UNITED STATES BANKRUPTCY COURT
DISTRICT OF ARIZONA
TUCSON DIVISION James
A Walsh Courthouse
38 S. Scott Avenue
Tucson, AZ 85701
520- 202-7500
PHOENIX DIVISION Federal
Building & U.S. Courthouse
230 N. First Ave., Suite 101
Phoenix AZ 85003
602-682-4000
www.azb.uscourts.gov
CHAPTER 7
YUMA DIVISION U.S.
Bankruptcy Court
325 W. 19
th
St., Suite D
Yuma, AZ 85364
928-783-2288
A bankruptcy case starts with the filing of a petition identifying the chapter. All
documents must be filed on official forms which can be found on the court’s website,
www.azb.uscourts.gov or on www.uscourts.gov/bankruptcy. Other helpful information is
also available on these websites. Filing bankruptcy can be a complex legal process and you
are advised to seek competent bankruptcy counsel before filing a petition.
THE FOLLOWING DOCUMENTS ARE NEEDED FOR INITIAL FILING OF A CASE.
1. Voluntary Petition for Individuals Filing for Bankruptcy (Form 101, 101A, 101B)
2. Valid State Issued ID
3. Statement about Your Social Security Numbers (Form 121)
THE FOLLOWING DOCUMENTS, IF THEY WERE NOT FILED WITH THE
BANKRUPTCY PETITION, ARE REQUIRED TO BE FILED NO LATER THAN 7
DAYS FROM THE DATE THE PETITION WAS FILED. IF ANY OF THESE
DOCUMENTS ARE NOT FILED WITHIN THAT TIME, YOUR CASE COULD BE
DISMISSED.
1. Typed Mailing List of Creditors
2. Credit Counseling Certificate. You may check the following web site for
approved providers, www.usdoj.gov/ust or call 602-682-4000. The credit
counselor will provide you the certificate you need to file with the court.
THE FOLLOWING DOCUMENTS, IF THEY WERE NOT FILED WITH THE
BANKRUPTCY PETITION, ARE REQUIRED TO BE FILED NO LATER THAN 14
DAYS FROM THE DATE THE PETITION WAS FILED. IF ANY OF THESE
DOCUMENTS ARE NOT FILED WITHIN THAT TIME, YOUR CASE COULD BE
DISMISSED.
1. Schedules (Form 106A/B, 106C, 106D, 106E/F, 106G, 106H, 106I, 106J, 106J-2,
106 Sum, 106 Dec)
2. Statement of Financial Affairs for Individuals Filing for Bankruptcy (Form 107)
3. Statement of Intention for Individuals Filing for Bankruptcy (Form 108)
4. Chapter 7 Statement of Your Current Monthly Income (Form 122A-1, 122A-2,
122A-1Supp)
5. Declaration of Evidence of Employers’ Payments within 60 Days
6. Declaration Under Penalty of Perjury for Debtor(s) Without an Attorney
FILING FEE $338
Cashier Check or
Money Order
ONLY
PREVIOUS BANKRUPTCY FILINGS
If you had a previous case pending within the preceding year that was dismissed, you are advised
that pursuant to 11 USC Section 362(c)(3), the automatic stay provided by Section 362(a) when
the bankruptcy petition is filed will terminate 30 days after the filing of your petition. You may
file a motion with the court seeking a continuation of the automatic stay and you will need to
demonstrate that the second case was filed in good faith. If you file a motion, please caption it
as an Emergency Motion.
If you had two or more previous cases pending within the preceding year that were dismissed,
you are advised that pursuant to 11 USC Section 362(c)(4), no stay under Section 362(a) went
into effect when your petition was filed. To obtain a stay, you must file a motion, within 30 days
of the date of the filing of the petition, and demonstrate that the new case was filed in good faith.
If you file this motion, please caption it as an Emergency Motion.
COMPLETION OF INSTRUCTIONAL COURSE CONCERNING PERSONAL
FINANCIAL MANAGEMENT
Subject to limited exceptions, an individual debtor must complete an instructional course in
personal financial management before a discharge can be entered by the court. You must
complete and file a Debtor’s Certification of Completion of Instructional Course Concerning
Personal Financial Management on the official form. This form is required to be filed within 60
days after the first date set for the meeting of creditors. Failure to file the certification could
result in your case being closed without entry of your discharge. If your case is closed without
entry of a discharge, to reopen the case to obtain your discharge, you could be required to pay a
reopening fee of $260.00.
