Free FORM1.PDF - Virginia

(Official Form 1) (12/03)
FORM B1

USBC, EDVA (12/1/03)

United States Bankruptcy Court Eastern District of Virginia ______________________ Division

Voluntary Petition

Name of Debtor (if individual, enter Last, First, Middle): All Other Names used by the Debtor in the last 6 years (include married, maiden, and trade names):

Name of Joint Debtor (Spouse) (Last, First, Middle): All Other Names used by the Joint Debtor in the last 6 years (include married, maiden, and trade names):

Last four digits of Soc. Sec. No./Complete EIN or other Tax I.D. No. (if more than one, state all): Street Address of Debtor (No. & Street, City, State & Zip Code):

Last four digits of Soc. Sec. No./Complete EIN or other Tax I.D.
No. (if more than one, state all):

Street Address of Joint Debtor (No. & Street, City, State & Zip Code):

County of Residence or of the Principal Place of Business: Mailing Address of Debtor (if different from street address):

County of Residence or of the Principal Place of Business: Mailing Address of Joint Debtor (if different from street address):

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

Information Regarding the Debtor (Check the Applicable Boxes)
Venue (Check any applicable box) Debtor has been domiciled or has had a residence, principal place of business, or principal assets in this District for 180 days immediately preceding the date of this petition or for a longer part of such 180 days than in any other District. There is a bankruptcy case concerning debtor's affiliate, general partner, or partnership pending in this District. Type of Debtor (Check all boxes that apply) Railroad Individual(s) Stockbroker Corporation Commodity Broker Partnership Clearing Bank Other Nature of Debts (Check one box) Consumer/Non-Business Business Chapter 11 Small Business (Check all boxes that apply) Debtor is a small business as defined in 11 U.S.C. § 101 Debtor is and elects to be considered a small business under
11 U.S.C. § 1121(e) (Optional)

Chapter or Section of Bankruptcy Code Under Which the Petition is Filed (Check one box) Chapter 11 Chapter 7 Chapter 13 Chapter 12 Chapter 9 Sec. 304 - Case ancillary to foreign proceeding Filing Fee (Check one box) Full Filing Fee attached Filing Fee to be paid in installments (Applicable to individuals only) Must attach signed application for the court's consideration certifying that the debtor is unable to pay fee except in installments. Rule 1006(b). See Official Form No. 3.
THIS SPACE IS FOR COURT USE ONLY

Statistical/Administrative Information (Estimates only) Debtor estimates that funds will be available for distribution to unsecured creditors. Debtor estimates that, after any exempt property is excluded and administrative expenses paid, there will be no funds available for distribution to unsecured creditors. Estimated Number of Creditors Estimated Assets
$0 to $50,000 $50,001 to $100,000 $100,001 to $500,000 $500,001 to $1 million $1,000,001 to $10 million $10,000,001 to $50 million $50,000,001 to $100 million More than $100 million 1-15 16-49 50-99 100-199 200-999 1000-over

Estimated Debts
$0 to $50,000 $50,001 to $100,000 $100,001 to $500,000 $500,001 to $1 million $1,000,001 to $10 million $10,000,001 to $50 million $50,000,001 to $100 million More than $100 million

(Official Form 1)(12/03)

FORM B1, Page 2 Name of Debtor(s):

Voluntary Petition
Location Where Filed: Name of Debtor: District:

(This page must be completed and filed in every case) Prior Bankruptcy Case Filed Within Last 6 Years (If more than one, attach additional sheet)
Case Number: Date Filed:

Pending Bankruptcy Case Filed by any Spouse, Partner or Affiliate of this Debtor (If more than one, attach additional sheet)
Case Number: Relationship: Date Filed: Judge:

Signatures
Signature(s) of Debtor(s) (Individual/Joint)
I declare under penalty of perjury that the information provided in this petition is true and correct. [If petitioner is an individual whose debts are primarily consumer debts and has chosen to file under chapter 7] I am aware that I may proceed under chapter 7, 11, 12 or 13 of title 11, United States Code, understand the relief available under each such chapter, and choose to proceed under chapter 7. I request relief in accordance with the chapter of title 11, United States Code, specified in this petition.

Exhibit A
(To be completed if debtor is required to file periodic reports (e.g., forms 10K and 10Q) with the Securities and Exchange Commission pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 and is requesting relief under chapter 11) Exhibit A is attached and made a part of this petition.

Exhibit B
(To be completed if debtor is an individual whose debts are primarily consumer debts) I, the attorney for the petitioner named in the foregoing petition, declare that I have informed the petitioner that [he or she] may proceed under chapter 7, 11, 12, or 13 of title 11, United States Code, and have explained the relief available under each such chapter.

X
Signature of Debtor

X
Signature of Joint Debtor Telephone Number (If not represented by attorney) Date

X
Signature of Attorney for Debtor(s) Date

Exhibit C
Does the debtor own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety? Yes, and Exhibit C is attached and made a part of this petition. No

Signature of Attorney

X

Signature of Attorney for Debtor(s) Printed Name of Attorney for Debtor(s) Firm Name Address Bar ID Number

Signature of Non-Attorney Petition Preparer
I certify that I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110, that I prepared this document for compensation, and that I have provided the debtor with a copy of this document. Printed Name of Bankruptcy Petition Preparer Social Security Number

Telephone Number Date

Address Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document:

Signature of Debtor (Corporation/Partnership)
I declare under penalty of perjury that the information provided in this petition is true and correct, and that I have been authorized to file this petition on behalf of the debtor. The debtor requests relief in accordance with the chapter of title 11, United States Code, specified in this petition.

X

If more than one person prepared this document, attach additional sheets conforming to the appropriate official form for each person.

Signature of Authorized Individual Printed Name of Authorized Individual Title of Authorized Individual Date

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