked, the rest of § 3.5 need not be completed or reproduced.

 The debtor(s) elect to surrender to each creditor listed below the collateral that secures the creditor’s claim. The debtor(s) request that

upon confirmation of this plan the stay under 11 U.S.C. § 362(a) be terminated as to the collateral only and that the stay under § 1301

be terminated in all respects. Any allowed unsecured claim resulting from the disposition of the collateral will be treated in Part 5 below.

Name of creditor Collateral

______________________________________________________ _____________________________________________

Insert additional claims as needed.

Debtor ___________________________________________________________________________ Case number ___________________________

Official Form 113 Chapter 13 Plan

Page 5

Part 4:

Treatment of Fees and Priority Claims

4.1 General

Trustee’s fees and all allowed priority claims, including domestic support obligations other than those treated in § 4.5, will be paid in full without

postpetition interest.

4.2 Trustee’s fees

Trustee’s fees are governed by statute and may change during the course of the case but are estimated to be ________% of plan payments; and

during the plan term, they are estimated to total $___________.

4.3 Attorney’s fees

The balance of the fees owed to the attorney for the debtor(s) is estimated to be $___________.

4.4 Priority claims other than attorney’s fees and those treated in § 4.5.

Check one.

 None. If “None” is checked, the rest of § 4.4 need not be completed or reproduced.

 The debtor(s) estimate the total amount of other priority claims to be _____________.

4.5 Domestic support obligations assigned or owed to a governmental unit and paid less than full amount.

Check one.

 None. If “None” is checked, the rest of § 4.5 need not be completed or reproduced.

 The allowed priority claims listed below are based on a domestic support obligation that has been assigned to or is owed to a

governmental unit and will be paid less than the full amount of the claim under 11 U.S.C. § 1322(a)(4). This plan provision

requires that payments in § 2.1 be for a term of 60 months; see 11 U.S.C. § 1322(a)(4).

Name of creditor Amount of claim to be paid

_______________________________________________________________________________

$__________________________

_______________________________________________________________________________

$__________________________

Insert additional claims as needed.

Part 5: Treatment of Nonpriority Unsecured Claims

5.1 Nonpriority unsecured claims not separately classified.

Allowed nonpriority unsecured claims that are not separately classified will be paid, pro rata. If more than one option is checked, the option

providing the largest payment will be effective. Check all that apply.

 The sum of $___________.

 _______% of the total amount of these claims, an estimated payment of $_________.

 The funds remaining after disbursements have been made to all other creditors provided for in this plan.

If the estate of the debtor(s) were liquidated under chapter 7, nonpriority unsecured claims would be paid approximately $__________.

Regardless of the options checked above, payments on allowed nonpriority unsecured claims will be made in at least this amount.

Debtor ___________________________________________________________________________ Case number ___________________________

Official Form 113 Chapter 13 Plan

Page 6

5.2 Maintenance of payments and cure of any default on nonpriority unsecured claims. Check one.

 None. If “None” is checked, the rest of § 5.2 need not be completed or reproduced.

 The debtor(s) will maintain the contractual installment payments and cure any default in payments on the unsecured claims listed below

on which the last payment is due after the final plan payment. These payments will be disbursed either by the trustee or directly by the

debtor(s), as specified below. The claim for the arrearage amount will be paid in full as specified below and disbursed by the trustee.

The final column includes only payments disbursed by the trustee rather than by the debtor(s).

Name of creditor Current installment

payment

Amount of arrearage

to be paid

Estimated total

payments by

trustee

__________________________________________________

$___________

Disbursed by:

 Trustee

 Debtor(s)

$______________ $____________

__________________________________________________

$___________

Disbursed by:

 Trustee

 Debtor(s)

$______________ $____________

Insert additional claims as needed.

5.3 Other separately classified nonpriority unsecured claims. Check one.

 None. If “None” is checked, the rest of § 5.3 need not be completed or reproduced.

 The nonpriority unsecured allowed claims listed below are separately classified and will be treated as follows

Name of creditor Basis for separate classification

and treatment

Amount to be paid

on the claim

Interest rate

(if applicable)

Estimated total

amount of

payments

_______________________________ ____________________________ $_____________ ______% $__________

Insert additional claims as needed.

Part 6: Executory Contracts and Unexpired Leases

6.1 The executory contracts and unexpired leases listed below are assumed and will be treated as specified. All other executory contracts

and unexpired leases are rejected. Check one.

 None. If “None” is checked, the rest of § 6.1 need not be completed or reproduced.

 Assumed items. Current installment payments will be disbursed either by the trustee or directly by the debtor(s), as specified below, subject

to any contrary court order or rule. Arrearage payments will be disbursed by the trustee. The final column includes only payments disbursed

by the trustee rather than by the debtor(s).

Debtor ___________________________________________________________________________ Case number ___________________________

Official Form 113 Chapter 13 Plan

Page 7

Name of creditor Description of leased

property or executory

contract

Current installment

payment

Amount of

arrearage to

be paid

Treatment of arrearage

(Refer to other plan

section if applicable)

Estimated total

payments by

trustee

____________________ __________________

$___________

Disbursed by:

 Trustee

 Debtor(s)

$__________

__________________

$__________

____________________ __________________

$___________

Disbursed by:

 Trustee



Debtor(s)

$__________

__________________

$__________

Insert additional contracts or leases as needed.

Part 7: Vesting of Property of the Estate

7.1 Property of the estate will vest in the debtor(s) upon

Check the applicable box:

 plan confirmation.

 entry of discharge.

 other: ____________________________________________.

Part 8:

Nonstandard Plan Provisions

8.1 Check “None” or List Nonstandard Plan Provisions

 None. If “None” is checked, the rest of Part 8 need not be completed or reproduced.

Under Bankruptcy Rule 3015(c), nonstandard provisions must be set forth below. A nonstandard provision is a provision not otherwise included in the

Official Form or deviating from it. Nonstandard provisions set out elsewhere in this plan are ineffective.

The following plan provisions will be effective only if there is a check in the box “Included” in § 1.3.

_____________________________________________________________________________________________________________

Official Form 113 Chapter 13 Plan – Exhibit Page 1

Exhibit: Total Amount of Estimated Trustee Payments

The following are the estimated payments that the plan requires the trustee to disburse. If there is any difference between the amounts set

out below and the actual plan terms, the plan terms control.

a. Maintenance and cure payments on secured claims (Part 3, Section 3.1 total)

b. Modified secured claims (Part 3, Section 3.2 total)

c. Secured claims excluded from 11 U.S.C. § 506 (Part 3, Section 3.3 total)

d. Judicial liens or security interests partially avoided (Part 3, Section 3.4 total)

e. Fees and priority claims (Part 4 total)

f. Nonpriority unsecured claims (Part 5, Section 5.1, highest stated amount)

g. Maintenance and cure payments on unsecured claims (Part 5, Section 5.2 total)

h. Separately classified unsecured claims (Part 5, Section 5.3 total)

i. Trustee payments on executory contracts and unexpired leases (Part 6, Section 6.1 total)

j. Nonstandard payments (Part 8, total) +

$______________

Total of lines a through j

$_______________

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