You may check the following web site for approved providers, www.usdoj.gov/ust or call 602-
682-4000.
Official Form 121 Statement About Your Social Security Numbers
United States Bankruptcy Court for the:
__________ District of __________
Case number
(If known): _________________________
Fill in this information to identify your case:
Official Form 121
Statement About Your Social Security Numbers 12/15
Use this form to tell the court about any Social Security or federal Individual Taxpayer Identification numbers you have used. Do not file this
form as part of the public case file. This form must be submitted separately and must not be included in the court’s public electronic records.
Please consult local court procedures for submission requirements.
To protect your privacy, the court will not make this form available to the public. You should not include a full Social Security Number or
Individual Taxpayer Number on any other document filed with the court. The court will make only the last four digits of your numbers known
to the public. However, the full numbers will be available to your creditors, the U.S. Trustee or bankruptcy administrator, and the trustee
assigned to your case.
Making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in
fines up to $250,000, or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
Part 1: Tell the Court About Yourself and Your spouse if Your Spouse is Filing With You
For Debtor 1: For Debtor 2 (Only If Spouse Is Filing):
1. Your name
_________________________________________________
First name
_________________________________________________
Middle name
_________________________________________________
Last name
_________________________________________________
First name
_________________________________________________
Middle name
_________________________________________________
Last name
Part 2: Tell the Court About all of Your Social Security or Federal Individual Taxpayer Identification Numbers
2. All Social Security
Numbers you have
used
__ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __
You do not have a Social Security number.
__ __ __ __ __
__ __ __ __
__ __ __ __ __
__ __ __ __
You do not have a Social Security number.
3. All federal Individual
Taxpayer
Identification
Numbers (ITIN) you
have used
9 __ __ __ __ __ __ __ __
9 __ __ __ __ __ __ __ __
You do not have an ITIN.
9 __ __ __ __ __ __ __ __
9 __ __ __ __ __ __ __ __
You do not have an ITIN.
Part 3: Sign Below
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
_______________________________________
Signature of Debtor 1
Date _________________
M
M / DD / YYYY
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
_______________________________________
Signature of Debtor 2
Date _________________
M
M / DD / YYYY
District of Arizona
Print
Save As...
Reset
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 1
Official Form 101
Voluntary Petition for Individuals Filing for Bankruptcy 04/20
The bankruptcy forms use you and Debtor 1 to refer to a debtor filing alone. A married couple may file a bankruptcy case togethercalled a
joint caseand in joint cases, these forms use you to ask for information from both debtors. For example, if a form asks, “Do you own a car,
the answer would be yes if either debtor owns a car. When information is needed about the spouses separately, the form uses Debtor 1 and
Debtor 2 to distinguish between them. In joint cases, one of the spouses must report information as Debtor 1 and the other as Debtor 2. The
same person must be Debtor 1 in all of the forms.
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number
(if known). Answer every question.
Part 1:
Identify Yourself
About Debtor 2 (Spouse Only in a Joint Case):
1. Your full name
Write the name that is on your
government-issued picture
identification (for example,
your driver’s license or
passport).
Bring your picture
identification to your meeting
with the trustee.
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
___________________________
Suffix (Sr., Jr., II, III)
2. All other names you
have used in the last 8
years
Include your married or
maiden names.
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
3. Only the last 4 digits of
your Social Security
number or federal
Individual Taxpayer
Identification number
(ITIN)
xxx xx ____ ____ ____ ____
OR
9 xx xx ____ ____ ____ ____
United States Bankruptcy Court for the:
________________ District of ________
Case number (If known): _________________________ Chapter you are filing under:
Chapter 7
Chapter 11
Chapter 12
Chapter 13
Fill in this information to identify your case:
Check if this is an
amended filing
District of Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 2
About Debtor 2 (Spouse Only in a Joint Case):
4. Any business names
and Employer
Identification Numbers
(EIN) you have used in
the last 8 years
Include trade names and
doing business as names
I have not used any business names or EINs.
_________________________________________________
Business name
_________________________________________________
Business name
___ ___ ___ ___ ___ ___ ___ ___ ___
EIN
___ ___ ___ ___ ___ ___ ___ ___ ___
EIN
5. Where you live
If Debtor 2 lives at a different address:
_________________________________________________
Number Street
_________________________________________________
_________________________________________________
City State ZIP Code
_________________________________________________
County
If Debtor 2’s mailing address is different from
yours, fill it in here. Note that the court will send
any notices to this mailing address.
_________________________________________________
Number Street
_________________________________________________
P.O. Box
_________________________________________________
City State ZIP Code
6. Why you are choosing
this district to file for
bankruptcy
Check one:
Over the last 180 days before filing this petition,
I have lived in this district longer than in any
other district.
I have another reason. Explain.
(See 28 U.S.C. § 1408.)
________________________________________
________________________________________
________________________________________
________________________________________
Check one:
Over the last 180 days before filing this petition,
I have lived in this district longer than in any
other district.
I have another reason. Explain.
(See 28 U.S.C. § 1408.)
________________________________________
________________________________________
________________________________________
________________________________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 3
Part 2:
Tell the Court About Your Bankruptcy Case
7. The chapter of the
Bankruptcy Code you
are choosing to file
under
Check one. (For a brief description of each, see Notice Required by 11 U.S.C. § 342(b) for Individuals Filing
for Bankruptcy (Form 2010)). Also, go to the top of page 1 and check the appropriate box.
Chapter 7
Chapter 11
Chapter 12
Chapter 13
8. How you will pay the fee
I will pay the entire fee when I file my petition. Please check with the clerk’s office in your
local court for more details about how you may pay. Typically, if you are paying the fee
yourself, you may pay with cash, cashier’s check, or money order. If your attorney is
submitting your payment on your behalf, your attorney may pay with a credit card or check
with a pre-printed address.
I need to pay the fee in installments. If you choose this option, sign and attach the
Application for Individuals to Pay The Filing Fee in Installments (Official Form 103A).
I request that my fee be waived (You may request this option only if you are filing for Chapter 7.
By law, a judge may, but is not required to, waive your fee, and may do so only if your income is
less than 150% of the official poverty line that applies to your family size and you are unable to
pay the fee in installments). If you choose this option, you must fill out the Application to Have the
Chapter 7 Filing Fee Waived (Official Form 103B) and file it with your petition.
9. Have you filed for
bankruptcy within the
last 8 years?
No
Yes. District __________________________ When _______________ Case number ___________________________
MM / DD / YYYY
District __________________________ When _______________ Case number ___________________________
MM / DD / YYYY
District __________________________ When _______________ Case number ___________________________
MM / DD / YYYY
10. Are any bankruptcy
cases pending or being
filed by a spouse who is
not filing this case with
you, or by a business
partner, or by an
affiliate?
No
Yes. Debtor _________________________________________________ Relationship to you _____________________
District __________________________ When _______________ Case number, if known____________________
MM / DD / YYYY
Debtor _________________________________________________ Relationship to you _____________________
District __________________________ When _______________ Case number, if known____________________
MM / DD / YYYY
11. Do you rent your
residence?
No. Go to line 12.
Yes. Has your landlord obtained an eviction judgment against you?
No. Go to line 12.
Yes. Fill out Initial Statement About an Eviction Judgment Against You (Form 101A) and file it as
part of this bankruptcy petition.
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 4
Part 3:
Report About Any Businesses You Own as a Sole Proprietor
12. Are you a sole proprietor
of any full- or part-time
business?
A sole proprietorship is a
business you operate as an
individual, and is not a
separate legal entity such as
a corporation, partnership, or
LLC.
If you have more than one
sole proprietorship, use a
separate sheet and attach it
to this petition.
No. Go to Part 4.
Yes. Name and location of business
_______________________________________________________________________________________
Name of business, if any
_______________________________________________________________________________________
Number Street
_______________________________________________________________________________________
_______________________________________________ _______ __________________________
City State ZIP Code
Check the appropriate box to describe your business:
Health Care Business (as defined in 11 U.S.C. § 101(27A))
Single Asset Real Estate (as defined in 11 U.S.C. § 101(51B))
Stockbroker (as defined in 11 U.S.C. § 101(53A))
Commodity Broker (as defined in 11 U.S.C. § 101(6))
None of the above
13. Are you filing under
Chapter 11 of the
Bankruptcy Code, and
are you a small business
debtor or a debtor as
defined by 11 U.S. C. §
1182(1)?
For a definition of small
business debtor, see
11 U.S.C. § 101(51D).
If you are filing under Chapter 11, the court must know whether you are a small business debtor or a debtor
choosing to proceed under Subchapter V so that it can set appropriate deadlines. If you indicate that you
are a small business debtor or you are choosing to proceed under Subchapter V, you must attach your
most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or
if any of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B).
No. I am not filing under Chapter 11.
No. I am filing under Chapter 11, but I am NOT a small business debtor according to the definition in
the Bankruptcy Code.
Yes. I am filing under Chapter 11, I am a small business debtor according to the definition in the Bankruptcy
Code, and I do not choose to proceed under Subchapter V of Chapter 11.
Yes. I am filing under Chapter 11, I am a debtor according to the definition in § 1182(1) of the
Bankruptcy Code, and I choose to proceed under Subchapter V of Chapter 11.
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 5
Part 4: Report if You Own or Have Any Hazardous Property or Any Property That Needs Immediate Attention
14. Do you own or have any
property that poses or is
alleged to pose a threat
of imminent and
identifiable hazard to
public health or safety?
Or do you own any
property that needs
immediate attention?
For example, do you own
perishable goods, or livestock
that must be fed, or a buildi
ng
t
hat needs urgent repairs?
No
Yes. What is the hazard? ________________________________________________________________________
___
_____________________________________________________________________
If immediate attention is needed, why is it needed? _______________________________________________
________________________________________________________________________
Where is the property? ________________________________________________________________________
Number Street
________________________________________________________________________
________________________________________ _______ ____________________
City State ZIP Code
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 6
Part 5:
Explain Your Efforts to Receive a Briefing About Credit Counseling
15. Tell the court whether
you have received a
briefing about credit
counseling.
The law requires that you
receive a briefing about credit
counseling before you file for
bankruptcy. You must
truthfully check one of the
following choices. If you
cannot do so, you are not
eligible to file.
If you file anyway, the court
can dismiss your case, you
will lose whatever filing fee
you paid, and your creditors
can begin collection activities
again.
About Debtor 1:
About Debtor 2 (Spouse Only in a Joint Case):
You must check one:
I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, and I received a
certificate of completion.
Attach a copy of the certificate and the payment
plan, if any, that you developed with the agency.
I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, but I do not have a
certificate of completion.
Within 14 days after you file this bankruptcy petition,
you MUST file a copy of the certificate and payment
plan, if any.
I certify that I asked for credit counseling
services from an approved agency, but was
unable to obtain those services during the 7
days after I made my request, and exigent
circumstances merit a 30-day temporary waiver
of the requirement.
To ask for a 30-day temporary waiver of the
requirement, attach a separate sheet explaining
what efforts you made to obtain the briefing, why
you were unable to obtain it before you filed for
bankruptcy, and what exigent circumstances
required you to file this case.
Your case may be dismissed if the court is
dissatisfied with your reasons for not receiving a
briefing before you filed for bankruptcy.
If the court is satisfied with your reasons, you must
still receive a briefing within 30 days after you file.
You must file a certificate from the approved
agency, along with a copy of the payment plan you
developed, if any. If you do not do so, your case
may be dismissed.
Any extension of the 30-day deadline is granted
only for cause and is limited to a maximum of 15
days.
I am not required to receive a briefing about
credit counseling because of:
Incapacity. I have a mental illness or a mental
deficiency that makes me
incapable of realizing or making
rational decisions about finances.
Disability. My physical disability causes me
to be unable to participate in a
briefing in person, by phone, or
through the internet, even after I
reasonably tried to do so.
Active duty. I am currently on active military
duty in a military combat zone.
If you believe you are not required to receive a
briefing about credit counseling, you must file a
motion for waiver of credit counseling with the court.
You must check one:
I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, and I received a
certificate of completion.
Attach a copy of the certificate and the payment
plan, if any, that you developed with the agency.
I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, but I do not have a
certificate of completion.
Within 14 days after you file this bankruptcy petition,
you MUST file a copy of the certificate and payment
plan, if any.
I certify that I asked for credit counseling
services from an approved agency, but was
unable to obtain those services during the 7
days after I made my request, and exigent
circumstances merit a 30-day temporary waiver
of the requirement.
To ask for a 30-day temporary waiver of the
requirement, attach a separate sheet explaining
what efforts you made to obtain the briefing, why
you were unable to obtain it before you filed for
bankruptcy, and what exigent circumstances
required you to file this case.
Your case may be dismissed if the court is
dissatisfied with your reasons for not receiving a
briefing before you filed for bankruptcy.
If the court is satisfied with your reasons, you must
still receive a briefing within 30 days after you file.
You must file a certificate from the approved
agency, along with a copy of the payment plan you
developed, if any. If you do not do so, your case
may be dismissed.
Any extension of the 30-day deadline is granted
only for cause and is limited to a maximum of 15
days.
I am not required to receive a briefing about
credit counseling because of:
Incapacity. I have a mental illness or a mental
deficiency that makes me
incapable of realizing or making
rational decisions about finances.
Disability. My physical disability causes me
to be unable to participate in a
briefing in person, by phone, or
through the internet, even after I
reasonably tried to do so.
Active duty. I am currently on active military
duty in a military combat zone.
If you believe you are not required to receive a
briefing about credit counseling, you must file a
motion for waiver of credit counseling with the court.
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 7
Part 6:
Answer These Questions for Reporting Purposes
16. What kind of debts do
you have?
16a. Are your debts primarily consumer debts? Consumer debts are defined in 11 U.S.C. § 101(8)
as “incurred by an individual primarily for a personal, family, or household purpose.”
No. Go to line 16b.
Yes. Go to line 17.
16b. Are your debts primarily business debts? Business debts are debts that you incurred to obtain
money for a business or investment or through the operation of the business or investment.
No. Go to line 16c.
Yes. Go to line 17.
16c. State the type of debts you owe that are not consumer debts or business debts.
_______________________________________________________________
17. Are you filing under
Chapter 7?
Do you estimate that after
any exempt property is
excluded and
administrative expenses
are paid that funds will be
available for distribution
to unsecured creditors?
No. I am not filing under Chapter 7. Go to line 18.
Yes. I am filing under Chapter 7. Do you estimate that after any exempt property is excluded and
administrative expenses are paid that funds will be available to distribute to unsecured creditors?
No
Yes
18. How many creditors do
you estimate that you
owe?
1-49
50-99
100-199
200-999
1,000-5,000
5,001-10,000
10,001-25,000
25,001-50,000
50,001-100,000
More than 100,000
19. How much do you
estimate your assets to
be worth?
$0-$50,000
$50,001-$100,000
$100,001-$500,000
$500,001-$1 million
$1,000,001-$10 million
$10,000,001-$50 million
$50,000,001-$100 million
$100,000,001-$500 million
$500,000,001-$1 billion
$1,000,000,001-$10 billion
$10,000,000,001-$50 billion
More than $50 billion
20. How much do you
estimate your liabilities
to be?
$0-$50,000
$50,001-$100,000
$100,001-$500,000
$500,001-$1 million
$1,000,001-$10 million
$10,000,001-$50 million
$50,000,001-$100 million
$100,000,001-$500 million
$500,000,001-$1 billion
$1,000,000,001-$10 billion
$10,000,000,001-$50 billion
More than $50 billion
Part 7:
Sign Below
For you
I have examined this petition, and I declare under penalty of perjury that the information provided is true and
correct.
If I have chosen to file under Chapter 7, I am aware that I may proceed, if eligible, under Chapter 7, 11,12, or 13
of title 11, United States Code. I understand the relief available under each chapter, and I choose to proceed
under Chapter 7.
If no attorney represents me and I did not pay or agree to pay someone who is not an attorney to help me fill out
this document, I have obtained and read the notice required by 11 U.S.C. § 342(b).
I request relief in accordance with the chapter of title 11, United States Code, specified in this petition.
I understand making a false statement, concealing property, or obtaining money or property by fraud in connection
with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both.
18 U.S.C. §§ 152, 1341, 1519, and 3571.
______________________________________________ _____________________________
Signature of Debtor 1 Signature of Debtor 2
Executed on _________________ Executed on __________________
MM / DD / YYYY MM / DD / YYYY
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 8
For your attorney, if you are
represented by one
If you are not represented
by an attorney, you do not
need to file this page.
I, the attorney for the debtor(s) named in this petition, declare that I have informed the debtor(s) about eligibility
to proceed under Chapter 7, 11, 12, or 13 of title 11, United States Code, and have explained the relief
available under each chapter for which the person is eligible. I also certify that I have delivered to the debtor(s)
the notice required by 11 U.S.C. § 342(b) and, in a case in which § 707(b)(4)(D) applies, certify that I have no
knowledge after an inquiry that the information in the schedules filed with the petition is incorrect.
_________________________________ Date _________________
Signature of Attorney for Debtor MM / DD / YYYY
_________________________________________________________________________________________________
Printed name
_________________________________________________________________________________________________
Firm name
_________________________________________________________________________________________________
Number Street
_________________________________________________________________________________________________
______________________________________________________ ____________ ______________________________
City State ZIP Code
Contact phone _____________________________________ Email address ______________________________
______________________________________________________ ____________
Bar number State
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 101 Voluntary Petition for Individuals Filing for Bankruptcy page 9
For you if you are filing this
bankruptcy without an
attorney
If you are represented by
an attorney, you do not
need to file this page.
The law allows you, as an individual, to represent yourself in bankruptcy court, but you
should understand that many people find it extremely difficult to represent
themselves successfully. Because bankruptcy has long-term financial and legal
consequences, you are strongly urged to hire a qualified attorney.
To be successful, you must correctly file and handle your bankruptcy case. The rules are very
technical, and a mistake or inaction may affect your rights. For example, your case may be
dismissed because you did not file a required document, pay a fee on time, attend a meeting or
hearing, or cooperate with the court, case trustee, U.S. trustee, bankruptcy administrator, or audit
firm if your case is selected for audit. If that happens, you could lose your right to file another
case, or you may lose protections, including the benefit of the automatic stay.
You must list all your property and debts in the schedules that you are required to file with the
court. Even if you plan to pay a particular debt outside of your bankruptcy, you must list that debt
in your schedules. If you do not list a debt, the debt may not be discharged. If you do not list
property or properly claim it as exempt, you may not be able to keep the property. The judge can
also deny you a discharge of all your debts if you do something dishonest in your bankruptcy
case, such as destroying or hiding property, falsifying records, or lying. Individual bankruptcy
cases are randomly audited to determine if debtors have been accurate, truthful, and complete.
Bankruptcy fraud is a serious crime; you could be fined and imprisoned.
If you decide to file without an attorney, the court expects you to follow the rules as if you had
hired an attorney. The court will not treat you differently because you are filing for yourself. To be
successful, you must be familiar with the United States Bankruptcy Code, the Federal Rules of
Bankruptcy Procedure, and the local rules of the court in which your case is filed. You must also
be familiar with any state exemption laws that apply.
Are you aware that filing for bankruptcy is a serious action with long-term financial and legal
consequences?
No
Yes
Are you aware that bankruptcy fraud is a serious crime and that if your bankruptcy forms are
inaccurate or incomplete, you could be fined or imprisoned?
No
Yes
Did you pay or agree to pay someone who is not an attorney to help you fill out your bankruptcy forms?
No
Yes. Name of Person_____________________________________________________________________.
Attach Bankruptcy Petition Preparer’s Notice, Declaration, and Signature (Official Form 119).
By signing here, I acknowledge that I understand the risks involved in filing without an attorney. I
have read and understood this notice, and I am aware that filing a bankruptcy case without an
attorney may cause me to lose my rights or property if I do not properly handle the case.
_______________________________________________ ______________________________
Signature of Debtor 1 Signature of Debtor 2
Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY
Contact phone ______________________________________ Contact phone ________________________________
Cell phone ______________________________________ Cell phone ________________________________
Email address ______________________________________ Email address ________________________________
Print
Save As...
Add Attachment
Reset
MML-1
United States Bankruptcy Court
District of Arizona
MASTER MAILING LIST REQUIREMENTS
The ba
nkruptcy rules require that debtor file with the petition a list containing the names and
address of all creditors. The list must conform to the following requirements:
1.
The mailing list must be typed in black ink. Handwritten lists will not be accepted.
2.
Include the debtor name and case number in the one inch top margin.
3.
The list must be typed in a straight column on the left margin, using ALL CAPS
.
4.
Typing on each line shall not exceed 40 charac
ters.
5.
Each name and address must consist of no more than five (5) total lines
.
6.
Include the City, State and Zip Code on the last line of each address.
The State must
be ab
breviated using the U.S. Postal Codes below.
7.
Single space the list with at least one blank line between creditors.
8.
Do not include the name and address of the debtor, joint debtor, attorney for debt
or,
U.S. Truste
e or Case Trustee. This information is added by the court.
9.
Complete and submit the attached Declaration page with the mailing
list.
10.
Attorneys refer to the ECF Procedural Manuals and Guides on the court’s webs
ite
for add
itional requirem
ents.
Supplemental (Amen
ded) Mailing Lists
Pursu
ant to Local Rule of Bankruptcy Procedure 1007-1(a)(2) “When an addition or change
is made to the master mailing list, the entire master mailing list shall not be filed or
electronically submitted. Only a supplemental master mailing list, in the required format,
containing only the newly added or changed creditors shall be filed and electronically
submitted.”
Incomplete Addresses
An ad
dress that does not include a Street Address or PO Box, City, State and Zip Code
may not be mailed.
Notice of Returned Mail
Notic
es that are mailed by the Bankruptcy Noticing Center, but returned by the post office
as undeliverable, are returned to the debtor or debtor’s attorney. The debtor or their
attorney may correct the address on the notice and file it with the Clerk's Office. The debtor
or their attorney must mail the returned notice to that creditor at the corrected address.
Notice of Undeliverable Mail
The Ban
kruptcy Noticing Center will send to the debtor and debtor’s attorney a Notice of
Undeliverable Mail stating why a notice was not mailed to a particular creditor. The debtor
or their attorney may correct the address on the notice and file it with the Clerk's Office. The
address will then be corrected for any future notices. The debtor or their attorney must mail
the non-mailed notice to that creditor at the corrected address.
MML-2
JONES, JOHN AND JANE 18-00000
ABC COMPANY
C/O JOHN DOE
ATTORNEY AT LAW
1234 MAIN ST #567
ANYWHERE AZ 85000
XYZ COMPANY
ATTN: BANKRUPTCY DEPT
1234 CENTRAL AVE
ANYWHERE AZ 85000
JANE DOE
3456 CENTRAL AVE
ANYWHERE AZ 85000
STATE/TERRITORY ABBREVIATIONS
Alabama AL Kentucky KY Oklahoma OK
A
laska
A
K Louisiana L
A
Oregon OR
A
rizona
A
Z Maine ME Pennsylvania P
A
A
rkansas
A
R Maryland MD Puerto Rico PR
California C
A
Massachusetts M
A
Rhode Island RI
Colorado CO Michigan MI South Carolina SC
Connecticut CT Minnesota MN South Dakota SD
Delaware DE Mississippi MS Tennessee TN
District of Missouri MO Texas TX
Columbia DC Montana MT Utah UT
Florida FL Nebraska NE Vermont VT
Georgia G
A
Nevada NV Virginia V
A
Guam GU New Hampshire NH Virgin Islands VI
Hawaii HI New Jersey NJ Washington W
A
Idaho ID New Mexico NM West Virginia WV
Illinois IL New York NY Wisconsin WI
Indiana IN North Carolina NC Wyoming WY
Iowa I
A
North Dakota ND
Kansas KS Ohio OH
MML-3
MAILING LIST DECLARATION
Debtor(s)' Name(s) Case No._________________________________
_______________________________________
_______________________________________
I, ________________________________, do hereby certify, under penalty of perjury, that the
Mailing List, consisting of ________ page(s), is complete, correct and consistent with the debtor(s)'
Schedules.
Dated: _________________________________ ______________________________________
(Debtor)
_______________________________________ _______________________________________
(Attorney, if applicable) (Joint Debtor)
MML_Requirements_4-2018
Check if this is an
Amended/Supplemental Mailing List
(Include only newly added or
changed creditors.)
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
District of Arizona
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.
$_____________________
Print
Save As...
Add Attachment
Reset
Official Form 106A/B Schedule A/B: Property page 1
Official Form 106A/B
Schedule A/B: Property 12/15
In each category, separately list and describe items. List an asset only once. If an asset fits in more than one category, list the asset in the
category where you think it fits best. 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: Describe Each Residence, Building, Land, or Other Real Estate You Own or Have an Interest In
1. Do you own or have any legal or equitable interest in any residence, building, land, or similar property?
No. Go to Part 2.
Yes. Where is the property?
1.1. _________________________________________
Street address, if available, or other description
_________________________________________
_________________________________________
City State ZIP Code
_________________________________________
County
What is the property? Check all that apply.
Single-family home
Duplex or multi-unit building
Condominium or cooperative
Manufactured or mobile home
Land
Investment property
Timeshare
Other __________________________________
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?
$_______________
Describe the nature of your ownership
interest (such as fee simple, tenancy by
the entireties, or a life estate), if known.
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 instructions)
Other in
formation you wish to add about this item, such as local
property identification number: _______________________________
If you own or have more than one, list here:
1.2. ________________________________________
Street address, if available, or other description
________________________________________
________________________________________
City State ZIP Code
________________________________________
County
What is the property? Check all that apply.
Single-family home
Duplex or multi-unit building
Condominium or cooperative
Manufactured or mobile home
Land
Investment property
Timeshare
Other __________________________________
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?
$_________________
Describe the nature of your ownership
interest (such as fee simple, tenancy by
the entireties, or a life estate), if known.
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 instructions)
Other in
formation you wish to add about this item, such as local
property identification number: _______________________________
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 ___________________________________________
Fill in this information to identify your case and this filing:
Check if this is an
amended filing
District of Arizona
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 106A/B
Schedule A/B: Property page 2
1.3. ________________________________________
Street address, if available, or other description
________________________________________
________________________________________
City State ZIP Code
________________________________________
County
What is the property? Check all that apply.
Single-family home
Duplex or multi-unit building
Condominium or cooperative
Manufactured or mobile home
Land
Investment property
Timeshare
Other __________________________________
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?
$_________________
Describe the nature of your ownership
interest (such as fee simple, tenancy by
the entireties, or a life estate), if known.
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 instructions)
Other in
formation you wish to add about this item, such as local
property identification number: _______________________________
2. Add the dollar value of the portion you own for all of your entries from Part 1, including any entries for pages
you have attached for Part 1. Write that number here.
......................................................................................
$_________________
Part 2:
Describe Your Vehicles
Do you own, lease, or have legal or equitable interest in any vehicles, whether they are registered or not? Include any vehicles
you own that someone else drives. If you lease a vehicle, also report it on Schedule G: Executory Contracts and Unexpired Leases.
3. Cars, vans, trucks, tractors, sport utility vehicles, motorcycles
No
Yes
3.1.
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
instructions)
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, describe here:
3.2.
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
instructions)
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?
$________________
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
instructions)
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
instructions)
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
Examples: 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
instructions)
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
instructions)
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
you 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, printers, scanners; music
collections; electronic 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 objects;
stamp, coin, or baseball card collections; other collections, memorabilia, collectibles
No
Yes. Describe. .........
$____________
_______
9. Equipment for sports and hobbies
Examples: Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes
and kayaks; carpentry tools; musical instruments
No
Yes. Describe. .........
$____________
_______
10. Firearms
Examples: Pistols, rifles, shotguns, ammunition, and related equipment
No
Yes. Describe. .........
.
$____________
_______
11. Clothes
Examples: Everyday clothes, furs, leather coats, designer wear, shoes, accessories
No
Yes. Describe. .........
.
$____________
_______
12. Jewelry
Examples: Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems,
gold, silver
No
Yes. Describe. ..........
$____________
_______
13. Non-farm animals
Examples: 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, brokerage 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 accounts
 No
 Yes .................
Institution or issuer name:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
$__________________
$__________________
$__________________
19. Non-publicly traded stock and interests in incorporated and unincorporated businesses, including an interest in
an LLC, partnership, and joint venture
No
Yes. Give specific
information about
them
.........................
Name of entity: % of ownership:
_____________________________________________________________________ ___________%
_____________________________________________________________________ ___________%
_____________________________________________________________________ ___________%
$__________________
$__________________
$__________________
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 abou
t
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-sharing plans
No
Yes. List each
account separately.
Type of account: Institution name:
401(k) or similar plan: ___________________________________________________________________
Pension plan: ___________________________________________________________________
IRA: ____________
_______________________________________________________
Retirement account: ___________________________________________________________________
Keogh: ___________________________________________________________________
Additional account: ___________________________________________________________________
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 company
Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications
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 already 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:
Maintenan
ce:
Support:
Div
o
rce settlement:
Property settlement:
$________________
$________________
$________________
$________________
$________________
30. Other amounts someone owes you
Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compensation,
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
property 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 set 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
Examples: 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
information
. ............
$___________________
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
information
. ............
$________________
$________________
$________________
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. ......................................................................................... $_________________
0.00
0.00
0.00
0.00
Print
Save As...
Add Attachment
Reset
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 exemptionssuch as those for health aids, rights to receive certain benefits, and tax-exempt
retirement fundsmay 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
District of Arizona
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
Print
Save As...
Add Attachment
Reset
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
District of Arizona
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 ___ ___ ___ ___
Print
Save As...
Add Attachment
Reset
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
District of Arizona
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 3: List Others to Be Notified About a Debt That You Already Listed
5. Use this page only if you have others to be notified about your bankruptcy, for a debt that you already listed in Parts 1 or 2. For
example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or
2, then list the collection agency here.
Similarly, if you have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the
additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill out or submit this page.
_______________
______________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one): Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
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.
Add the amounts for each type of unsecured claim.
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.
$_________________________
Print
Save As...
Add Attachment
Reset
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 contracts and
unexpired 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
District of Arizona
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
Print
Save As...
Add Attachment
Reset
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
shown 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
District of Arizona